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Müller-Wirtz LM, O'Gara B, Gama de Abreu M, Schultz MJ, Beitler JR, Jerath A, Meiser A. Volatile anesthetics for lung- and diaphragm-protective sedation. Crit Care 2024; 28:269. [PMID: 39217380 PMCID: PMC11366159 DOI: 10.1186/s13054-024-05049-0] [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: 06/12/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients.
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Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany
- Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Brian O'Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marcelo Gama de Abreu
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Division of Intensive Care and Resuscitation, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, New York-Presbyterian Hospital and Columbia University, New York, NY, USA
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany.
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2
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Liu M, Chen X, Guo D. Effect of epidural dexmedetomidine in single-dose combined with ropivacaine for cesarean section. BMC Anesthesiol 2024; 24:134. [PMID: 38589819 PMCID: PMC11000346 DOI: 10.1186/s12871-024-02519-4] [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: 12/22/2023] [Accepted: 03/31/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Dexmedetomidine has arousal sedation and analgesic effects. We hypothesize that epidural dexmedetomidine in single-dose combined with ropivacaine improves the experience of parturient undergoing cesarean section under epidural anesthesia. This study is to investigate the effect of 0.5 µg/kg epidural dexmedetomidine combined with epidural anesthesia (EA) in parturients undergoing cesarean section. METHODS A total of 92 parturients were randomly divided into Group R (receiveing epidural ropivacaine alone) Group RD (receiveing epidural ropivacaine with 0.5 µg/kg dexmedetomidine). The primary outcome and second outcome will be intraoperative NRS pain scores and Ramsay Sedation Scale. RESULTS All 92 parturients were included in the analysis. The NRS were significantly lower in Group RD compared to Group R at all observation timepoint (P > 0.05). Higher Ramsay Sedation Scale was found in Group RD compared to Group R (P < 0.001). No parturient has experienced sedation score of 4 and above. No significant difference regarding the incidence of hypotension, bradycardia and nausea or vomiting, Apgar scores and the overall satisfaction with anesthesia was found between Group R and Group RD (P > 0.05). CONCLUSION Epidural dexmedetomidine of 0.5 µg/kg added slightly extra analgesic effect to ropivacaine in EA for cesarean section. The sedation of 0.5 µg/kg epidural dexmedetomidine did not cause mother-baby bonding deficit. Satisfaction with anesthesia wasn't significantly improved by epidural dexmedetomidine of 0.5 µg/kg. No additional side effect allows larger dose of epidural dexmedetomidine attempt. TRIAL REGISTRATION This study was registered at www.chictr.org.cn (ChiCTR2000038853).
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Affiliation(s)
- Minghao Liu
- Department of Anesthesiology, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Geriatric Diseases Institute of Chengdu/Cancer Prevention and Treatment Institute of Chengdu, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Xuezi Chen
- Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Guo
- Department of Anesthesiology, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Geriatric Diseases Institute of Chengdu/Cancer Prevention and Treatment Institute of Chengdu, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China.
- Department of Ultrasound Imaging, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Geriatric Diseases Institute of Chengdu/Cancer Prevention and Treatment Institute of Chengdu, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, 611137, China.
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3
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Iavarone IG, Al-Husinat L, Vélez-Páez JL, Robba C, Silva PL, Rocco PRM, Battaglini D. Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases. J Clin Med 2024; 13:1182. [PMID: 38398494 PMCID: PMC10889521 DOI: 10.3390/jcm13041182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Jorge Luis Vélez-Páez
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Centro de Investigación Clínica, Quito 170129, Ecuador
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
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Quickfall D, Sklar MC, Tomlinson G, Orchanian-Cheff A, Goligher EC. The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis. EClinicalMedicine 2024; 68:102417. [PMID: 38235422 PMCID: PMC10789641 DOI: 10.1016/j.eclinm.2023.102417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation. Methods This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools. Findings Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume. Interpretation Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients. Funding This study did not receive any funding support.
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Affiliation(s)
- Danica Quickfall
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Michael C. Sklar
- Unity Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
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5
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Ye ZH, Li Y, Wu XP, Yu Z, Ma ZR, Hai KR, Ye QS. Efficacy of dexmedetomidine combined with ropivacaine on postoperative analgesia and delirium in elderly patients with total knee arthroplasty. J Robot Surg 2024; 18:35. [PMID: 38231364 DOI: 10.1007/s11701-023-01773-x] [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: 08/28/2023] [Accepted: 12/02/2023] [Indexed: 01/18/2024]
Abstract
This study aimed to investigate the impact of dexmedetomidine combined with ropivacaine on continuous femoral nerve block (CFNB) in postoperative analgesia and delirium in elderly patients with total knee arthroplasty (TKA). A total of 120 patients who undergone TKA were randomly assigned into group D + R (dexmedetomidine combined with ropivacaine) and group R (only ropivacaine), with 60 cases in each group. The pain scores at rest and exercise at 6 h, 12 h, 24 h, and 48 h postoperatively. The occurrence of delirium on Day 1, Day 2, and Day 3 postoperatively were measured, and the sleep quality was evaluated before surgery, the night of surgery, and 24 h postoperatively to observe the occurrence of postoperative complications. The Visual analogu scale (VAS) of group D + R at 12 h, 24 h, and 48 h postoperatively were lower than those of group R in both rest and exercise states. The incidence of postoperative delirium in group D + R was lower than that in group R on Day 1 and Day 2. Pittsburgh sleep quality index (PSQI) scores in group D + R were lower than those in group R. There was no significant difference in postoperative adverse reactions between the two groups. Dexmedetomidine combined with ropivacaine improves postoperative analgesia and sleep quality, and alleviates the occurrence of postoperative delirium in elderly patients with TKA.
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Affiliation(s)
- Zhen-Hai Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China
| | - Yan Li
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China
| | - Xi-Ping Wu
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China
| | - Zhi Yu
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China
| | - Zeng-Rui Ma
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China
| | - Ke-Rong Hai
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China
| | - Qing-Shan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University Affiliated People's Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, 750002, Ningxia, China.
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6
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Longhini F, Simonte R, Vaschetto R, Navalesi P, Cammarota G. Reverse Triggered Breath during Pressure Support Ventilation and Neurally Adjusted Ventilatory Assist at Increasing Propofol Infusion. J Clin Med 2023; 12:4857. [PMID: 37510970 PMCID: PMC10381884 DOI: 10.3390/jcm12144857] [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: 06/29/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Reverse triggered breath (RTB) has been extensively described during assisted-controlled modes of ventilation. We aimed to assess whether RTB occurs during Pressure Support Ventilation (PSV) and Neurally Adjusted Ventilatory Assist (NAVA) at varying depths of propofol sedation. METHODS This is a retrospective analysis of a prospective crossover randomized controlled trial conducted in an Intensive Care Unit (ICU) of a university hospital. Fourteen intubated patients for acute respiratory failure received six trials of 25 minutes randomly applying PSV and NAVA at three different propofol infusions: awake, light, and deep sedation. We assessed the occurrence of RTBs at each protocol step. The incidence level of RTBs was determined through the RTB index, which was calculated by dividing RTBs by the total number of breaths triggered and not triggered. RESULTS RTBs occurred during both PSV and NAVA. The RTB index was greater during PSV than during NAVA at mild (1.5 [0.0; 5.3]% vs. 0.6 [0.0; 1.1]%) and deep (5.9 [0.7; 9.0]% vs. 1.7 [0.9; 3.5]%) sedation. CONCLUSIONS RTB occurs in patients undergoing assisted mechanical ventilation. The level of propofol sedation and the mode of ventilation may influence the incidence of RTBs.
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Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, 88100 Catanzaro, Italy
| | - Rachele Simonte
- Division of Anesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, Hospital S. Maria della Misericordia, University of Perugia, 06123 Perugia, Italy
| | - Rosanna Vaschetto
- Anesthesia and Intensive Care, Department of Translational Medicine, Eastern Piedmont University, 28100 Novara, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Padua Hospital, Department of Medicine-DIMED, University of Padua, 35128 Padova, Italy
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care, Department of Translational Medicine, Eastern Piedmont University, 28100 Novara, Italy
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7
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Poon WH, Ling RR, Yang IX, Luo H, Kofidis T, MacLaren G, Tham C, Teoh KLK, Ramanathan K. Dexmedetomidine for adult cardiac surgery: a systematic review, meta-analysis and trial sequential analysis. Anaesthesia 2023; 78:371-380. [PMID: 36535747 DOI: 10.1111/anae.15947] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
The effects of dexmedetomidine in adults undergoing cardiac surgery are inconsistent. We conducted a systematic review and meta-analysis to analyse the effects of peri-operative dexmedetomidine in adults undergoing cardiac surgery. We searched MEDLINE via Pubmed, EMBASE, Scopus and Cochrane for relevant randomised controlled trials between 1 January 1990 and 1 March 2022. We used the Joanna Briggs Institute methodology checklist to assess study quality and the GRADE approach to certainty of evidence. We assessed the sensitivity of results to false data. We used random-effects meta-analyses to analyse the primary outcomes: durations of intensive care and tracheal intubation. We included 48 trials of 6273 participants. Dexmedetomidine reduced the mean (95%CI) duration of intensive care by 5.0 (2.2-7.7) h, p = 0.001, and tracheal intubation by 1.6 (0.6-2.7) h, p = 0.003. The relative risk (95%CI) for postoperative delirium was 0.58 (0.43-0.78), p = 0.001; 0.76 (0.61-0.95) for atrial fibrillation, p = 0.015; and 0.49 (0.25-0.97) for short-term mortality, p = 0.041. Bradycardia and hypotension were not significantly affected. Trial sequential analysis was consistent with the primary meta-analysis. Adjustments for possible false data reduced the mean (95%CI) reduction in duration of intensive care and tracheal intubation by dexmedetomidine to 3.6 (1.8-5.4) h and 0.8 (0.2-1.4) h, respectively. Binary adjustment for methodological quality at a Joanna Briggs Institute score threshold of 10 did not alter the results significantly. In summary, peri-operative dexmedetomidine reduced the durations of intensive care and tracheal intubation and the incidence of short-term mortality after adult cardiac surgery. The reductions in intensive care stay and tracheal intubation may or may not be considered clinically useful, particularly after adjustment for possible false data.
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Affiliation(s)
- W H Poon
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - R R Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - I X Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - H Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - T Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - G MacLaren
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - C Tham
- Department of Anesthesiology, National University Hospital, Singapore
| | - K L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - K Ramanathan
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
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8
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Gregory AJ, Noss CD, Chun R, Gysel M, Prusinkiewicz C, Webb N, Raymond M, Cogan J, Rousseau-Saine N, Lam W, van Rensburg G, Alli A, de Vasconcelos Papa F. Perioperative Optimization of the Cardiac Surgical Patient. Can J Cardiol 2023; 39:497-514. [PMID: 36746372 DOI: 10.1016/j.cjca.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/06/2023] Open
Abstract
Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.
