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Shao F, Yao Y, Weng D, Wang R, Liu R, Zhang Y, Li E, Wang M, Tang Y, Ding Y, Xie Y. Causal association of plasma circulating metabolites with nephritis: a Mendelian randomization study. Front Nutr 2024; 11:1364841. [PMID: 38765814 PMCID: PMC11099270 DOI: 10.3389/fnut.2024.1364841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
Background Nephritis is a pivotal catalyst in chronic kidney disease (CKD) progression. Although epidemiological studies have explored the impact of plasma circulating metabolites and drugs on nephritis, few have harnessed genetic methodologies to establish causal relationships. Methods Through Mendelian randomization (MR) in two substantial cohorts, spanning large sample sizes, we evaluated over 100 plasma circulating metabolites and 263 drugs to discern their causal effects on nephritis risk. The primary analytical tool was the inverse variance weighted (IVW) analysis. Our bioinformatic scrutiny of GSE115857 (IgA nephropathy, 86 samples) and GSE72326 (lupus nephritis, 238 samples) unveiled anomalies in lipid metabolism and immunological characteristics in nephritis. Thorough sensitivity analyses (MR-Egger, MR-PRESSO, leave-one-out analysis) were undertaken to verify the instrumental variables' (IVs) assumptions. Results Unique lipoprotein-related molecules established causal links with diverse nephritis subtypes. Notably, docosahexaenoic acid (DHA) emerged as a protective factor for acute tubulointerstitial nephritis (ATIN) (OR1 = 0.84, [95% CI 0.78-0.90], p1 = 0.013; OR2 = 0.89, [95% CI 0.82-0.97], p2 = 0.007). Conversely, multivitamin supplementation minus minerals notably increased the risk of ATIN (OR = 31.25, [95% CI 9.23-105.85], p = 0.004). Reduced α-linolenic acid (ALA) levels due to lipid-lowering drugs were linked to both ATIN (OR = 4.88, [95% CI 3.52-6.77], p < 0.001) and tubulointerstitial nephritis (TIN) (OR = 7.52, [95% CI 2.78-20.30], p = 0.042). While the non-renal drug indivina showed promise for TIN treatment, the use of digoxin, hydroxocobalamin, and liothyronine elevated the risk of chronic tubulointerstitial nephritis (CTIN). Transcriptome analysis affirmed that anomalous lipid metabolism and immune infiltration are characteristic of IgA nephropathy and lupus nephritis. The robustness of these causal links was reinforced by sensitivity analyses and leave-one-out tests, indicating no signs of pleiotropy. Conclusion Dyslipidemia significantly contributes to nephritis development. Strategies aimed at reducing plasma low-density lipoprotein levels or ALA supplementation may enhance the efficacy of existing lipid-lowering drug regimens for nephritis treatment. Renal functional status should also be judiciously considered with regard to the use of nonrenal medications.
