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Smith MD, Sampson CS, Wall SP, Diercks DB, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman BW, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Mattu A, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Thompson JT, Tomaszewski CA, Trent SA, Valente JH, Westafer LM, Wall SP, Yu Y, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Seizures: Approved by the ACEP Board of Directors, April 17, 2024. Ann Emerg Med 2024; 84:e1-e12. [PMID: 38906639 DOI: 10.1016/j.annemergmed.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
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2
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Almohaish S, Tesoro EP, Brophy GM. Status Epilepticus: An Update on Pharmacological Management. Semin Neurol 2024; 44:324-332. [PMID: 38580318 DOI: 10.1055/s-0044-1785503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Status epilepticus (SE) is a neurological emergency that requires timely pharmacological therapy to cease seizure activity. The treatment approach varies based on the time and the treatment stage of SE. Benzodiazepines are considered the first-line therapy during the emergent treatment phase of SE. Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase. These drugs appear to have a similar safety and efficacy profile, and individualized therapy should be chosen based on patient characteristics. Midazolam, propofol, pentobarbital, and ketamine are continuous intravenous infusions of anesthetic medications utilized in the refractory SE (RSE) period. The most efficacious pharmacotherapeutic treatments for RSE and superrefractory status epilepticus are not clearly defined.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
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3
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Williams NC, Morgan LA, Friedman J, Siegler J. Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians. Air Med J 2024; 43:84-89. [PMID: 38490790 DOI: 10.1016/j.amj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024]
Abstract
Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.
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Affiliation(s)
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
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4
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Shehata IM, Kohaf NA, ElSayed MW, Latifi K, Aboutaleb AM, Kaye AD. Ketamine: Pro or antiepileptic agent? A systematic review. Heliyon 2024; 10:e24433. [PMID: 38293492 PMCID: PMC10826813 DOI: 10.1016/j.heliyon.2024.e24433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice. Recent findings Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent. Summary Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.
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Affiliation(s)
| | - Neveen A. Kohaf
- Department of Clinical Pharmacy, Alazhar, University, Cairo, 11651, Egypt
| | - Mohamed W. ElSayed
- Geisel School of Medicine at Dartmouth, New Hampshire Hospital, SUNY School of Graduate Studies, USA
| | - Kaveh Latifi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alan David Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
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Charalambous M, Muñana K, Patterson EE, Platt SR, Volk HA. ACVIM Consensus Statement on the management of status epilepticus and cluster seizures in dogs and cats. J Vet Intern Med 2024; 38:19-40. [PMID: 37921621 PMCID: PMC10800221 DOI: 10.1111/jvim.16928] [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: 10/04/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Seizure emergencies (ie, status epilepticus [SE] and cluster seizures [CS]), are common challenging disorders with complex pathophysiology, rapidly progressive drug-resistant and self-sustaining character, and high morbidity and mortality. Current treatment approaches are characterized by considerable variations, but official guidelines are lacking. OBJECTIVES To establish evidence-based guidelines and an agreement among board-certified specialists for the appropriate management of SE and CS in dogs and cats. ANIMALS None. MATERIALS AND METHODS A panel of 5 specialists was formed to assess and summarize evidence in the peer-reviewed literature with the aim to establish consensus clinical recommendations. Evidence from veterinary pharmacokinetic studies, basic research, and human medicine also was used to support the panel's recommendations, especially for the interventions where veterinary clinical evidence was lacking. RESULTS The majority of the evidence was on the first-line management (ie, benzodiazepines and their various administration routes) in both species. Overall, there was less evidence available on the management of emergency seizure disorders in cats in contrast to dogs. Most recommendations made by the panel were supported by a combination of a moderate level of veterinary clinical evidence and pharmacokinetic data as well as studies in humans and basic research studies. CONCLUSIONS AND CLINICAL RELEVANCE Successful management of seizure emergencies should include an early, rapid, and stage-based treatment approach consisting of interventions with moderate to preferably high ACVIM recommendations; management of complications and underlying causes related to seizure emergencies should accompany antiseizure medications.