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Affiliation(s)
- Alexander J Gregory
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Christopher D Noss
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosaleen Chun
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Gysel
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Prusinkiewicz
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Webb
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meggie Raymond
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Gerry van Rensburg
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmad Alli
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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9
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Kassis EB, Beitler JR, Talmor D. Lung-protective sedation: moving toward a new paradigm of precision sedation. Intensive Care Med 2023; 49:91-94. [PMID: 36239747 DOI: 10.1007/s00134-022-06901-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/24/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Ave, MASCO Building, Boston, MA, 02215, USA.
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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10
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Heybati K, Zhou F, Ali S, Deng J, Mohananey D, Villablanca P, Ramakrishna H. Outcomes of dexmedetomidine versus propofol sedation in critically ill adults requiring mechanical ventilation: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2022; 129:515-526. [PMID: 35961815 DOI: 10.1016/j.bja.2022.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/02/2022] [Accepted: 06/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Guidelines have recommended the use of dexmedetomidine or propofol for sedation after cardiac surgery, and propofol monotherapy for other patients. Further outcome data are required for these drugs. METHODS This systematic review and meta-analysis was prospectively registered on PROSPERO. The primary outcome was ICU length of stay. Secondary outcomes included duration of mechanical ventilation, ICU delirium, all-cause mortality, and haemodynamic effects. Intensive care patients were analysed separately as cardiac surgical, medical/noncardiac surgical, those with sepsis, and patients in neurocritical care. Subgroup analyses based on age and dosage were conducted. RESULTS Forty-one trials (N=3948) were included. Dexmedetomidine did not significantly affect ICU length of stay across any ICU patient subtype when compared with propofol, but it reduced the duration of mechanical ventilation (mean difference -0.67 h; 95% confidence interval: -1.31 to -0.03 h; P=0.041; low certainty) and the risk of ICU delirium (risk ratio 0.49; 95% confidence interval: 0.29-0.87; P=0.019; high certainty) across cardiac surgical patients. Dexmedetomidine was also associated with a greater risk of bradycardia across a variety of ICU patients. Subgroup analyses revealed that age might affect the incidence of haemodynamic side-effects and mortality among cardiac surgical and medical/other surgical patients. CONCLUSION Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN, USA
| | - Fangwen Zhou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Saif Ali
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic - Rochester, Rochester, MN, USA
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11
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Murray B, Sikora A, Mock JR, Devlin T, Keats K, Powell R, Bice T. Reverse Triggering: An Introduction to Diagnosis, Management, and Pharmacologic Implications. Front Pharmacol 2022; 13:879011. [PMID: 35814233 PMCID: PMC9256988 DOI: 10.3389/fphar.2022.879011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Reverse triggering is an underdiagnosed form of patient-ventilator asynchrony in which a passive ventilator-delivered breath triggers a neural response resulting in involuntary patient effort and diaphragmatic contraction. Reverse triggering may significantly impact patient outcomes, and the unique physiology underscores critical potential implications for drug-device-patient interactions. The purpose of this review is to summarize what is known of reverse triggering and its pharmacotherapeutic consequences, with a particular focus on describing reported cases, physiology, historical context, epidemiology, and management. The PubMed database was searched for publications that reported patients presenting with reverse triggering. The current body of evidence suggests that deep sedation may predispose patients to episodes of reverse triggering; as such, providers may consider decreasing sedation or modifying ventilator settings in patients exhibiting ventilator asynchrony as an initial measure. Increased clinician awareness and research focus are necessary to understand appropriate management of reverse triggering and its association with patient outcomes.
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Affiliation(s)
- Brian Murray
- University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Andrea Sikora
- College of Pharmacy, University of Georgia, Athens, GA, United States
- *Correspondence: Andrea Sikora,
| | - Jason R. Mock
- University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Thomas Devlin
- University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Kelli Keats
- Augusta University Medical Center, Augusta, GA, United States
| | - Rebecca Powell
- College of Pharmacy, University of Georgia, Athens, GA, United States
| | - Thomas Bice
- Novant Health, Winston-Salem, NC, United States
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12
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Lewis K, Alshamsi F, Carayannopoulos KL, Granholm A, Piticaru J, Al Duhailib Z, Chaudhuri D, Spatafora L, Yuan Y, Centofanti J, Spence J, Rochwerg B, Perri D, Needham DM, Holbrook A, Devlin JW, Nishida O, Honarmand K, Ergan B, Khorochkov E, Pandharipande P, Alshahrani M, Karachi T, Soth M, Shehabi Y, Møller MH, Alhazzani W. Dexmedetomidine vs other sedatives in critically ill mechanically ventilated adults: a systematic review and meta-analysis of randomized trials. Intensive Care Med 2022; 48:811-840. [PMID: 35648198 DOI: 10.1007/s00134-022-06712-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
Conventional gabaminergic sedatives such as benzodiazepines and propofol are commonly used in mechanically ventilated patients in the intensive care unit (ICU). Dexmedetomidine is an alternative sedative that may achieve lighter sedation, reduce delirium, and provide analgesia. Our objective was to perform a comprehensive systematic review summarizing the large body of evidence, determining if dexmedetomidine reduces delirium compared to conventional sedatives. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov and the WHO ICTRP from inception to October 2021. Independent pairs of reviewers identified randomized clinical trials comparing dexmedetomidine to other sedatives for mechanically ventilated adults in the ICU. We conducted meta-analyses using random-effects models. The results were reported as relative risks (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs). In total, 77 randomized trials (n = 11,997) were included. Compared to other sedatives, dexmedetomidine reduced the risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty), the duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71; low certainty), and ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty). Dexmedetomidine use increased the risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty). In mechanically ventilated adults, the use of dexmedetomidine compared to other sedatives, resulted in a lower risk of delirium, and a modest reduction in duration of mechanical ventilation and ICU stay, but increased the risks of bradycardia and hypotension.
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Affiliation(s)
- Kimberley Lewis
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Kallirroi Laiya Carayannopoulos
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joshua Piticaru
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Zainab Al Duhailib
- Department of Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Dipayan Chaudhuri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Laura Spatafora
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Canada
| | - John Centofanti
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Jessica Spence
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada.,Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dan Perri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, USA.,Armstrong Institute for Patient Safety and Quality, John Hopkins University, Baltimore, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - John W Devlin
- School of Pharmacy, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Northeastern University, Boston, MA, USA
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Kimia Honarmand
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Canada
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Eugenia Khorochkov
- Department of Medical Imaging, Memorial University of Newfoundland, St. John's, Canada
| | - Pratik Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, College of Medicine, Imam Abdulrahman Ben Faisal University, Al Khobar, Kingdom of Saudi Arabia
| | - Tim Karachi
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Mark Soth
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yahya Shehabi
- Department of Intensive Care, Monash Health School of Clinical Sciences, The School of Clinical Medicine, University of New South Wales, Clayton, VIC 3168, Randwick, 2031, Australia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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13
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Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation. Crit Care Med 2021; 49:2090-2101. [PMID: 34115638 PMCID: PMC8602777 DOI: 10.1097/ccm.0000000000005113] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, deep sedation is often assumed to induce "respirolysis," that is, lyse spontaneous respiratory effort, whereas light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure. DESIGN Prospective cohort study. SETTING Patients were enrolled during 2 month-long periods in 2016-2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital. PATIENTS Eligible patients were critically ill adults receiving invasive ventilation initiated no more than 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded. INTERVENTIONS Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond Agitation-Sedation Scale. Analyses evaluated the association of P0.1 with Richmond Agitation-Sedation Scale (primary outcome) and ventilator-free days. MEASUREMENTS AND MAIN RESULTS Fifty-six patients undergoing 197 bedside evaluations across five ICUs were included. P0.1 ranged between 0 and 13.3 cm H2O (median [interquartile range], 0.1 cm H2O [0.0-1.3 cm H2O]). P0.1 was not significantly correlated with the Richmond Agitation-Sedation Scale (RSpearman, 0.02; 95% CI, -0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range less than 0.2, 0.2-1.0, and greater than 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio, 0.78; 95% CI, 0.65-0.93; p < 0.01) or highest tercile (incidence rate ratio, 0.58; 95% CI, 0.48-0.70; p < 0.01). CONCLUSIONS Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth.
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14
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Kyo M, Shimatani T, Hosokawa K, Taito S, Kataoka Y, Ohshimo S, Shime N. Patient-ventilator asynchrony, impact on clinical outcomes and effectiveness of interventions: a systematic review and meta-analysis. J Intensive Care 2021; 9:50. [PMID: 34399855 PMCID: PMC8365272 DOI: 10.1186/s40560-021-00565-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/03/2021] [Indexed: 12/16/2022] Open
Abstract
Background Patient–ventilator asynchrony (PVA) is a common problem in patients undergoing invasive mechanical ventilation (MV) in the intensive care unit (ICU), and may accelerate lung injury and diaphragm mis-contraction. The impact of PVA on clinical outcomes has not been systematically evaluated. Effective interventions (except for closed-loop ventilation) for reducing PVA are not well established. Methods We performed a systematic review and meta-analysis to investigate the impact of PVA on clinical outcomes in patients undergoing MV (Part A) and the effectiveness of interventions for patients undergoing MV except for closed-loop ventilation (Part B). We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ClinicalTrials.gov, and WHO-ICTRP until August 2020. In Part A, we defined asynchrony index (AI) ≥ 10 or ineffective triggering index (ITI) ≥ 10 as high PVA. We compared patients having high PVA with those having low PVA. Results Eight studies in Part A and eight trials in Part B fulfilled the eligibility criteria. In Part A, five studies were related to the AI and three studies were related to the ITI. High PVA may be associated with longer duration of mechanical ventilation (mean difference, 5.16 days; 95% confidence interval [CI], 2.38 to 7.94; n = 8; certainty of evidence [CoE], low), higher ICU mortality (odds ratio [OR], 2.73; 95% CI 1.76 to 4.24; n = 6; CoE, low), and higher hospital mortality (OR, 1.94; 95% CI 1.14 to 3.30; n = 5; CoE, low). In Part B, interventions involving MV mode, tidal volume, and pressure-support level were associated with reduced PVA. Sedation protocol, sedation depth, and sedation with dexmedetomidine rather than propofol were also associated with reduced PVA. Conclusions PVA may be associated with longer MV duration, higher ICU mortality, and higher hospital mortality. Physicians may consider monitoring PVA and adjusting ventilator settings and sedatives to reduce PVA. Further studies with adjustment for confounding factors are warranted to determine the impact of PVA on clinical outcomes. Trial registration protocols.io (URL: https://www.protocols.io/view/the-impact-of-patient-ventilator-asynchrony-in-adu-bsqtndwn, 08/27/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00565-5.