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Affiliation(s)
- Fengling Shao
- The Ministry of Education, Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Yingling Yao
- Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China
- Department of Pharmacology, Academician Workstation, Changsha Medical University, Changsha, China
| | - Dunchu Weng
- The Ministry of Education, Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Runzhi Wang
- The Ministry of Education, Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Ruiling Liu
- Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China
- Department of Pharmacology, Academician Workstation, Changsha Medical University, Changsha, China
| | - Yongjia Zhang
- Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China
- Department of Pharmacology, Academician Workstation, Changsha Medical University, Changsha, China
| | - Erhan Li
- Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China
- Department of Pharmacology, Academician Workstation, Changsha Medical University, Changsha, China
| | - Mengdi Wang
- Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China
- Department of Pharmacology, Academician Workstation, Changsha Medical University, Changsha, China
| | - Yuewu Tang
- Department of Nephrology, Chongqing Three Gorges Central Hospital, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Yubin Ding
- Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China
- Department of Pharmacology, Academician Workstation, Changsha Medical University, Changsha, China
| | - Yajun Xie
- The Ministry of Education, Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
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2
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Zdunczyk A, Schumm L, Helgers SOA, Nieminen-Kelhä M, Bai X, Major S, Dreier JP, Hecht N, Woitzik J. Ketamine-induced prevention of SD-associated late infarct progression in experimental ischemia. Sci Rep 2024; 14:10186. [PMID: 38702377 PMCID: PMC11068759 DOI: 10.1038/s41598-024-59835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/16/2024] [Indexed: 05/06/2024] Open
Abstract
Spreading depolarizations (SDs) occur frequently in patients with malignant hemispheric stroke. In animal-based experiments, SDs have been shown to cause secondary neuronal damage and infarct expansion during the initial period of infarct progression. In contrast, the influence of SDs during the delayed period is not well characterized yet. Here, we analyzed the impact of SDs in the delayed phase after cerebral ischemia and the potential protective effect of ketamine. Focal ischemia was induced by distal occlusion of the left middle cerebral artery in C57BL6/J mice. 24 h after occlusion, SDs were measured using electrocorticography and laser-speckle imaging in three different study groups: control group without SD induction, SD induction with potassium chloride, and SD induction with potassium chloride and ketamine administration. Infarct progression was evaluated by sequential MRI scans. 24 h after occlusion, we observed spontaneous SDs with a rate of 0.33 SDs/hour which increased during potassium chloride application (3.37 SDs/hour). The analysis of the neurovascular coupling revealed prolonged hypoemic and hyperemic responses in this group. Stroke volume increased even 24 h after stroke onset in the SD-group. Ketamine treatment caused a lesser pronounced hypoemic response and prevented infarct growth in the delayed phase after experimental ischemia. Induction of SDs with potassium chloride was significantly associated with stroke progression even 24 h after stroke onset. Therefore, SD might be a significant contributor to delayed stroke progression. Ketamine might be a possible drug to prevent SD-induced delayed stroke progression.
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Affiliation(s)
- A Zdunczyk
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - L Schumm
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S O A Helgers
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M Nieminen-Kelhä
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - X Bai
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S Major
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - J P Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - N Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
- University Clinic for Neurosurgery, Marienstr. 11, 26121, Oldenburg, Germany.
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Evans SL, Olney WJ, Bernard AC, Gesin G. Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know. J Trauma Acute Care Surg 2024; 96:166-177. [PMID: 37822025 DOI: 10.1097/ta.0000000000004154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
ABSTRACT Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist's toolbox. In addition, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients.
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Affiliation(s)
- Susan L Evans
- From the Department of Surgery (S.L.E.), Carolinas Medical Center, Atrium Health, Charlotte, North Carolina; Department of Pharmacy (W.J.O.), Acute Care Surgery, UK HealthCare, Lexington, Kentucky; Department of Surgery (A.C.B.), University of Kentucky, Lexington, Kentucky; and Division of Pharmacy (G.G.), Atrium Health, Charlotte, North Carolina
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Ommati MM, Mobasheri A, Niknahad H, Rezaei M, Alidaee S, Arjmand A, Mazloomi S, Abdoli N, Sadeghian I, Sabouri S, Saeed M, Mousavi K, Najibi A, Heidari R. Low-dose ketamine improves animals' locomotor activity and decreases brain oxidative stress and inflammation in ammonia-induced neurotoxicity. J Biochem Mol Toxicol 2023; 37:e23468. [PMID: 37491939 DOI: 10.1002/jbt.23468] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 06/10/2023] [Accepted: 07/08/2023] [Indexed: 07/27/2023]
Abstract
Ammonium ion (NH4 + ) is the major suspected molecule responsible for neurological complications of hepatic encephalopathy (HE). No specific pharmacological action for NH4 + -induced brain injury exists so far. Excitotoxicity is a well-known phenomenon in the brain of hyperammonemic cases. The hyperactivation of the N-Methyl- d-aspartate (NMDA) receptors by agents such as glutamate, an NH4 + metabolite, could cause excitotoxicity. Excitotoxicity is connected with events such as oxidative stress and neuroinflammation. Hence, utilizing NMDA receptor antagonists could prevent neurological complications of NH4 + neurotoxicity. In the current study, C57BL6/J mice received acetaminophen (APAP; 800 mg/kg, i.p) to induce HE. Hyperammonemic animals were treated with ketamine (0.25, 0.5, and 1 mg/kg, s.c) as an NMDA receptor antagonist. Animals' brain and plasma levels of NH4 + were dramatically high, and animals' locomotor activities were disturbed. Moreover, several markers of oxidative stress were significantly increased in the brain. A significant increase in brain tissue levels of TNF-α, IL-6, and IL-1β was also detected in hyperammonemic animals. It was found that ketamine significantly normalized animals' locomotor activity, improved biomarkers of oxidative stress, and decreased proinflammatory cytokines. The effects of ketamine on oxidative stress biomarkers and inflammation seem to play a key role in its neuroprotective mechanisms in the current study.