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Affiliation(s)
| | - Karen Muñana
- North Carolina State UniversityRaleighNorth CarolinaUSA
| | | | | | - Holger A. Volk
- University of Veterinary Medicine HannoverHannoverGermany
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Trinh NHNY, Reid AS, Robertson B. Perioperative considerations for adult patients with Dravet syndrome in regional centres. BMJ Case Rep 2023; 16:e256261. [PMID: 38056933 PMCID: PMC10711814 DOI: 10.1136/bcr-2023-256261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
Dravet syndrome (DS) is a rare and intractable severe form of epilepsy presenting in infancy with frequent prolonged myoclonic seizures and neurodevelopmental impairment, associated with a SCN1A gene mutation. Seizures are often triggered by temperature fluctuations and hyperthermia. This report presents a woman in her late adolescence with DS complicated with intractable catamenial epilepsy, a sex-specific form of epilepsy with seizure activity prominent during phases of the menstrual cycle. The patient underwent general anaesthesia for a hysteroscopy, cervical dilatation and endometrial curettage with Mirena insertion to improve seizure control. Her perioperative care was optimised for seizure prevention with continuation of antiepileptic medications, strict temperature monitoring and control, optimised anaesthetic agents encompassing induction with propofol and fentanyl with maintenance sevoflurane, followed by attentive postoperative care and monitoring. This case demonstrates that general anaesthesia can safely be delivered to adult patients with DS in rural and regional areas with thorough perioperative planning.
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Affiliation(s)
| | - Amy Susan Reid
- Anaesthesia, Albury Wodonga Health, East Albury, New South Wales, Australia
| | - Barbara Robertson
- Anaesthesia, Albury Wodonga Health, East Albury, New South Wales, Australia
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Calvano J, Paluska MR, Armijo AJ, Petersen TR, Soneru C, Broman A, Lopez-Hernandez G. Propofol-Related Infusion Syndrome in a Child With Refractory Status Epilepticus: Successful Resuscitation With Veno-Arterial Extracorporeal Membrane Oxygenation, Continuous Renal Replacement Therapy, and Therapeutic Plasma Exchange. Cureus 2023; 15:e47866. [PMID: 37908691 PMCID: PMC10613782 DOI: 10.7759/cureus.47866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 11/02/2023] Open
Abstract
Propofol is used for sedation, anxiolysis, anesthesia induction, and as an anticonvulsant. In cases of refractory status epilepticus (RSE), propofol is more efficient than barbiturates. We present a case of a 3-year-old female with RSE who developed propofol-related infusion syndrome (PRIS) despite low dosage after failed attempts with multiple anti-epileptic drips and bolus therapies. Careful consideration must be made before initiating propofol administration for RSE. We discuss our PRIS treatment approach with extracorporeal membrane oxygenation, therapeutic plasma exchange, and continuous renal replacement therapy leading to our patient recovering to baseline and being discharged home from the hospital.
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Affiliation(s)
- Joshua Calvano
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
| | - Matthew R Paluska
- Department of Anesthesiology, Rocky Vista University College of Osteopathic Medicine, Englewood, USA
| | - Arthur J Armijo
- Department of Graduate Medical Education, Healthcare Corporation of America/HealthOne, Lone Tree, USA
| | - Timothy R Petersen
- Department of Graduate Medical Education, University of New Mexico School of Medicine, Albuquerque, USA
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Codruta Soneru
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
| | - Alia Broman
- Department of Pediatrics, University of Colorado School of Medicine, Denver Health Medical Center, Denver, USA
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Espiñeira I, Alzate D, Araos J, Pellegrino F, Tunesi M, Jensen M, Donati PA. Propofol versus sodium thiopentone for the treatment of status epilepticus and refractory status epilepticus in dogs. N Z Vet J 2023; 71:128-132. [PMID: 36688794 DOI: 10.1080/00480169.2023.2172089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
AIMS To compare the effect on mortality and length of hospital stay of propofol with that of sodium thiopentone for the management of dogs with status epilepticus (SE) and refractory status epilepticus (RSE). METHODS In this cohort study, medical records of a veterinary referral clinic in Argentina were retrospectively searched for dogs that were hospitalised and required induction of therapeutic coma (TC) with either propofol or sodium thiopentone for the management of SE or RSE of any cause. A logistic regression model was performed to evaluate the association between the type of anaesthetic used and in-hospital mortality adjusting for the type of epilepsy (idiopathic, structural, or reactive). Kaplan-Meier estimated survival curves for the length of hospital stay by the type of anaesthetic drug were compared using the log-rank test (deaths were considered censored events). Cox proportional hazards regression was used to estimate hazard ratios for time to hospital discharge, unadjusted and adjusted for type of epilepsy. RESULTS A total of 24 dogs with SE were included in the study: eight treated with propofol and 16 treated with sodium thiopentone. Four dogs treated with propofol (proportion = 0.50; 95% CI = 0.15-0.84), and eight treated with sodium thiopentone (proportion = 0.50; 95% CI = 0.50-0.74) died during hospitalisation. The median hospitalisation time was 43 (IQR 24-56) hours for dogs that were treated with propofol and 72 (IQR 64-96) hours for dogs that were treated with sodium thiopentone. There was no evidence of a difference in the median duration of TC in dogs treated with propofol (12 (IQR 8-24) hours) or with sodium thiopentone (12 (IQR 7.5-20) hours; p = 0.946). In the logistic regression model, no evidence of association between the anaesthetic protocol for the management of RSE and in-hospital mortality, adjusted for the type of epilepsy, was found (OR 1.09 (95% CI = 0.17-6.87); p = 0.925). Cox regression analysis revealed a difference in the time to hospital discharge, adjusted by the type of epilepsy, between treatment groups (HR = 0.05 (95% CI = 0.01-0.54); p = 0.013). CONCLUSIONS AND CLINICAL RELEVANCE The time spent in hospital before discharge was longer in dogs with RSE treated with sodium thiopentone compared to those treated with propofol. However, as the sample size was very small, the results obtained in the present study should be analysed with caution. Further studies including a greater number of dogs are required.