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Affiliation(s)
- Michihito Kyo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
| | - Koji Hosokawa
- Department of Anesthesiology and Reanimatology, Faculty of Medicine Sciences, University of Fukui, 23-3 Eiheijicho, Yoshidagun, Fukui, 910-1193, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan.,Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Tanaka Asukai-cho 89, Sakyo-ku, Kyoto, 606-8226, Japan.,Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
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15
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Affiliation(s)
- Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.
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16
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The effects of sedatives, neuromuscular blocking agents and opioids on ventilator-associated events. Eur J Anaesthesiol 2021; 37:67-69. [PMID: 31913933 DOI: 10.1097/eja.0000000000001132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Hu AM, Shan ZM, Zhang ZJ, Li HP. Comparative Efficacy of Fentanyl and Morphine in Patients with or At Risk for Acute Respiratory Distress Syndrome: A Propensity Score-Matched Cohort Study. Drugs R D 2021; 21:149-155. [PMID: 33876394 PMCID: PMC8054845 DOI: 10.1007/s40268-021-00338-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction Opioids are potent painkillers but can have severe adverse effects in the intensive care unit (ICU). The aim of this study was to compare the outcomes of fentanyl and morphine use among patients at risk for and with acute respiratory distress syndrome (ARDS). Methods We developed a dataset of real-world data to enable the comparison of the effectiveness and safety of opioids and the associated outcomes from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC)-III database and the eICU Collaborative Research Database. Patients who were admitted to the ICU with a diagnosis of or at risk for ARDS and received mechanical ventilation for at least 12 h were included. Patients were enrolled sequentially into one of six groups in three cohorts: treated with fentanyl or not; treated with morphine or not; and treated with fentanyl or morphine. Propensity score matching and multivariable analyses were performed. Results Fentanyl was associated with higher in-hospital mortality in the propensity score-matched model but not in the linear regression model. The use of morphine was associated with a higher in-hospital mortality in both models. Both fentanyl and morphine were associated with longer duration of mechanical ventilation, ICU stay, and hospitalization and a decreased likelihood of being discharged home in both models. Notably, compared with morphine, fentanyl was associated with a lower mortality and an increased likelihood of being discharged home. Conclusions Both fentanyl and morphine were independent risk factors for worse outcomes in patients with or at risk for ARDS. Compared with morphine, fentanyl may be preferred in these patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40268-021-00338-3.
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Affiliation(s)
- An-Min Hu
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China
| | - Zhi-Ming Shan
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China
| | - Zhong-Jun Zhang
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China
| | - Hui-Ping Li
- Department of Respiratory and Critical Care Medicine, Shenzhen People's Hospital, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China.
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18
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Aoki Y, Niwa T, Shiko Y, Kawasaki Y, Mimuro S, Doi M, Nakajima Y. Remifentanil provides an increased proportion of time under light sedation than fentanyl when combined with dexmedetomidine for mechanical ventilation. J Int Med Res 2021; 49:3000605211002683. [PMID: 33745360 PMCID: PMC7989131 DOI: 10.1177/03000605211002683] [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] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the effects of remifentanil versus fentanyl during light sedation with dexmedetomidine in adults receiving mechanical ventilation (MV) in the intensive care unit. Methods In this retrospective cohort study, we compared the use of remifentanil versus fentanyl in adults receiving MV with dexmedetomidine sedation. The primary outcome was the proportion of time under light sedation (Richmond Agitation–Sedation Scale score between −1 and 0) during MV. Results We included 94 patients and classified 58 into the remifentanil group and 36 into the fentanyl group. The mean proportion of time under light sedation during MV was 66.6% ± 18.5% in the remifentanil group and 39.9% ± 27.3% in the fentanyl group. In the multivariate analysis with control for confounding factors, patients in the remifentanil group showed a significantly higher proportion of time under light sedation than patients in the fentanyl group (mean difference: 24.3 percentage points; 95% confidence interval: 12.9–35.8). Conclusions Remifentanil use might increase the proportion of time under light sedation in patients receiving MV compared with fentanyl administration.
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Affiliation(s)
- Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Takuya Niwa
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Centre, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Soichiro Mimuro
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
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19
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Lin TY, Huang YC, Kuo CH, Chung FT, Lin YT, Wang TY, Lin SM, Lo YL. Dexmedetomidine sedation for endobronchial ultrasound-guided transbronchial needle aspiration, a randomised controlled trial. ERJ Open Res 2021; 6:00064-2020. [PMID: 33693047 PMCID: PMC7927785 DOI: 10.1183/23120541.00064-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 09/04/2020] [Indexed: 12/25/2022] Open
Abstract
Background and aim Appropriate sedation is important to the success of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine is a sedative agent that operates via the α2 adrenergic agonist, which provides sleep-like sedation with little respiratory suppression. This study compared the efficacy and safety of dexmedetomidine sedation with propofol in cases of EBUS-TBNA. Methods Patients requiring EBUS-TBNA were randomly assigned dexmedetomidine sedation (D, n=25) or propofol sedation (P, n=25). Vital signs, diagnostic yield and the bispectral index (BIS) were recorded throughout the bronchoscopic procedure and recovery period. The tolerance and cooperation of the patients were evaluated using questionnaires. Measurements and results The lowest mean arterial blood pressure in group D (79.2±9.9 versus 72.5±12.9 mmHg, p=0.049) exceeded that in group P, the lowest heart rate was lower (60.9±10.2 versus 71.4±11.8 beats·min−1, p=0.006) and the mean BIS during sedation was significantly higher (84.1±8.3 versus 73.6±5.7, p<0.001). Patients in group D were more likely to report perceiving procedure-related symptoms and express an unwillingness to undergo the bronchoscopy again, if indicated (41.1 versus 83.3%, p=0.007). One subject in group D aborted EBUS-TBNA due to intolerance. Many of the variables in the two groups were similar, including the proportion of hypoxaemic events, recovery times, patient cooperation and diagnostic yield. Conclusions The effects of dexmedetomidine on haemodynamics were in line with its pharmacodynamic features. Patients who received dexmedetomidine were more likely than those who received propofol to perceive the procedures. Overall, dexmedetomidine did not prove inferior to propofol sedation in terms of patient cooperation or diagnostic yield. Compared to propofol sedation for EBUS-TBNA, dexmedetomidine provided patients lighter sedation with lower heart rates and less decrease in blood pressure. The recovery times, hypoxaemia, cooperation and diagnostic yield in the two groups were similar.https://bit.ly/33qgEj3
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Affiliation(s)
- Ting-Yu Lin
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
| | - Yu-Chen Huang
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
| | - Chih-Hsi Kuo
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
| | - Fu-Tsai Chung
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
| | - Yu-Ting Lin
- Dept of Anesthesiology, Taipei-Veterans General Hospital, Taipei, Taiwan
| | - Tsai-Yu Wang
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
| | - Shu-Min Lin
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
| | - Yu-Lun Lo
- Dept of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan
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20
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Donato M, Carini FC, Meschini MJ, Saubidet IL, Goldberg A, Sarubio MG, Olmos D, Reina R. Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome. Rev Bras Ter Intensiva 2021; 33:48-67. [PMID: 33886853 PMCID: PMC8075332 DOI: 10.5935/0103-507x.20210005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. METHODS A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. RESULTS Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. DISCUSSION Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.
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Affiliation(s)
- Manuel Donato
- Hospital General de Agudos José María Penna - Buenos Aires, Argentina
- Ministerio de Salud de la Nación Argentina - Buenos Aires, Argentina
- Instituto de Efectividad Clínica y Sanitaria - Buenos Aires, Argentina
| | | | | | - Ignacio López Saubidet
- Centro de Educación Médica e Investigaciones Clínicas “Norberto Quirno” - Buenos Aires, Argentina
| | - Adela Goldberg
- Sanatorio de La Trinidad Mitre - Buenos Aires, Argentina
| | | | - Daniela Olmos
- Hospital Municipal Príncipe de Asturias - Córdoba, Argentina
| | - Rosa Reina
- Hospital Interzonal General de Agudos General San Martín - La Plata, Argentina
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21
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Luo XY, He X, Zhou YM, Wang YM, Chen JR, Chen GQ, Li HL, Yang YL, Zhang L, Zhou JX. Patient-ventilator asynchrony in acute brain-injured patients: a prospective observational study. Ann Intensive Care 2020; 10:144. [PMID: 33074406 PMCID: PMC7570406 DOI: 10.1186/s13613-020-00763-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/14/2020] [Indexed: 12/27/2022] Open
Abstract
Background Patient–ventilator asynchrony is common in mechanically ventilated patients and may be related to adverse outcomes. Few studies have reported the occurrence of asynchrony in brain-injured patients. We aimed to investigate the prevalence, type and severity of patient–ventilator asynchrony in mechanically ventilated patients with brain injury. Methods This prospective observational study enrolled acute brain-injured patients undergoing mechanical ventilation. Esophageal pressure monitoring was established after enrollment. Flow, airway pressure, and esophageal pressure–time waveforms were recorded for a 15-min interval, four times daily for 3 days, for visually detecting asynchrony by offline analysis. At the end of each dataset recording, the respiratory drive was determined by the airway occlusion maneuver. The asynchrony index was calculated to represent the severity. The relationship between the prevalence and the severity of asynchrony with ventilatory modes and settings, respiratory drive, and analgesia and sedation were determined. Association of severe patient–ventilator asynchrony, which was defined as an asynchrony index ≥ 10%, with clinical outcomes was analyzed. Results In 100 enrolled patients, a total of 1076 15-min waveform datasets covering 330,292 breaths were collected, in which 70,156 (38%) asynchronous breaths were detected. Asynchrony occurred in 96% of patients with the median (interquartile range) asynchrony index of 12.4% (4.3%–26.4%). The most prevalent type was ineffective triggering. No significant difference was found in either prevalence or asynchrony index among different classifications of brain injury (p > 0.05). The prevalence of asynchrony was significantly lower during pressure control/assist ventilation than during other ventilatory modes (p < 0.05). Compared to the datasets without asynchrony, the airway occlusion pressure was significantly lower in datasets with ineffective triggering (p < 0.001). The asynchrony index was significantly higher during the combined use of opioids and sedatives (p < 0.001). Significantly longer duration of ventilation and hospital length of stay after the inclusion were found in patients with severe ineffective triggering (p < 0.05). Conclusions Patient–ventilator asynchrony is common in brain-injured patients. The most prevalent type is ineffective triggering and its severity is likely related to a long duration of ventilation and hospital stay. Prevalence and severity of asynchrony are associated with ventilatory modes, respiratory drive and analgesia/sedation strategy, suggesting treatment adjustment in this particular population. Trial registration The study has been registered on 4 July 2017 in ClinicalTrials.gov (NCT03212482) (https://clinicaltrials.gov/ct2/show/NCT03212482).