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Affiliation(s)
- Mohammad Mehdi Ommati
- College of Life Sciences, Shanxi Agricultural University, Taigu, Shanxi, China
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, Henan, China
| | - Ali Mobasheri
- Research Unit of Medical Imaging, Physics, and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Departments of Orthopedics, Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Hossein Niknahad
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Rezaei
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sepideh Alidaee
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdollah Arjmand
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sahra Mazloomi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Narges Abdoli
- Food and Drug Administration, Iran Ministry of Health and Medical Education, Tehran, Iran
| | - Issa Sadeghian
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Biotechnology Incubator, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samira Sabouri
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, Henan, China
| | - Mohsen Saeed
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khadijeh Mousavi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asma Najibi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Reede K, Bartholomew R, Nielsen D, Ahmeti M, Zreik K. Ketamine in Trauma: A Literature Review and Administration Guidelines. Cureus 2023; 15:e48099. [PMID: 37920424 PMCID: PMC10620013 DOI: 10.7759/cureus.48099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/04/2023] Open
Abstract
Ketamine is a phencyclidine (PCP) derivative, which primarily acts as a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist. Ketamine serves as an analgesic and a dissociative sedative that produces potent analgesia, sedation, and amnesia while preserving spontaneous respiratory drive. It is rapidly gaining acceptance in the management of pain as multiple studies have demonstrated its reliable efficacy and a wide margin of safety. This article reviews some of these studies, the history of ketamine, and its pharmacological and pharmacokinetic properties. The article also discusses the use of ketamine in the trauma setting, including joint reductions, procedures, sedation, and pain control, as well as dosing recommendations.
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Affiliation(s)
- Kristen Reede
- General Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | - Reid Bartholomew
- Trauma Surgery, University of Tennessee Health Science Center, Memphis, USA
| | - Dana Nielsen
- General Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | | | - Khaled Zreik
- Surgical Critical Care, Sanford Medical Center, Fargo, USA
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Patel S, Maria-Rios J, Parikh A, Okorie ON. Diagnosis and management of elevated intracranial pressure in the emergency department. Int J Emerg Med 2023; 16:72. [PMID: 37833652 PMCID: PMC10571389 DOI: 10.1186/s12245-023-00540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Elevated intracranial pressure is a devastating complication of catastrophic brain injury. Intracranial hypertension is commonly seen in neurologic injury secondary to traumatic brain injuries. Uncontrolled pressures can lead to permanent neurologic damage, but acute medical management is often overlooked when pursuing surgical management options that may not always be indicated. DISCUSSION Traumatic brain injury is the leading cause of death in patients with severe neurologic injury. Diagnosing elevated intracranial pressures is imperative in initiating prompt treatment to reduce secondary central nervous system injury, morbidity, and mortality. Although the initial injury to the brain is typically irreversible, intracranial pressure control can assist in salvaging the remaining brain tissue from additional damage. We will discuss the initial medical and surgical management of traumatic brain injury to prevent further neurologic deterioration and reduce mortality. CONCLUSION Recent literature has reported several methods to detect elevated intracranial pressure easily and studies describing multiple treatment modalities. These investigations suggest that early detection and timely treatment of intracranial hypertension are beneficial in reducing mortality.