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Affiliation(s)
- I Espiñeira
- UCICOOP, Buenos Aires, Argentina.,Small Animal Clinic, Faculty of Veterinary Sciences, University of Buenos Aires, Buenos Aires, Argentina
| | - D Alzate
- Canines and Felines Animal Hospital, Medellín, Colombia
| | - J Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - F Pellegrino
- Department of Anatomy, Faculty of Veterinary Sciences, University of Buenos Aires, Buenos Aires, Argentina
| | - M Tunesi
- UCICOOP, Buenos Aires, Argentina
| | - M Jensen
- UCICOOP, Buenos Aires, Argentina
| | - P A Donati
- UCICOOP, Buenos Aires, Argentina.,Department of Anaesthesiology and Algiology, Faculty of Veterinary Sciences, University of Buenos Aires, Buenos Aires, Argentina
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Pence A, Hoyt H, McGrath M, Forman SA, Raines DE. Competitive Interactions Between Propofol and Diazepam: Studies in GABA A Receptors and Zebrafish. J Pharmacol Exp Ther 2022; 383:238-245. [PMID: 36167415 PMCID: PMC9667980 DOI: 10.1124/jpet.122.001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023] Open
Abstract
Although propofol is among the most commonly administered general anesthetics, its mechanism of action is not fully understood. It has been hypothesized that propofol acts via a similar mechanism as (R)-ethyl 1-(1-phenylethyl)-1H-imidazole-5-carboxylate (etomidate) by binding within the GABAA receptor transmembrane receptor domain at the two β +/α - subunit interfaces with resultant positive allosteric modulation. To test this hypothesis, we leveraged the ability of diazepam to bind to those sites and act as a competitive antagonist. We used oocyte-expressed α 1 β 3 γ 2L GABAA receptors to define the actions of diazepam (± flumazenil) on currents activated or potentiated by propofol and a zebrafish activity assay to define the impact of diazepam and flumazenil on propofol-induced anesthesia. We found that diazepam increased the amplitudes of GABAA receptor-mediated currents at nanomolar concentrations but reduced them at micromolar concentrations. The current amplitude changes produced by nanomolar diazepam concentrations were inhibited by flumazenil whereas those produced by micromolar diazepam concentrations were not. Studies of agonist potentiation showed that the micromolar inhibitory action of diazepam was surmountable by high concentrations of propofol and produced a rightward shift in the propofol concentration-response curve characterized by a Schild slope not statistically significantly different from 1, consistent with competition between diazepam and propofol. Although micromolar concentrations of diazepam (plus flumazenil) similarly reduced GABAA receptor currents modulated by propofol and etomidate, it only reduced the anesthetic actions of etomidate. We conclude that while both propofol and etomidate can modulate GABAA receptors by binding to the β +/α - subunit interfacial sites, propofol-induced anesthesia likely involves additional target sites. SIGNIFICANCE STATEMENT: Although the drug combination of diazepam and flumazenil reverses the GABAA receptor positive modulatory actions of both propofol and (R)-ethyl 1-(1-phenylethyl)-1H-imidazole-5-carboxylate (etomidate), it only reverses the in vivo anesthetic actions of etomidate. These results strongly suggest that distinct mechanisms of action account for the anesthetic actions of these two commonly administered anesthetic agents.