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Affiliation(s)
- Xu-Ying Luo
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Jing-Ran Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, No. 119, South 4th Ring West Road, Beijing, 100070, China.
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22
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Shehabi Y, Al-Bassam W, Pakavakis A, Murfin B, Howe B. Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm. Semin Respir Crit Care Med 2020; 42:98-111. [PMID: 32957139 DOI: 10.1055/s-0040-1716736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.
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Affiliation(s)
- Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia.,Prince of Wales Clinical School of Medicine, University of New South Wales, Randwick, New South Wales, Sydney, Australia
| | - Wisam Al-Bassam
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Adrian Pakavakis
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Brendan Murfin
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Belinda Howe
- The Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
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Longhini F, Bruni A, Garofalo E, Ronco C, Gusmano A, Cammarota G, Pasin L, Frigerio P, Chiumello D, Navalesi P. Chest physiotherapy improves lung aeration in hypersecretive critically ill patients: a pilot randomized physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:479. [PMID: 32746877 PMCID: PMC7396943 DOI: 10.1186/s13054-020-03198-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
Abstract
Background Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) benefit of different combinations of chest physiotherapy techniques, to improve mucus removal. To date, little is known about the clearance effects of oscillating devices on patients with acute respiratory failure undergoing iMV. This study aimed to assess (1) the effects of high-frequency chest wall oscillation (HFCWO) on lung aeration and ventilation distribution, as assessed by electrical impedance tomography (EIT), and (2) the effect of the association of HFCWO with recruitment manoeuvres (RM). Methods Sixty critically ill patients, 30 classified as normosecretive and 30 as hypersecretive, who received ≥ 48 h of iMV, underwent HFCWO; patients from both subgroups were randomized to receive RM or not, according to two separated randomization sequences. We therefore obtained four arms of 15 patients each. After baseline record (T0), HFCWO was applied for 10 min. At the end of the treatment (T1) or after 1 (T2) and 3 h (T3), EIT data were recorded. At the beginning of each step, closed tracheobronchial suctioning was performed. In the RM subgroup, tracheobronchial suctioning was followed by application of 30 cmH2O to the patient’s airway for 30 s. At each step, we assessed the change in end-expiratory lung impedance (ΔEELI) and in tidal impedance variation (ΔTIV), and the center of gravity (COG) through EIT. We also analysed arterial blood gases (ABGs). Results ΔTIV and COG did not differ between normosecretive and hypersecretive patients. Compared to T0, ΔEELI significantly increased in hypersecretive patients at T2 and T3, irrespective of the RM; on the contrary, no differences were observed in normosecretive patients. No differences of ABGs were recorded. Conclusions In hypersecretive patients, HFCWO significantly improved aeration of the dorsal lung region, without affecting ABGs. The application of RM did not provide any further improvements. Trial registration Prospectively registered at the Australian New Zealand Clinical Trial Registry (www.anzctr.org.au; number of registration: ACTRN12615001257550; date of registration: 17th November 2015).
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Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Chiara Ronco
- Anesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy
| | - Andrea Gusmano
- Anesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy
| | - Gianmaria Cammarota
- Department of Anesthesia and Intensive Care, "Maggiore della carità" University Hospital, Novara, Italy
| | - Laura Pasin
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | | | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Paolo Navalesi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy. .,Dipartimento di Medicina-DIMED, Università degli Studi di Padova, Via Giustiniani, 2 -, 35128, Padova, Italy.
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24
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Damiani LF, Bruhn A, Retamal J, Bugedo G. Patient-ventilator dyssynchronies: Are they all the same? A clinical classification to guide actions. J Crit Care 2020; 60:50-57. [PMID: 32739760 DOI: 10.1016/j.jcrc.2020.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/06/2020] [Accepted: 07/13/2020] [Indexed: 11/18/2022]
Abstract
Patient ventilatory dyssynchrony (PVD) is a mismatch between the respiratory drive of the patient and ventilatory assistance. It is a complex event seen in almost all ventilated patients and at any ventilator mode, with uncertain significance and prognosis. Due to its different pathophysiological mechanisms, there is still not consensual classification to guide us in selecting the best treatment. In the present review we aimed to summarize some clinical data on PVD, and to propose a clinical classification based on the type of PVD, from potentially innocuous to clearly harmful PVD, which could help clinicians in the decision-making process from adjusting ventilator settings to deeply sedate or paralyze the patient. Clearly, further studies are needed addressing risk factors, physiologic mechanisms and direct consequences of PVD in order to help clinicians to design effective and proven strategies at the bedside.
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Affiliation(s)
- L Felipe Damiani
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile; Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
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25
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Martos-Benítez FD, Domínguez-Valdés Y, Burgos-Aragüez D, Larrondo-Muguercia H, Orama-Requejo V, Lara-Ponce KX, González-Martínez I. Outcomes of ventilatory asynchrony in patients with inspiratory effort. Rev Bras Ter Intensiva 2020; 32:284-294. [PMID: 32667451 PMCID: PMC7405741 DOI: 10.5935/0103-507x.20200045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/04/2020] [Indexed: 01/21/2023] Open
Abstract
Objective To identify the relationship of patient-ventilator asynchrony with the level of sedation and hemogasometric and clinical results. Methods This was a prospective study of 122 patients admitted to the intensive care unit who underwent > 24 hours of invasive mechanical ventilation with inspiratory effort. In the first 7 days of ventilation, patient-ventilator asynchrony was evaluated daily for 30 minutes. Severe patient-ventilator asynchrony was defined as an asynchrony index > 10%. Results A total of 339,652 respiratory cycles were evaluated in 504 observations. The mean asynchrony index was 37.8% (standard deviation 14.1 - 61.5%). The prevalence of severe patient-ventilator asynchrony was 46.6%. The most frequent patient-ventilator asynchronies were ineffective trigger (13.3%), autotrigger (15.3%), insufficient flow (13.5%), and delayed cycling (13.7%). Severe patient-ventilator asynchrony was related to the level of sedation (ineffective trigger: p = 0.020; insufficient flow: p = 0.016; premature cycling: p = 0.023) and the use of midazolam (p = 0.020). Severe patient-ventilator asynchrony was also associated with hemogasometric changes. The persistence of severe patient-ventilator asynchrony was an independent risk factor for failure of the spontaneous breathing test, ventilation time, ventilator-associated pneumonia, organ dysfunction, mortality in the intensive care unit, and length of stay in the intensive care unit. Conclusion Patient-ventilator asynchrony is a frequent disorder in critically ill patients with inspiratory effort. The patient’s interaction with the ventilator should be optimized to improve hemogasometric parameters and clinical results. Further studies are required to confirm these results.
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Affiliation(s)
- Frank Daniel Martos-Benítez
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Yairén Domínguez-Valdés
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Dailé Burgos-Aragüez
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Hilev Larrondo-Muguercia
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Versis Orama-Requejo
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Karla Ximena Lara-Ponce
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Iraida González-Martínez
- Unidad de Cuidados Intensivos, Hospital Universitario "Dr. Miguel Enríquez", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
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26
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Buckley MS, Smithburger PL, Wong A, Fraser GL, Reade MC, Klein-Fedyshin M, Ardiles T, Kane-Gill SL. Dexmedetomidine for Facilitating Mechanical Ventilation Extubation in Difficult-to-Wean ICU Patients: Systematic Review and Meta-Analysis of Clinical Trials. J Intensive Care Med 2020; 36:925-936. [PMID: 32627672 DOI: 10.1177/0885066620937673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Agitation and delirium are common in mechanically ventilated adult intensive care unit (ICU) patients and may contribute to delayed extubation times. Difficult-to-wean ICU patients have been associated with an increased risk of longer ICU length of stays and mortality. The purpose of this systematic review and meta-analysis is to evaluate the evidence of dexmedetomidine facilitating successful mechanical ventilation extubation in difficult-to-wean ICU patients and clinical outcomes. METHODS A literature search was conducted using MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Cochrane Central Register of Controlled Trials, Clinical Trial Registries, and the Health Technology Assessment Database from inception to December 5, 2019. Randomized controlled trials evaluating dexmedetomidine with the intended purpose to facilitate mechanical ventilation liberation in adult ICU patients (≥18 years) experiencing extubation failure were included. The primary outcome of time to extubation was evaluated using the weighted mean difference (WMD), with a random effects model. Secondary analyses included hospital and ICU length of stay, in-hospital mortality, hypotension, and bradycardia. RESULTS A total of 6 trials (n = 306 patients) were included. Dexmedetomidine significantly reduced the time to extubation (WMD: -11.61 hours, 95% CI: -16.5 to -6.7, P = .005) and ICU length of stay (WMD: -3.04 days; 95% CI: -4.66 to -1.43). Hypotension risk was increased with dexmedetomidine (risk ratio [RR]: 1.62, 95% CI: 1.05-2.51), but there was no difference in bradycardia risk (RR: 3.98, 95% CI: 0.70-22.78). No differences were observed in mortality rates (RR: 1.30, 95% CI: 0.45-3.75) or hospital length of stay (WMD: -2.67 days; 95% CI: -7.73 to 2.39). CONCLUSIONS Dexmedetomidine was associated with a significant reduction in the time to extubation and shorter ICU stay in difficult-to-wean ICU patients. Although hypotension risk was increased with dexmedetomidine, no differences in other clinical outcomes were observed.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, 22386Banner-University Medical Center Phoenix, Phoenix, AZ, USA
| | - Pamela L Smithburger
- Department of Pharmacy and Therapeutics, 15523University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Adrian Wong
- Department of Pharmacy Practice, 1825MCPHS University, Boston, MA, USA
| | - Gilles L Fraser
- Department of Medicine, 12261Tufts University School of Medicine, Boston, MA, USA.,Maine Medical Center, Portland, ME, USA
| | - Michael C Reade
- University of Queensland, 3883Royal Brisbane and Women's Hospital, Queensland, Australia
| | | | - Thomas Ardiles
- 42283University of Arizona Phoenix School of Medicine, Phoenix, AZ, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Critical Care Medicine, Clinical Translational Science Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.,Department of Pharmacy, 199716University Pittsburgh Medical Center, Pittsburgh, PA, USA
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27
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Sun S, Wang J, Wang J, Wang F, Xia H, Yao S. Fetal and Maternal Responses to Dexmedetomidine Intrathecal Application During Cesarean Section: A Meta-Analysis. Med Sci Monit 2020; 26:e918523. [PMID: 31995551 PMCID: PMC7001518 DOI: 10.12659/msm.918523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Intrathecal dexmedetomidine (DEX) can improve the blockade of spinal anesthesia, but there is no clear conclusion on whether it has an effect on the fetus during cesarean section. Our meta-analysis evaluated the safety and efficacy of intrathecal DEX in cesarean delivery. Material/Methods We searched Cochrane, Embase, PubMed, and CBM for eligible studies, and used the Revised Cochrane Risk of Bias Tool (RoB 2.0) to assess the risk of bias of each study. RevMan was used for statistical analyses. We have registered this meta-analysis on PROSPERO (CRD42019120995). Results The meta-analysis included 10 RCTs, but only 5 were prospectively registered. The results of preregistration studies, including the 1- or 5-min Apgar score (mean difference [MD], −0.03; 95% confidence intervals [CI], −0.16 to 0.10; P=0.64 or MD, 0.00; 95% CI, −0.09 to 0.09; P=1), the umbilical arterial oxygen or carbon dioxide partial pressure (MD, 0.90; 95% CI, −4.92 to 6.72; P=0.76 or MD, 1.20; 95% CI, −2.06 to 4.46; P=0.47), and the cord blood pH (MD, −0.01; 95% CI, −0.05 to 0.03; P=0.72), showed that intrathecal DEX had no significant difference in neonatal outcomes compared with placebo. In maternal outcomes, intrathecal DEX significantly prolonged postoperative pain-free period and reduced the incidence of postoperative shivering, which did not increase spinal anesthesia-associated adverse effects. Conclusions Intrathecal DEX is safe for the fetus during cesarean section and can improve the blockade effects of spinal anesthesia on puerperae.