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Affiliation(s)
- Sima Patel
- Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA.
| | - Jose Maria-Rios
- Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA
| | - Amay Parikh
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA
| | - Okorie Nduka Okorie
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA
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Jeffcote T, Weir T, Anstey J, Mcnamara R, Bellomo R, Udy A. The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2023; 35:265-273. [PMID: 35142704 DOI: 10.1097/ana.0000000000000836] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
Although sedative use is near-ubiquitous in the acute management of moderate to severe traumatic brain injury (m-sTBI), the evidence base for these agents is undefined. This review summarizes the evidence for analgosedative agent use in the intensive care unit management of m-sTBI. Clinical studies of sedative and analgosedative agents currently utilized in adult m-sTBI management (propofol, ketamine, benzodiazepines, opioids, and alpha-2 agonists) were identified and assessed for relevance and methodological quality. The primary outcome was the effect of the analgosedative agent on intracranial pressure (ICP). Secondary outcomes included intracranial hemodynamic and metabolic parameters, systemic hemodynamic parameters, measures of therapeutic intensity, and clinical outcomes. Of 594 articles identified, 61 met methodological review criteria, and 40 were included in the qualitative summary; of these, 33 were prospective studies, 18 were randomized controlled trials, and 8 were blinded. There was consistent evidence for the efficacy of sedative agents in the management of m-sTBI and raised ICP, but the overall quality of the evidence was poor, consisting of small studies (median sample size, 23.5) of variable methodological quality. Propofol and midazolam achieve the goals of sedation without notable differences in efficacy or safety, although high-dose propofol may disrupt cerebral autoregulation. Dexmedetomidine and propofol/ dexmedetomidine combination may cause clinically significant hypotension. Dexmedetomidine was effective to achieve a target sedation score. De novo opioid boluses were associated with increased ICP and reduced cerebral perfusion pressure. Ketamine bolus and infusions were not associated with increased ICP and may reduce the incidence of cortical spreading depolarization events. In conclusion, there is a paucity of high-quality evidence to inform the optimal use of analgosedative agents in the management of m-sTBI, inferring significant scope for further research.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Timothy Weir
- Department of Intensive Care Medicine, The Alfred Hospital
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
| | - Robert Mcnamara
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The Austin Hospital
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
- Department of Critical Care, University of Melbourne, Parkville
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Andrew Udy
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
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Denchev K, Gomez J, Chen P, Rosenblatt K. Traumatic Brain Injury: Intraoperative Management and Intensive Care Unit Multimodality Monitoring. Anesthesiol Clin 2023; 41:39-78. [PMID: 36872007 DOI: 10.1016/j.anclin.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Traumatic brain injury is a devastating event associated with substantial morbidity. Pathophysiology involves the initial trauma, subsequent inflammatory response, and secondary insults, which worsen brain injury severity. Management entails cardiopulmonary stabilization and diagnostic imaging with targeted interventions, such as decompressive hemicraniectomy, intracranial monitors or drains, and pharmacological agents to reduce intracranial pressure. Anesthesia and intensive care requires control of multiple physiologic variables and evidence-based practices to reduce secondary brain injury. Advances in biomedical engineering have enhanced assessments of cerebral oxygenation, pressure, metabolism, blood flow, and autoregulation. Many centers employ multimodality neuromonitoring for targeted therapies with the hope to improve recovery.