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Affiliation(s)
- Andrea Pence
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen Hoyt
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Megan McGrath
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Stuart A Forman
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas E Raines
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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10
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Singh A, Anjankar AP. Propofol-Related Infusion Syndrome: A Clinical Review. Cureus 2022; 14:e30383. [PMID: 36407194 PMCID: PMC9671386 DOI: 10.7759/cureus.30383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023] Open
Abstract
Propofol-related infusion syndrome (PRIS) is a lethal condition characterized by multiple organ system failures. It can occur due to prolonged administration of propofol (an anesthetic) in mechanically intubated patients. The main presenting features of this condition include cardiovascular dysfunction with particular emphasis on impairment of cardiovascular contractility, metabolic acidosis, lactic acidosis, rhabdomyolysis, hyperkalaemia, lipidaemia, hepatomegaly, acute renal failure, and eventually mortality in most cases. The significant risk factors that predispose one to PRIS are: critical illnesses, increased serum catecholamines, steroid therapy, obesity, young age (significantly below three years), depleted carbohydrate stores in the body, increased serum lipids, and most importantly, heavy or extended dosage of propofol. The primary pathophysiology behind PRIS is the disruption of the mitochondrial respiratory chain that causes inhibition of adenosine triphosphate (ATP) synthesis and cellular hypoxia. Further, excess lipolysis of adipose tissue occurs, especially in critically ill patients where the energy source is lipid breakdown instead of carbohydrates. This process generates excess free fatty acids (FFAs) that cannot undergo adequate beta-oxidation. These FFAs contribute to the clinical pathology of PRIS. It requires prompt management as it is a fatal condition. The clinicians must observe the patient's electrocardiogram (ECG), serum creatine kinase, lipase, amylase, lactate, liver enzymes, and myoglobin levels in urine, under propofol sedation. Doctors should immediately stop propofol infusion upon noticing any abnormality in these parameters. The other essentials of management of various manifestations of PRIS will be discussed in this article, along with a detailed explanation of the condition, its risk factors, diagnosis, pathophysiology, and presenting features. This article aims to make clinicians more aware of the occurrence of this syndrome so that better ways to manage and treat this condition can be formulated in the future.
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Affiliation(s)
- Aayushi Singh
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Ashish P Anjankar
- Biochemistry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
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11
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Gong X, Shi S, Zhang D, Gamez G. Quantitative Analysis of Exhaled Breath Collected on Filter Substrates via Low-Temperature Plasma Desorption/Ionization Mass Spectrometry. JOURNAL OF THE AMERICAN SOCIETY FOR MASS SPECTROMETRY 2022; 33:1518-1529. [PMID: 35792104 DOI: 10.1021/jasms.2c00109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Breath analysis has attracted increasing attention in recent years due to its great potential for disease diagnostics at early stages and for clinical drug monitoring. There are several recent examples of successful development of real-time, in vivo quantitative analysis of exhaled breath metabolites via mass spectrometry. On the other hand, current mass spectrometer accessibility limitations restrict point-of-care applications. Here now, an offline method is developed for quantitative analysis of exhaled breath collected on inexpensive filter substrates for direct desorption and ionization by using low-temperature plasma-mass spectrometry (LTP-MS). In particular, different operating conditions of the ionization source were systematically studied to optimize desorption/ionization by using glycerol, a low volatility compound. Applications with respect to propofol, γ-valprolactone, and nicotine analysis in exhaled breath are demonstrated in this study. The effects of several filter substrate properties, including filter material and pore size, on the analyte signal were characterized. Cellulose filter papers performed best with the present analytes. In addition, filters with smaller pores enabled a more efficient sample collection. Furthermore, sample-collection flow rate was determined to have a very significant effect, with slower flow rates yielding the best results. It was also found that filters loaded with sample can be successfully stored in glass vials with no observable sample loss even after 3 days. Limits of detection under optimized conditions are shown to be competitive or significantly better compared with relevant techniques and with additional benefits of cost-efficiency and sample storage capabilities.