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Affiliation(s)
- ShuJun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - JiaMei Wang
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning, China (mainland)
| | - JingXu Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - FuQuan Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - HaiFa Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - ShangLong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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28
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Ge H, Duan K, Wang J, Jiang L, Zhang L, Zhou Y, Fang L, Heunks LMA, Pan Q, Zhang Z. Risk Factors for Patient-Ventilator Asynchrony and Its Impact on Clinical Outcomes: Analytics Based on Deep Learning Algorithm. Front Med (Lausanne) 2020; 7:597406. [PMID: 33324663 PMCID: PMC7724969 DOI: 10.3389/fmed.2020.597406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/16/2020] [Indexed: 02/05/2023] Open
Abstract
Background and objectives: Patient-ventilator asynchronies (PVAs) are common in mechanically ventilated patients. However, the epidemiology of PVAs and its impact on clinical outcome remains controversial. The current study aims to evaluate the epidemiology and risk factors of PVAs and their impact on clinical outcomes using big data analytics. Methods: The study was conducted in a tertiary care hospital; all patients with mechanical ventilation from June to December 2019 were included for analysis. Negative binomial regression and distributed lag non-linear models (DLNM) were used to explore risk factors for PVAs. PVAs were included as a time-varying covariate into Cox regression models to investigate its influence on the hazard of mortality and ventilator-associated events (VAEs). Results: A total of 146 patients involving 50,124 h and 51,451,138 respiratory cycles were analyzed. The overall mortality rate was 15.6%. Double triggering was less likely to occur during day hours (RR: 0.88; 95% CI: 0.85-0.90; p < 0.001) and occurred most frequently in pressure control ventilation (PCV) mode (median: 3; IQR: 1-9 per hour). Ineffective effort was more likely to occur during day time (RR: 1.09; 95% CI: 1.05-1.13; p < 0.001), and occurred most frequently in PSV mode (median: 8; IQR: 2-29 per hour). The effect of sedatives and analgesics showed temporal patterns in DLNM. PVAs were not associated mortality and VAE in Cox regression models with time-varying covariates. Conclusions: Our study showed that counts of PVAs were significantly influenced by time of the day, ventilation mode, ventilation settings (e.g., tidal volume and plateau pressure), and sedatives and analgesics. However, PVAs were not associated with the hazard of VAE or mortality after adjusting for protective ventilation strategies such as tidal volume, plateau pressure, and positive end expiratory pressure (PEEP).
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Affiliation(s)
- Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Regional Medical Center for National Institute of Respiratory Diseases, Bethesda, MD, United States
| | - Kailiang Duan
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jimei Wang
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liuqing Jiang
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lingwei Zhang
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Yuhan Zhou
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Luping Fang
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Leo M. A. Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Qing Pan
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
- Qing Pan
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Zhongheng Zhang
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Ge H, Pan Q, Zhou Y, Xu P, Zhang L, Zhang J, Yi J, Yang C, Zhou Y, Liu L, Zhang Z. Lung Mechanics of Mechanically Ventilated Patients With COVID-19: Analytics With High-Granularity Ventilator Waveform Data. Front Med (Lausanne) 2020; 7:541. [PMID: 32974375 PMCID: PMC7472529 DOI: 10.3389/fmed.2020.00541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Lung mechanics during invasive mechanical ventilation (IMV) for both prognostic and therapeutic implications; however, the full trajectory lung mechanics has never been described for novel coronavirus disease 2019 (COVID-19) patients requiring IMV. The study aimed to describe the full trajectory of lung mechanics of mechanically ventilated COVID-19 patients. The clinical and ventilator setting that can influence patient-ventilator asynchrony (PVA) and compliance were explored. Post-extubation spirometry test was performed to assess the pulmonary function after COVID-19 induced ARDS. Methods: This was a retrospective study conducted in a tertiary care hospital. All patients with IMV due to COVID-19 induced ARDS were included. High-granularity ventilator waveforms were analyzed with deep learning algorithm to obtain PVAs. Asynchrony index (AI) was calculated as the number of asynchronous events divided by the number of ventilator cycles and wasted efforts. Mortality was recorded as the vital status on hospital discharge. Results: A total of 3,923,450 respiratory cycles in 2,778 h were analyzed (average: 24 cycles/min) for seven patients. Higher plateau pressure (Coefficient: -0.90; 95% CI: -1.02 to -0.78) and neuromuscular blockades (Coefficient: -6.54; 95% CI: -9.92 to -3.16) were associated with lower AI. Survivors showed increasing compliance over time, whereas non-survivors showed persistently low compliance. Recruitment maneuver was not able to improve lung compliance. Patients were on supine position in 1,422 h (51%), followed by prone positioning (499 h, 18%), left positioning (453 h, 16%), and right positioning (404 h, 15%). As compared with supine positioning, prone positioning was associated with 2.31 ml/cmH2O (95% CI: 1.75 to 2.86; p < 0.001) increase in lung compliance. Spirometry tests showed that pulmonary functions were reduced to one third of the predicted values after extubation. Conclusions: The study for the first time described full trajectory of lung mechanics of patients with COVID-19. The result showed that prone positioning was associated with improved compliance; higher plateau pressure and use of neuromuscular blockades were associated with lower risk of AI.
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Affiliation(s)
- Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Pan
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Yong Zhou
- Department of Pulmonary Disease, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peifeng Xu
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lingwei Zhang
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Junli Zhang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Yi
- Thoracic Cardiovascular Surgery, Jingmen First People's Hospital, Jingmen, China
| | - Changming Yang
- Department of Anesthesiology, The First People's of Hospital of Jingmen City, Jingmen, China
| | - Yuhan Zhou
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Limin Liu
- Department of Administration, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Limin Liu
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhongheng Zhang
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30
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Missair A, Cata JP, Votta-Velis G, Johnson M, Borgeat A, Tiouririne M, Gottumukkala V, Buggy D, Vallejo R, Marrero EBD, Sessler D, Huntoon MA, Andres JD, Casasola ODL. Impact of perioperative pain management on cancer recurrence: an ASRA/ESRA special article. Reg Anesth Pain Med 2019; 44:13-28. [PMID: 30640648 DOI: 10.1136/rapm-2018-000001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/31/2018] [Accepted: 06/05/2018] [Indexed: 12/31/2022]
Abstract
Cancer causes considerable suffering and 80% of advanced cancer patients experience moderate to severe pain. Surgical tumor excision remains a cornerstone of primary cancer treatment, but is also recognized as one of the greatest risk factors for metastatic spread. The perioperative period, characterized by the surgical stress response, pharmacologic-induced angiogenesis, and immunomodulation results in a physiologic environment that supports tumor spread and distant reimplantation.In the perioperative period, anesthesiologists may have a brief and uniquewindow of opportunity to modulate the unwanted consequences of the stressresponse on the immune system and minimize residual disease. This reviewdiscusses the current research on analgesic therapies and their impact ondisease progression, followed by an evidence-based evaluation of perioperativepain interventions and medications.
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Affiliation(s)
- Andres Missair
- Department of Anesthesiology, Veterans Affairs Hospital, Miami, Florida, USA .,Department of Anesthesiology, University of Miami, Miami, Florida, USA
| | - Juan Pablo Cata
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gina Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Mark Johnson
- Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Alain Borgeat
- Department of Anesthesiology, University of Zurich, Balgrist, Switzerland
| | - Mohammed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Vijay Gottumukkala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Donal Buggy
- Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ricardo Vallejo
- Department of Anesthesiology, Illinois Wesleyan University, Bloomington, Illinois, USA
| | - Esther Benedetti de Marrero
- Department of Anesthesiology, Veterans Affairs Hospital, Miami, Florida, USA.,Department of Anesthesiology, University of Miami, Miami, Florida, USA
| | - Dan Sessler
- Department of Anesthesiology and Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jose De Andres
- Department of Anesthesiology, General University Hospital, Valencia, Spain
| | - Oscar De Leon Casasola
- Department of Anesthesiology, University of Buffalo / Roswell Park Cancer Institute, Buffalo, New York, USA
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31
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Shi W, Zhang P. Effect of dexmedetomidine combined with lumbar anesthesia on Th1/Th2 in maternal patients and neonates undergoing caesarean section. Exp Ther Med 2019; 18:1426-1432. [PMID: 31316629 DOI: 10.3892/etm.2019.7648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 03/29/2019] [Indexed: 01/02/2023] Open
Abstract
The selection of anesthetic method and drugs is of utmost importance for patients undergoing caesarean section. The application of anesthetic drugs may affect the immune system of the maternal patient and neonate. Therefore, the present study aimed to analyze the effect of dexmedetomidine combined with lumbar anesthesia on type 1 T-helper cells (Th1) and Th2 cytokines in mothers and their neonates undergoing caesarean section. A total of 60 females with full-term pregnancies and an American Society of Anesthesiologists grade I or II who received caesarean section were selected and equally divided in a randomized manner into a control group receiving lumbar epidural anesthesia and a combination group treated by dexmedetomidine combined with lumbar epidural anesthesia. The visual analogue scale (VAS) score, adverse reactions, traction response and the neonates' Apgar score were compared between the two groups. The levels of interleukin-2 (IL-2), tumor necrosis factor-α (TNF-α), IL-4 and IL-10 in the blood of mothers and neonates were detected by reverse transcription-quantitative PCR and ELISA. The results indicated no statistically significant difference in the Apgar score between the two groups. The VAS scores, adverse reactions, reduced traction response, as well as IL-2 and TNF-α expression, in the mothers of the combination group were significantly decreased, while IL-4 and IL-10 were obviously elevated compared with those in the controls (P<0.05). Furthermore, IL-2 and TNF-α levels were markedly declined, whereas IL-4 and IL-10 expression was apparently enhanced in the neonates from the combination group compared with those in the control group (P<0.05). In conclusion, dexmedetomidine in addition to lumbar epidural anesthesia reduces the VAS score, adverse reactions and traction response, and promotes the conversion of Th1 cytokines to Th2 cytokines in mothers/nonates after caesarean section.