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Affiliation(s)
- Krassimir Denchev
- Department of Anesthesiology, Wayne State University, 44555 Woodward Avenue, SJMO Medical Office Building, Suite 308, Pontiac, MI 48341, USA
| | - Jonathan Gomez
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA
| | - Pinxia Chen
- Department of Anesthesiology and Critical Care Medicine, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA; Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA.
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Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury. Crit Care Med 2023; 51:563-572. [PMID: 36825892 DOI: 10.1097/ccm.0000000000005806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVES The acute cerebral physiologic effects of ketamine in children have been incompletely described. We assessed the acute effects of ketamine on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children with severe traumatic brain injury (TBI). DESIGN In this retrospective observational study, patients received bolus doses of ketamine for sedation or as a treatment for ICP crisis (ICP > 20 mm Hg for > 5 min). Administration times were synchronized with ICP and CPP recordings at 1-minute intervals logged in an automated database within the electronic health record. ICP and CPP were each averaged in epochs following drug administration and compared with baseline values. Age-based CPP thresholds were subtracted from CPP recordings and compared with baseline values. Trends in ICP and CPP over time were assessed using generalized least squares regression. SETTING A 30-bed tertiary care children's hospital PICU. PATIENTS Children with severe TBI who underwent ICP monitoring. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed data from 33 patients, ages 1 month to 16 years, 22 of whom received bolus doses of ketamine, with 127 doses analyzed. Demographics, patient, and injury characteristics were similar between patients who did versus did not receive ketamine boluses. In analysis of the subset of ketamine doses used only for sedation, there was no significant difference in ICP or CPP from baseline. Eighteen ketamine doses were given during ICP crises in 11 patients. ICP decreased following these doses and threshold-subtracted CPP rose. CONCLUSIONS In this retrospective, exploratory study, ICP did not increase following ketamine administration. In the setting of a guidelines-based protocol, ketamine was associated with a reduction in ICP during ICP crises. If these findings are reproduced in a larger study, ketamine may warrant consideration as a treatment for intracranial hypertension in children with severe TBI.
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Huang TH, Lai MC, Chen YS, Huang CW. The Roles of Glutamate Receptors and Their Antagonists in Status Epilepticus, Refractory Status Epilepticus, and Super-Refractory Status Epilepticus. Biomedicines 2023; 11:biomedicines11030686. [PMID: 36979664 PMCID: PMC10045490 DOI: 10.3390/biomedicines11030686] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Status epilepticus (SE) is a neurological emergency with a high mortality rate. When compared to chronic epilepsy, it is distinguished by the durability of seizures and frequent resistance to benzodiazepine (BZD). The Receptor Trafficking Hypothesis, which suggests that the downregulation of γ-Aminobutyric acid type A (GABAA) receptors, and upregulation of N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors play major roles in the establishment of SE is the most widely accepted hypothesis underlying BZD resistance. NMDA and AMPA are ionotropic glutamate receptor families that have important excitatory roles in the central nervous system (CNS). They are both essential in maintaining the normal function of the brain and are involved in a variety of neuropsychiatric diseases, including epilepsy. Based on animal and human studies, antagonists of NMDA and AMPA receptors have a significant impact in ending SE; albeit most of them are not yet approved to be in clinically therapeutic guidelines, due to their psychomimetic adverse effects. Although there is still a dearth of randomized, prospective research, NMDA antagonists such as ketamine, magnesium sulfate, and the AMPA antagonist, perampanel, are regarded to be reasonable optional adjuvant therapies in controlling SE, refractory SE (RSE) or super-refractory SE (SRSE), though there are still a lack of randomized, prospective studies. This review seeks to summarize and update knowledge on the SE development hypothesis, as well as clinical trials using NMDA and AMPA antagonists in animal and human studies of SE investigations.
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Affiliation(s)
- Tzu-Hsin Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
- Zhengxin Neurology & Rehabilitation Center, Tainan 70459, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
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11
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Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection. Biomedicines 2023; 11:biomedicines11020372. [PMID: 36830909 PMCID: PMC9953550 DOI: 10.3390/biomedicines11020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.