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Affiliation(s)
- Xiaoxia Gong
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409-1061, United States
| | - Songyue Shi
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409-1061, United States
| | - Dong Zhang
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409-1061, United States
| | - Gerardo Gamez
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409-1061, United States
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12
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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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13
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Pathak S, Gupta G, Thangavelu L, Singh SK, Dua K, Chellappan DK, Gilhotra RM. Recent update on barbiturate in relation to brain disorder. EXCLI JOURNAL 2021; 20:1028-1032. [PMID: 34267614 PMCID: PMC8278211 DOI: 10.17179/excli2021-3687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/27/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Sachchidanand Pathak
- School of Pharmacy, Suresh Gyan Vihar University, Mahal Road-302017, Jagatpura, Jaipur, India
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Mahal Road-302017, Jagatpura, Jaipur, India
| | - Lakshmi Thangavelu
- Department of Pharmacology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India
| | - Sachin K Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 144411, India
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW 2007, Australia
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Ritu M Gilhotra
- School of Pharmacy, Suresh Gyan Vihar University, Mahal Road-302017, Jagatpura, Jaipur, India
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14
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Woolsey AJ, Nanji JA, Moreau C, Sivapalan S, Bourque SL, Ceccherini-Nelli A, Gragasin FS. Low-dose ketamine does not improve the speed of recovery from depression in electroconvulsive therapy: a randomized controlled trial. ACTA ACUST UNITED AC 2021; 44:6-14. [PMID: 34076068 PMCID: PMC8827368 DOI: 10.1590/1516-4446-2020-1705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is a well-established therapeutic intervention for major depressive disorder. Recent literature has shown that the anesthetic agent ketamine has some antidepressant properties at low doses and may be an alternative therapy for treatment-resistant major depressive disorder. We hypothesized that the use of low-dose ketamine as an anesthetic adjunct in ECT would more rapidly improve depression while maintaining hemodynamic stability than ECT with propofol alone. METHODS Institutional ethics approval was obtained, and the use of ketamine in this study was approved by Health Canada. This is a randomized, double-blinded, placebo-controlled trial that involved ketamine administration at 0.5 mg/kg IV in addition to propofol anesthesia for ECT. The primary outcome was the number of ECT treatments required to achieve a 50% reduction in the Montgomery-Asberg Depression Rating Scale (MADRS). Secondary outcomes included the number of ECT treatments required to achieve a 25% reduction in MADRS score, as well as any differences in the Clinical Global Impression Scale for Severity, hemodynamic variables, and seizure duration. Adverse events were recorded for safety assessment. RESULTS A total of 45 patients completed the study. No difference was found between groups with respect to the primary or secondary outcomes. The ketamine group showed a trend towards a decreased dose of propofol required to achieve adequate anesthesia. No adverse events were reported. CONCLUSION Low-dose ketamine does not improve psychiatric outcomes in the setting of propofol-based anesthesia for ECT. Specifically, ketamine did not reduce the number of ECT sessions necessary to achieve a 50 or 25% reduction in MADRS scores. Reassuringly, the fact that no differences in hemodynamic variables or unexpected adverse events occurred suggests that low-dose ketamine may be safely used in this setting should clinical indications warrant its use. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02579642.
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Affiliation(s)
- Adrianna J Woolsey
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jalal A Nanji
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Chantal Moreau
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Sudhakar Sivapalan
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Stephane L Bourque
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Ferrante S Gragasin
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Sheena Mary Y, Shyma Mary Y, Krátký M, Vinsova J, Baraldi C, Gamberini MC. DFT, SERS-concentration and solvent dependent and docking studies of a bioactive benzenesulfonamide derivative. J Mol Struct 2021. [DOI: 10.1016/j.molstruc.2020.129680] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Khandelwal A, Jangra K, Katikar MD, Durga P, Maheswara Rao GSU. Choosing Neuroanaesthesia as a career: Marching towards new horizons. Indian J Anaesth 2021; 65:35-42. [PMID: 33767501 PMCID: PMC7980245 DOI: 10.4103/ija.ija_1531_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/25/2022] Open
Abstract
Anaesthesiology is an ever-changing science and amongst its sub-specialities, the field of neuroanaesthesia is making rapid strides. The fragility of the brain and spinal cord and the multitude of complexities involved in neurosurgery and interventional neuroradiological procedures demand dedicated training in neuroanaesthesia. With rapid advancement in other neuroscience specialties, neuroanaesthesia too has made outstanding progress, owing to establishment of structured training, publication of high-quality scientific research, and invention of novel medications and monitoring modalities. The opportunities for training in India and abroad and resources to broaden knowledge in neuroanaesthesia have increased over the last two decades. A career in neuroanaesthesia offers a great future for budding anaesthesiologists.
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Affiliation(s)
- Ankur Khandelwal
- Department of Anaesthesia and Critical Care, School of Medical Sciences and Research & Sharda Hospital, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Manisha D Katikar
- Balwant Institute of Neurosurgery & Intensive Trauma Care, Solapur, Maharashtra, India
| | - Padmaja Durga
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - G S Uma Maheswara Rao
- Department of Neuronaesthesia, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Ccny knockout mice display an enhanced susceptibility to kainic acid-induced epilepsy. Pharmacol Res 2020; 160:105100. [DOI: 10.1016/j.phrs.2020.105100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 01/30/2023]
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