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Affiliation(s)
- Wentian Shi
- Department of Obstetrics and Gynecology, Liaocheng People's Hospital, Liaocheng, Shandong 252000, P.R. China
| | - Ping Zhang
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong 252000, P.R. China
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32
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de Haro C, Magrans R, López-Aguilar J, Montanyà J, Lena E, Subirà C, Fernandez-Gonzalo S, Gomà G, Fernández R, Albaiceta GM, Skrobik Y, Lucangelo U, Murias G, Ochagavia A, Kacmarek RM, Rue M, Blanch L. Effects of sedatives and opioids on trigger and cycling asynchronies throughout mechanical ventilation: an observational study in a large dataset from critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:245. [PMID: 31277722 PMCID: PMC6612107 DOI: 10.1186/s13054-019-2531-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/26/2019] [Indexed: 12/23/2022]
Abstract
Background In critically ill patients, poor patient-ventilator interaction may worsen outcomes. Although sedatives are often administered to improve comfort and facilitate ventilation, they can be deleterious. Whether opioids improve asynchronies with fewer negative effects is unknown. We hypothesized that opioids alone would improve asynchronies and result in more wakeful patients than sedatives alone or sedatives-plus-opioids. Methods This prospective multicenter observational trial enrolled critically ill adults mechanically ventilated (MV) > 24 h. We compared asynchronies and sedation depth in patients receiving sedatives, opioids, or both. We recorded sedation level and doses of sedatives and opioids. BetterCare™ software continuously registered ineffective inspiratory efforts during expiration (IEE), double cycling (DC), and asynchrony index (AI) as well as MV modes. All variables were averaged per day. We used linear mixed-effects models to analyze the relationships between asynchronies, sedation level, and sedative and opioid doses. Results In 79 patients, 14,166,469 breaths were recorded during 579 days of MV. Overall asynchronies were not significantly different in days classified as sedatives-only, opioids-only, and sedatives-plus-opioids and were more prevalent in days classified as no-drugs than in those classified as sedatives-plus-opioids, irrespective of the ventilatory mode. Sedative doses were associated with sedation level and with reduced DC (p < 0.0001) in sedatives-only days. However, on days classified as sedatives-plus-opioids, higher sedative doses and deeper sedation had more IEE (p < 0.0001) and higher AI (p = 0.0004). Opioid dosing was inversely associated with overall asynchronies (p < 0.001) without worsening sedation levels into morbid ranges. Conclusions Sedatives, whether alone or combined with opioids, do not result in better patient-ventilator interaction than opioids alone, in any ventilatory mode. Higher opioid dose (alone or with sedatives) was associated with lower AI without depressing consciousness. Higher sedative doses administered alone were associated only with less DC. Trial registration ClinicalTrial.gov, NCT03451461 Electronic supplementary material The online version of this article (10.1186/s13054-019-2531-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain. .,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. .,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| | - Rudys Magrans
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Enrico Lena
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Carles Subirà
- ICU, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Sol Fernandez-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Gomà
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Rafael Fernández
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,ICU, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Guillermo M Albaiceta
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain.,Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montréal, Québec, Canada.,Regroupement des Soins Critiques Respiratoires, Réseau de Santé Respiratoire, Fonds de Recherche du Québec en Santé, Montréal, Québec, Canada
| | - Umberto Lucangelo
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Gastón Murias
- Critical Care Department, Hospital Británico, Buenos Aires, Argentina
| | - Ana Ochagavia
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Department of Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Montserrat Rue
- Department of Basic Medical Sciences, Universitat de Lleida-IRB Lleida, Lleida, Spain.,Health Services Research Network in Chronic Diseases (REDISSEC), Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Ferrone G, Spinazzola G, Hadda V, Esquinas A. Proportional assist ventilation plus (PAVAV+) from weaning to assist control ventilation: insights for caution on issue. Minerva Anestesiol 2019; 85:1141-1142. [PMID: 31124627 DOI: 10.23736/s0375-9393.19.13733-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Giuliano Ferrone
- Department of Anesthesia and Intensive Care, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
| | - Giorgia Spinazzola
- Department of Anesthesia and Intensive Care, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India -
| | - Antonio Esquinas
- Unit of Intensive Care, Morales Meseguer Hospital, Murcia, Spain
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34
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Elgebaly AS, Sabry M. Sedation effects by dexmedetomidine versus propofol in decreasing duration of mechanical ventilation after open heart surgery. Ann Card Anaesth 2019; 21:235-242. [PMID: 30052208 PMCID: PMC6078043 DOI: 10.4103/aca.aca_168_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: The objective of this study was to compare the suitability (efficacy and safety) of dexmedetomidine versus propofol for patients admitted to the intensive care unit (ICU) after the cardiovascular surgery for the postoperative sedation before weaning from mechanical ventilation. Background: Sedation is prescribed in patients admitted to the ICU after cardiovascular surgery to reduce the patient discomfort, ventilator asynchrony, to make mechanical ventilation tolerable, prevent accidental device removal, and to reduce metabolic demands during respiratory and hemodynamic instability. Careful drug selection for sedation by the ICU team, postcardiovascular surgery should be done so that patients can be easily weaned from mechanical ventilation after sedation is stopped to achieve a shorter duration of mechanical ventilation and decreased the length of stay in ICU. Methods: A total of 50 patients admitted to the ICU after cardiovascular surgery, aged from 18 to 55 years and requiring mechanical ventilation on arrival to the ICU were enrolled in a prospective and comparative study. They were randomly divided into two groups as follows: Group D patients (n = 25) received dexmedetomidine in a maintenance infusion dose of 0.8 μg/kg/h and Group P patients (n = 25) received propofol in a maintenance infusion dose of 1.5 mg/kg/h. The patients were assessed for 12 h postoperatively, and dosing of the study drug was adjusted based on sedation assessment performed with the Richmond Agitation-Sedation Scale (RASS). The patients were required to be within the RASS target range of −2 to +1 at the time of study drug initiation. At every 4 h, the following information was recorded from each patient such as heart rate (HR), mean arterial pressure (MAP), arterial blood gases (ABG), tidal volume (TV), exhaled TV, maximum inspiratory pressure, respiratory rate and the rapid shallow breathing index, duration of mechanical ventilation, midazolam and fentanyl dose requirements, and financial costs. Results: The study results showed no statistically significant difference between both groups with regard to age and body mass index. Group P patients were more associated with lower MAP and HR than Group D patients. There was no statistically significant difference between groups with regard to ABG findings, oxygenation, ventilation, and respiratory parameters. There was significant difference between both the groups in midazolam and fentanyl dose requirement and financial costs with a value of P < 0.05. Conclusion: Dexmedetomidine is safer and equally effective agent for the sedation of mechanically ventilated patients admitted to the ICU after cardiovascular surgery compared to the patients receiving propofol, with good hemodynamic stability, and equally rapid extubation time.
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Affiliation(s)
- Ahmed Said Elgebaly
- Department of Anesthesia and PSIC, Faculty of Medicine, Tanta University, Tanta, Gharbia 31111, Egypt
| | - Mohab Sabry
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta University Hospital, Tanta, Gharbia 31111, Egypt
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35
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Smithburger PL, Patel MK. Pharmacologic Considerations Surrounding Sedation, Delirium, and Sleep in Critically Ill Adults: A Narrative Review. J Pharm Pract 2019; 32:271-291. [PMID: 30955461 DOI: 10.1177/0897190019840120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research. OBJECTIVE To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management. METHODS The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review. RESULTS Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep. CONCLUSION A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes.
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Affiliation(s)
- Pamela L Smithburger
- 1 Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mona K Patel
- 2 Department of Pharmacy, Surgical Intensive Care Unit, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
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Bruni A, Garofalo E, Pelaia C, Messina A, Cammarota G, Murabito P, Corrado S, Vetrugno L, Longhini F, Navalesi P. Patient-ventilator asynchrony in adult critically ill patients. Minerva Anestesiol 2019; 85:676-688. [PMID: 30762325 DOI: 10.23736/s0375-9393.19.13436-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Patient-ventilator asynchrony is considered a major clinical problem for mechanically ventilated patients. It occurs during partial ventilatory support, when the respiratory muscles and the ventilator interact to contribute generating the volume output. In this review article, we consider all studies published on patient-ventilator asynchrony in the last 25 years. EVIDENCE ACQUISITION We selected 62 studies. The different forms of asynchrony are first defined and classified. We also describe the methods used for detecting and quantifying asynchronies. We then outline the outcome variables considered for evaluating the clinical consequences of asynchronies. The methodology for detection and quantification of patient-ventilator asynchrony are quite heterogeneous. In particular, the Asynchrony Index is calculated differently among studies. EVIDENCE SYNTHESIS Sixteen studies established some relationship between asynchronies and one or more clinical outcomes, such as duration of mechanical ventilation (seven studies), mortality (five studies), length of intensive care and hospital stay (four studies), patient comfort (four studies), quality of sleep (three studies), and rate of tracheotomy (three studies). In patients with severe patient-ventilator asynchrony, four of seven studies (57%) report prolonged duration of mechanical ventilation, one of five (20%) increased mortality, one of four (25%) longer intensive care and hospital lengths of stay, four of four (100%) worsened comfort, three of four (75%) deteriorated quality of sleep, and one of three (33%) increased rate of tracheotomy. CONCLUSIONS Given the varying outcomes considered and the erratic results, it remains unclear whether asynchronies really affects patient outcome, and the relationship between asynchronies and outcome is causative or associative.