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12
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Picetti E, Catena F, Abu-Zidan F, Ansaloni L, Armonda RA, Bala M, Balogh ZJ, Bertuccio A, Biffl WL, Bouzat P, Buki A, Cerasti D, Chesnut RM, Citerio G, Coccolini F, Coimbra R, Coniglio C, Fainardi E, Gupta D, Gurney JM, Hawrylux GWJ, Helbok R, Hutchinson PJA, Iaccarino C, Kolias A, Maier RW, Martin MJ, Meyfroidt G, Okonkwo DO, Rasulo F, Rizoli S, Rubiano A, Sahuquillo J, Sams VG, Servadei F, Sharma D, Shutter L, Stahel PF, Taccone FS, Udy A, Zoerle T, Agnoletti V, Bravi F, De Simone B, Kluger Y, Martino C, Moore EE, Sartelli M, Weber D, Robba C. Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES). World J Emerg Surg 2023; 18:5. [PMID: 36624517 PMCID: PMC9830860 DOI: 10.1186/s13017-022-00468-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/01/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. METHODS A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. RESULTS A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. CONCLUSIONS This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
| | - Fausto Catena
- grid.414682.d0000 0004 1758 8744Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Fikri Abu-Zidan
- grid.43519.3a0000 0001 2193 6666The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736Unit of General Surgery, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Rocco A. Armonda
- grid.411663.70000 0000 8937 0972Department of Neurosurgery, 71541MedStar Georgetown University Hospital, Washington, DC USA ,grid.415235.40000 0000 8585 5745Department of Neurosurgery, 8405MedStar Washington Hospital Center, Washington, DC USA
| | - Miklosh Bala
- grid.9619.70000 0004 1937 0538Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel
| | - Zsolt J. Balogh
- grid.413648.cDepartment of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW Australia
| | - Alessandro Bertuccio
- Department of Neurosurgery, SS Antonio E Biagio E Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Walt L. Biffl
- grid.415401.5Scripps Clinic Medical Group, La Jolla, CA USA
| | - Pierre Bouzat
- grid.450308.a0000 0004 0369 268XInserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Andras Buki
- grid.15895.300000 0001 0738 8966Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Davide Cerasti
- grid.411482.aNeuroradiology Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Randall M. Chesnut
- grid.34477.330000000122986657Department of Neurological Surgery, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | - Giuseppe Citerio
- grid.7563.70000 0001 2174 1754School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy ,grid.415025.70000 0004 1756 8604Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, ASST Monza, Monza, Italy
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- grid.43582.380000 0000 9852 649XRiverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA USA
| | - Carlo Coniglio
- grid.416290.80000 0004 1759 7093Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Enrico Fainardi
- grid.8404.80000 0004 1757 2304Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Deepak Gupta
- grid.413618.90000 0004 1767 6103Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jennifer M. Gurney
- grid.420328.f0000 0001 2110 0308Department of Trauma, San Antonio Military Medical Center and the U.S. Army Institute of Surgical Research, San Antonio, TX 78234 USA ,grid.461685.80000 0004 0467 8038The Department of Defense Center of Excellence for Trauma, Joint Trauma System (JTS), JBSA Fort Sam Houston, San Antonio, TX 78234 USA
| | - Gregory W. J. Hawrylux
- grid.239578.20000 0001 0675 4725Cleveland Clinic, 762 S. Cleveland-Massillon Rd, Akron, OH 44333 USA
| | - Raimund Helbok
- grid.5361.10000 0000 8853 2677Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter J. A. Hutchinson
- grid.5335.00000000121885934Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Corrado Iaccarino
- grid.413363.00000 0004 1769 5275Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Angelos Kolias
- grid.5335.00000000121885934National Institute for Health Research Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital,, University of Cambridge, Cambridge, UK
| | - Ronald W. Maier
- grid.34477.330000000122986657Harborview Medical Center, University of Washington, Seattle, WA USA
| | - Matthew J. Martin
- grid.42505.360000 0001 2156 6853Division of Trauma and Acute Care Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA USA
| | - Geert Meyfroidt
- grid.410569.f0000 0004 0626 3338Department of Intensive Care, University Hospitals Leuven, Louvain, Belgium ,grid.5596.f0000 0001 0668 7884Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Louvain, Belgium
| | - David O. Okonkwo
- grid.412689.00000 0001 0650 7433Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Frank Rasulo
- grid.412725.7Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Sandro Rizoli
- grid.413542.50000 0004 0637 437XSurgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Andres Rubiano
- grid.412195.a0000 0004 1761 4447INUB-MEDITECH Research Group, Institute of Neurosciences, Universidad El Bosque, Bogotá, Colombia
| | - Juan Sahuquillo
- grid.7080.f0000 0001 2296 0625Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Valerie G. Sams
- grid.413561.40000 0000 9881 9161Trauma Critical Care and Acute Care Surgery, Air Force Center for Sustainment of Trauma and Readiness Skills, University of Cincinnati Medical Center, Cincinnati, OH USA
| | - Franco Servadei
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy ,grid.417728.f0000 0004 1756 8807Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Deepak Sharma
- grid.34477.330000000122986657Department of Anesthesiology and Pain Medicine and Neurological Surgery, University of Washington, Seattle, WA USA
| | - Lori Shutter
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, UPMC/University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Philip F. Stahel
- grid.461417.10000 0004 0445 646XCollege of Osteopathic Medicine, Rocky Vista University, Parker, CO USA
| | - Fabio S. Taccone
- grid.410566.00000 0004 0626 3303Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Andrew Udy
- grid.1623.60000 0004 0432 511XDepartment of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC 3004 Australia
| | - Tommaso Zoerle
- grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vanni Agnoletti
- grid.414682.d0000 0004 1758 8744Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Francesca Bravi
- grid.415207.50000 0004 1760 3756Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Yoram Kluger
- grid.413731.30000 0000 9950 8111Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl Della Romagna, Lugo, Italy
| | - Ernest E. Moore
- grid.241116.10000000107903411Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO USA
| | | | - Dieter Weber
- grid.1012.20000 0004 1936 7910Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
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13
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Sivakumar S, Ghasemi M, Schachter SC. Targeting NMDA Receptor Complex in Management of Epilepsy. Pharmaceuticals (Basel) 2022; 15:ph15101297. [PMID: 36297409 PMCID: PMC9609646 DOI: 10.3390/ph15101297] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
N-methyl-D-aspartate receptors (NMDARs) are widely distributed in the central nervous system (CNS) and play critical roles in neuronal excitability in the CNS. Both clinical and preclinical studies have revealed that the abnormal expression or function of these receptors can underlie the pathophysiology of seizure disorders and epilepsy. Accordingly, NMDAR modulators have been shown to exert anticonvulsive effects in various preclinical models of seizures, as well as in patients with epilepsy. In this review, we provide an update on the pathologic role of NMDARs in epilepsy and an overview of the NMDAR antagonists that have been evaluated as anticonvulsive agents in clinical studies, as well as in preclinical seizure models.
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Affiliation(s)
- Shravan Sivakumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Correspondence: (M.G.); (S.C.S.)
| | - Steven C. Schachter
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02114, USA
- Consortia for Improving Medicine with Innovation & Technology (CIMIT), Boston, MA 02114, USA
- Correspondence: (M.G.); (S.C.S.)