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Affiliation(s)
- Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | | | - Gianmaria Cammarota
- Unit of Anesthesia and Intensive Care, "Maggiore della Carità" Hospital, Novara, Italy
| | - Paolo Murabito
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", "G. Rodolico" University Policlinic, University of Catania, Catania, Italy
| | - Silvia Corrado
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, University of Udine, Udine, Italy
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy -
| | - Paolo Navalesi
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
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A systematic review of interventions to facilitate extubation in patients difficult-to-wean due to delirium, agitation, or anxiety and a meta-analysis of the effect of dexmedetomidine. Can J Anaesth 2019; 66:318-327. [PMID: 30674004 DOI: 10.1007/s12630-018-01289-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Delirium, agitation, and anxiety may hinder weaning from mechanical ventilation and lead to increased morbidity and healthcare costs. The most appropriate clinical approach to weaning in these contexts remains unclear and challenging to clinicians. The objective of this systematic review was to identify effective and safe interventions to wean patients that are difficult-to-wean from mechanical ventilation due to delirium, agitation, or anxiety. METHODS A systematic review was performed using MEDLINE, EMBASE, and PubMed. Studies evaluating mechanically ventilated patients deemed difficult-to-wean due to delirium, agitation, or anxiety, and comparing the effects of an intervention with a comparator arm were sought. Time-to-extubation was the primary outcome while the secondary outcome was intensive care unit (ICU) length of stay. RESULTS From 10,860 studies identified, eight met the inclusion criteria: six studies assessed dexmedetomidine while the remaining two assessed loxapine and biofeedback. Pooled analysis of studies assessing dexmedetomidine showed reduced time-to-extubation (six studies, n = 303) by 10.9 hr compared with controls (95% confidence interval [CI], -15.7 to -6.1; I2 = 68%) and ICU length of stay (four studies, n = 191) by 2.6 days (95% CI, 1.9 to 3.3; I2 = 0%). Nevertheless, the evidence was deemed to be of low quality given the small sample sizes and high heterogeneity. Studies assessing other interventions did not identify improvements compared with controls. Safety assessment was globally poorly reported. CONCLUSIONS This systematic review and meta-analysis provides low quality evidence to suggest the use of dexmedetomidine in patients deemed difficult-to-wean due to agitation, delirium, or anxiety. Insufficient evidence was found regarding other interventions to provide any recommendation. TRIAL REGISTRATION PROSPERO (CRD42016042528); registered 15 July, 2016.
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Wang W, Liu Y, Liu Y, Liu F, Ma Y. Comparison of Cognitive Impairments After Intensive Care Unit Sedation Using Dexmedetomidine and Propofol Among Older Patients. J Clin Pharmacol 2019; 59:821-828. [PMID: 30624767 DOI: 10.1002/jcph.1372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/10/2018] [Indexed: 12/31/2022]
Abstract
Despite the high prevalence of cognitive impairment among older adults, little is known about the association of the selection of dexmedetomidine and propofol on cognitive functions of patients after a critical illness. Patients aged ≥70 years who received intensive care unit (ICU) care from Cangzhou Central Hospital between 2013 and 2016 were enrolled and randomized into a dexmedetomidine group and a propofol group with matched demographic and clinical characteristics. At discharge from the ICU and 4 weeks later, the cognitive status of patients was assessed and compared using the Montreal Cognitive Assessment system. There were 164 patients included in the dexmedetomidine group and 159 patients in the propofol group. No significant difference was observed between the 2 groups in terms of age, female sex, body weight, educational level, ICU and hospital stay, comorbidities, and medications. Further, patients from the 2 groups at ICU discharge did not demonstrate significant difference on the Montreal Cognitive Assessment component scores, which showed significant differences between the 2 groups 4 weeks later (P < .05). Moreover, dexmedetomidine and propofol showed different levels of impacts on the cognitive function of patients discharged from the postanesthesia care unit, neurological ICU, and medical ICU. This study demonstrated that patients discharged from the ICU who received propofol for sedation showed less impairment on the cognitive functions when compared with patients who received dexmedetomidine during ICU care 4 weeks after discharge. Despite some limitations, this study provides insights to the decision-making process in the selection of appropriate sedation strategy, especially for the elderly patients.
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Affiliation(s)
- Wenhao Wang
- Department of Internal Medicine, Cangzhou Central Hospital, Hebei, China
| | - Yi Liu
- Cangzhou Prison, Hebei, China
| | - Yunfeng Liu
- Department of Internal Medicine, Cangzhou Central Hospital, Hebei, China
| | - Feifei Liu
- Department of Internal Medicine, Cangzhou People's Hospital, China
| | - Yuxia Ma
- Department of Internal Medicine, Cangzhou Central Hospital, Hebei, China
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Hasanin A, Taha K, Abdelhamid B, Abougabal A, Elsayad M, Refaie A, Amin S, Wahba S, Omar H, Kamel MM, Abdelwahab Y, Amin SM. Evaluation of the effects of dexmedetomidine infusion on oxygenation and lung mechanics in morbidly obese patients with restrictive lung disease. BMC Anesthesiol 2018; 18:104. [PMID: 30103679 PMCID: PMC6090793 DOI: 10.1186/s12871-018-0572-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/01/2018] [Indexed: 12/17/2022] Open
Abstract
Background Dexmedetomidine infusion improves oxygenation and lung mechanics in patients with chronic obstructive lung disease; however, its effect in patients with restrictive lung disease has not been thoroughly investigated yet. The aim of this work was to evaluate the effects of dexmedetomidine infusion on oxygenation and lung mechanics in morbidly obese patients with restrictive lung disease. Methods Forty-two morbidly obese patients scheduled for bariatric surgery were included in the study. Patients were randomized to receive either dexmedetomidine infusion at a bolus dose of 1mcg/Kg followed by infusion at 1 mcg/Kg/hour for 90 min (Dexmedetomidine group), or normal saline infusion (Control group). Both groups were compared with regard to: oxygenation {P/F ratio: PaO2/fraction of inspired oxygen (FiO2)}, lung compliance, dead space, plateau pressure, blood pressure, and heart rate. Results Dexmedetomidine group showed significant improvement of the PaO2/FiO2 ratio, and higher lung compliance compared to control group by the end of drug infusion. Dexmedetomidine group demonstrated decreased dead space, plateau pressure, blood pressure, and heart rate compared to control group by the end of drug infusion. Conclusion A 90-min dexmedetomidine infusion resulted in moderate improvement in oxygenation and lung mechanics in morbidly obese patients with restrictive lung disease. Trial registration clinicaltrials.gov: NCT02843698 on 20 July 2016.
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Affiliation(s)
- Ahmed Hasanin
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt.
| | - Kareem Taha
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Bassant Abdelhamid
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Ayman Abougabal
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Mohamed Elsayad
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Amira Refaie
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Sarah Amin
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Shaimaa Wahba
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Heba Omar
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Mohamed Maher Kamel
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Yaser Abdelwahab
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Shereen M Amin
- Department of anesthesia and critical care medicine, Cairo university, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
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Chang YF, Chao A, Shih PY, Hsu YC, Lee CT, Tien YW, Yeh YC, Chen LW. Comparison of dexmedetomidine versus propofol on hemodynamics in surgical critically ill patients. J Surg Res 2018; 228:194-200. [DOI: 10.1016/j.jss.2018.03.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/06/2018] [Accepted: 03/15/2018] [Indexed: 12/30/2022]
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Holanda MA, Vasconcelos RDS, Ferreira JC, Pinheiro BV. Patient-ventilator asynchrony. ACTA ACUST UNITED AC 2018; 44:321-333. [PMID: 30020347 DOI: 10.1590/s1806-37562017000000185] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/03/2017] [Indexed: 11/22/2022]
Abstract
Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.
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Affiliation(s)
- Marcelo Alcantara Holanda
- . Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza (CE) Brasil.,. Programa de Pós-Graduação de Mestrado em Ciências Médicas, Universidade Federal do Ceará, Fortaleza (CE) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Valle Pinheiro
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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42
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Garofalo E, Bruni A, Pelaia C, Liparota L, Lombardo N, Longhini F, Navalesi P. Recognizing, quantifying and managing patient-ventilator asynchrony in invasive and noninvasive ventilation. Expert Rev Respir Med 2018; 12:557-567. [DOI: 10.1080/17476348.2018.1480941] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Luisa Liparota
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nicola Lombardo
- Otolaryngology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Sant’Andrea Hospital, Vercelli, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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43
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Abstract
Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.
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Affiliation(s)
- Marcelo Alcantara Holanda
- . Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza (CE) Brasil.,. Programa de Pós-Graduação de Mestrado em Ciências Médicas, Universidade Federal do Ceará, Fortaleza (CE) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Valle Pinheiro
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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44
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Amezcua-Gutiérrez M, Montoya-Rojo J, Castañón-González J, Zamora-Gómez S, Gorordo-Delsol L, Hernández-López G, Pérez-Nieto O, Cabanillas-Cervantes A, Garduño-López J, Lima-Lucero I, Cruz-Montesinos S. The maximum expression of hypoxia and hypoventilation: Acute respiratory distress syndrome. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2018. [DOI: 10.1016/j.hgmx.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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45
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46
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Jaber S, Bellani G, Blanch L, Demoule A, Esteban A, Gattinoni L, Guérin C, Hill N, Laffey JG, Maggiore SM, Mancebo J, Mayo PH, Mosier JM, Navalesi P, Quintel M, Vincent JL, Marini JJ. The intensive care medicine research agenda for airways, invasive and noninvasive mechanical ventilation. Intensive Care Med 2017; 43:1352-1365. [PMID: 28785882 DOI: 10.1007/s00134-017-4896-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 07/20/2017] [Indexed: 12/12/2022]
Abstract
In an important sense, support of the respiratory system has been a defining characteristic of intensive care since its inception. The pace of basic and clinical research in this field has escalated over the past two decades, resulting in palpable improvement at the bedside as measured by both efficacy and outcome. As in all medical research, however, novel ideas built upon observations are continually proposed, tested, and either retained or discarded on the basis of the persuasiveness of the evidence. What follows are concise descriptions of the current standards of management practice in respiratory support, the areas of present-day uncertainty, and our suggested agenda for the near future of research aimed at testing current assumptions, probing uncertainties, and solidifying the foundation on which to base our progress to the next level.
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Affiliation(s)
- Samir Jaber
- Department of Anesthesiology and Critical Care Medicine B (DAR B), Saint-Eloi Hospital, University Teaching Hospital of Montpellier, INSERM U104680, avenue Augustin Fliche, 34295, Montpellier, France.
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Lluis Blanch
- Critical Care Center, Parc Tauli University Hospital, Institut de Investigació i Innovació Parc Taulí, I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBER Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Alexandre Demoule
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, UPMC Univ Paris 06, INSERM, Paris, France.,Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Andrés Esteban
- Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Claude Guérin
- Service de réanimation médicale, Hopital de la croix rousse, Lyon, France.,Université de Lyon and INSERM 955, Créteil, France
| | - Nicholas Hill
- Pulmonary Division APC 479A, Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903, USA
| | - John G Laffey
- Departments of Anesthesia and Critical Care Medicine, St Michael's Hospital, Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science, Toronto, Canada.,Departments of Anesthesia, Physiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Salvatore Maurizio Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, "SS. Annunziata" Hospital, "Gabriele d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Jordi Mancebo
- Department of Medicine, University of Montréal, Division of Intensive Care at Centre Hospitalier Université de Montréal (CHUM), Centre Recherche CHUM, Montréal, QC, Canada.,Institut de Recerca Hospital de St Pau, Barcelona, Spain
| | - Paul H Mayo
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health NSUH/LIJ, New Hyde Park, NY, 11040, USA
| | - Jarrod M Mosier
- Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep, University of Arizona, Tucson, AZ, USA
| | - Paolo Navalesi
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care, Magna Graecia University, Catanzaro, Italy
| | - Michael Quintel
- Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Jean Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - John J Marini
- Punmonary and Critical Care Medicine, Regions Hospital, University of Minnesota, Minneapolis/Saint Paul, MN, USA
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Liu H, Ji F, Peng K, Applegate RL, Fleming N. Sedation After Cardiac Surgery: Is One Drug Better Than Another? Anesth Analg 2017; 124:1061-1070. [PMID: 27984229 DOI: 10.1213/ane.0000000000001588] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The classic high-dose narcotic-based cardiac anesthetic has been modified to facilitate a fast-track, rapid recovery in the intensive care unit (ICU). Postoperative sedation is consequently now an essential component in recovery of the patient undergoing cardiac surgery. It must facilitate the patient's unawareness of the environment as well as reduce the discomfort and anxiety caused by surgery, intubation, mechanical ventilation, suction, and physiotherapy. Benzodiazepines seem well suited for this role, but propofol, opioids, and dexmedetomidine are among other agents commonly used for sedation in the ICU. However, what is an ideal sedative for this application? When compared with benzodiazepine-based sedation regimens, nonbenzodiazepines have been associated with shorter duration of mechanical ventilation and ICU length of stay. Current sedation guidelines recommend avoiding benzodiazepine use in the ICU. However, there are no recommendations on which alternatives should be used. In postcardiac surgery patients, inotropes and vasoactive medications are often required because of the poor cardiac function. This makes sedation after cardiac surgery unique in comparison with the requirements for most other ICU patient populations. We reviewed the current literature to try to determine if 1 sedative regimen might be better than others; in particular, we compare outcomes of propofol and dexmedetomidine in postoperative sedation in the cardiac surgical ICU.
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Affiliation(s)
- Hong Liu
- From the *Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, California; and †Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu/China
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Bourenne J, Hraiech S, Roch A, Gainnier M, Papazian L, Forel JM. Sedation and neuromuscular blocking agents in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:291. [PMID: 28828366 DOI: 10.21037/atm.2017.07.19] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Mechanical ventilation (MV) is the cornerstone of acute respiratory distress syndrome (ARDS) management. The use of protective ventilation is a priority in this acute phase of lung inflammation. Neuromuscular blocking agents (NMBAs) induce reversible muscle paralysis. Their use in patients with ARDS remains controversial but occurs frequently. NMBAs are used in 25-45% of ARDS patients for a mean period of 1±2 days. The main indications of NMBAs are hypoxemia and facilitation of MV. For ethical reasons, NMBA use is inseparable from sedation in the management of early ARDS. During paralysis, sedation monitoring seems to be necessary to avoid awareness with recall. Three randomized controlled trials (RCTs) have demonstrated that the systematic use of NMBAs in the early management of ARDS patients improves oxygenation. Furthermore, the most recent trial reported a reduction of mortality at 90 days when NMBAs were infused over 48 hours. Spontaneous ventilation (SV) during MV at the acute phase of ARDS could improve oxygenation and alveolar recruitment, but it may not allow protective ventilation. The major risk is an increase in ventilator-induced lung injury. However, the adverse effects of NMBAs are widely discussed, particularly the occurrence of intensive care unit (ICU)-acquired weakness. This review analyses the recent findings in the literature concerning sedation and paralysis in managing ARDS.
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Affiliation(s)
- Jeremy Bourenne
- APHM, Hôpital la Timone, Réanimation des urgences et médicale, Marseille, France.,Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Sami Hraiech
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
| | - Antoine Roch
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
| | - Marc Gainnier
- APHM, Hôpital la Timone, Réanimation des urgences et médicale, Marseille, France.,Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Laurent Papazian
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
| | - Jean-Marie Forel
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
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Pasero D, Sangalli F, Baiocchi M, Blangetti I, Cattaneo S, Paternoster G, Moltrasio M, Auci E, Murrino P, Forfori F, Forastiere E, De Cristofaro MG, Deste G, Feltracco P, Petrini F, Tritapepe L, Girardis M. Experienced Use of Dexmedetomidine in the Intensive Care Unit: A Report of a Structured Consensus. Turk J Anaesthesiol Reanim 2017; 46:176-183. [PMID: 30140512 DOI: 10.5152/tjar.2018.08058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/28/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice. Methods A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data. Results Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects. Conclusion DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.
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Affiliation(s)
- Daniela Pasero
- Department of Anaesthesia and Intensive Care, AOU Città della Salute e della Scienza, Turin, Italy
| | - Fabio Sangalli
- Department of Perioperative Medicine and Intensive Care, Cardiothoracic And Vascular Anaesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Massimo Baiocchi
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Bologna "s. Orsola-malpighi", Bologna, Italy
| | - Ilaria Blangetti
- Department of Cardiovascular and Thoracic Surgery, Azienda Ospedaliera Santa Croce E Carle, Cuneo, Italy
| | - Sergio Cattaneo
- Department of Anaesthesia and Intensive Care Medicine, Aziende Socio Sanitarie Territoriali Papa Giovanni Xxiii, Bergamo, Italy
| | - Gianluca Paternoster
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Marco Moltrasio
- Cardiac Intensive Care Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Elisabetta Auci
- Department of Anesthesiology and Intensive Care, S. Maria Della Misericordia Hospital, Udine, Italy
| | - Patrizia Murrino
- Department of Anaesthesia and Critical Care Medicine, Aorn Ospedali Dei Colli, Naples, Italy
| | - Francesco Forfori
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliera Pisana, Pisa, Italy
| | - Ester Forastiere
- Department of Anaesthesiology, Regina Elena National Cancer Institute, Rome, Italy
| | | | - Giorgio Deste
- Uoc Anestesia E Rianimazione, Policlinico Casilino, Roma
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Italy
| | - Flavia Petrini
- Department of Anaesthesia and Intensive Care, University Hospital of Chieti, Chieti, Italy
| | - Luigi Tritapepe
- Department of Anaesthesiology and Intensive Care Medicine, Umberto I Hospital, "sapienza" University, Rome, Italy
| | - Massimo Girardis
- Department of Anaesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
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50
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Piazza O, Staiano R, De Robertis E, Conti G, Di Crescenzo V, Loffredo S, Marone G, Marinosci GZ, Cataldi MM. Effect Of α2-Adrenergic Agonists And Antagonists On Cytokine Release From Human Lung Macrophages Cultured In Vitro. Transl Med UniSa 2016; 15:67-73. [PMID: 27896229 PMCID: PMC5120752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The most trusted hypothesis to explain how α2-adrenergic agonists may preserve pulmonary functions in critically ill patients is that they directly act on macrophages by interfering with an autocrine/paracrine adrenergic system that controls cytokine release through locally synthetized noradrenaline and α1- and α2-adrenoreceptors. We tested this hypothesis in primary cultures of resident macrophages from human lung (HLMs). HLMs were isolated by centrifugation on percoll gradients from macroscopically healthy human lung tissue obtained from four different patients at the time of lung resection for cancer. HLMs from these patients showed a significant expression of α2A, α2B and α2C adrenoreceptors both at the mRNA and at the protein level. To evaluate whether α2 adrenoreceptors controlled cytokine release from HMLs, we measured IL-6, IL-8 and TNF-α concentrations in the culture medium in basal conditions and after preincubation with several α2-adrenergic agonists or antagonists. Neither the pretreatment with the α2-adrenergic agonists clonidine, medetomidine or dexdemetomidine or with the α2-adrenergic antagonist yohimbine caused significant changes in the response of any of these cytokines to LPS. These results show that, different from what reported in rodents, clonidine and dexdemetomidine do not directly suppress cytokine release from human pulmonary macrophages. This suggests that alternative mechanisms such as effects on immune cells activation or the modulation of autonomic neurotransmission could be responsible for the beneficial effects of these drugs on lung function in critical patients.
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Affiliation(s)
- O. Piazza
- Università di Salerno, Department of Medicine and Surgery, Via Allende, 84081 Baronissi, (SA) Italy
| | - R.I. Staiano
- Università degli Studi di Napoli Federico II, Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), Naples, Italy
| | - E. De Robertis
- Università degli Studi di Napoli Federico II, Department of Neurosciences, Naples, Italy,Federico II University Hospital, Naples, Italy
| | - G. Conti
- Università Cattolica del Sacro Cuore, Anaesthesiology and Intensive Care, Rome, Italy
| | - V. Di Crescenzo
- Università di Salerno, Department of Medicine and Surgery, Via Allende, 84081 Baronissi, (SA) Italy
| | - S. Loffredo
- Università degli Studi di Napoli Federico II, Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), Naples, Italy
| | - G. Marone
- Università degli Studi di Napoli Federico II, Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), Naples, Italy
| | - G. Zito Marinosci
- Università di Salerno, Department of Medicine and Surgery, Via Allende, 84081 Baronissi, (SA) Italy
| | - M. M. Cataldi
- Università degli Studi di Napoli Federico II, Department of Neurosciences, Naples, Italy,Federico II University Hospital, Naples, Italy,()
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