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14
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Ornowska M, Wormsbecker A, Andolfatto G, Leung T, Khan I, Medvedev G. The use of ketamine as a neuroprotective agent following cardiac arrest: A scoping review of current literature. CNS Neurosci Ther 2022; 29:104-110. [PMID: 36184822 PMCID: PMC9804040 DOI: 10.1111/cns.13983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS The objective of this article is to summarize the state of the literature surrounding the use of ketamine as a neuroprotective agent following cardiac arrest. METHODS Five electronic databases were used to search for studies related to the use of ketamine for neuroprotection following cardiac arrest. This search was performed once in May 2020, and an updated search was conducted in May 2021 and March 2022. RESULTS All searches combined retrieved 181 results; no clinical trials were identified. As such, the authors were limited to writing a scoping review of the literature rather than a systematic review. CONCLUSIONS The current state of the literature describes the mechanism of action of ketamine as a neuroprotective agent through its action as an NMDA antagonist. There is evidence of its efficacy as a neuroprotective agent in preclinical models of cardiac arrest. Current published clinical work supports the use of ketamine ameliorating neurologic outcomes in other conditions such as epilepsy, traumatic brain injury, and depression. The current state of the literature is reflective of the notion that the use of ketamine following cardiac arrest may result in improved neurologic outcomes. Future research directions should focus on the use of ketamine as a possible clinical intervention following cardiac arrest.
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Affiliation(s)
- Marlena Ornowska
- Department of Biomedical PhysiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - Andrew Wormsbecker
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Critical Care, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gary Andolfatto
- Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Tim S. Leung
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada,Lower Mainland Pharmacy ServicesVancouverBritish ColumbiaCanada
| | - Idan Khan
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Neurology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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15
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Rueda Carrillo L, Garcia KA, Yalcin N, Shah M. Ketamine and Its Emergence in the Field of Neurology. Cureus 2022; 14:e27389. [PMID: 36046286 PMCID: PMC9419113 DOI: 10.7759/cureus.27389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/15/2022] Open
Abstract
The quest for a safe and effective anesthetic medication in the mid-20th century led to the discovery of CI-581, which was later named ketamine. Ketamine was labeled a “dissociative anesthetic” due to the state of sensory deprivation that it induces in the subjects receiving it. Although it enjoyed widespread use at the beginning of the Vietnam war, its use rapidly waned due to its psychedelic effect and it became more popular as a recreational drug, and in the field of veterinary medicine. However, as we gained more knowledge about its multiple sites of action, it has reemerged as a useful anesthetic/analgesic agent. In the last decade, the field of neurology has witnessed the growing use of ketamine for the treatment of several neurological conditions including migraine, status epilepticus, stroke, and traumatic brain injury (TBI). Ketamine acts primarily as a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. The binding of ketamine to NMDA receptors leads to decreased frequency and duration of Ca+2 channel opening and thus inhibits glutaminergic transmission. This mechanism has proven to be neuroprotective in several neurological conditions. Ketamine does not increase intracranial pressure (ICP), and it maintains cerebral perfusion pressure (CPP) by increasing cerebral blood flow. Ketamine has also been shown to inhibit massive slow waves of neurological depolarizations called cortical spreading depolarizations (CSD), usually seen during acute neurological injury and are responsible for further neurological deterioration. Unlike other anesthetic agents, ketamine does not cause cardiac or respiratory suppression. All these favorable mechanisms and cerebral/hemodynamic actions have led to increased interest among clinicians and researchers regarding the novel uses of ketamine. This review will focus on the use of ketamine for various neurological indications.
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16
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Effect of Intravenous Ketamine on Hypocranial Pressure Symptoms in Patients with Spinal Anesthetic Cesarean Sections: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11144129. [PMID: 35887893 PMCID: PMC9317657 DOI: 10.3390/jcm11144129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 12/22/2022] Open
Abstract
Background: Pregnant women are more likely to suffer post-puncture symptoms such as headaches and nausea due to the outflow of cerebrospinal fluid after spinal anesthesia. Because ketamine has the effect of raising intracranial pressure, it may be able to improve the symptoms of perioperative hypocranial pressure and effectively prevent the occurrence of hypocranial pressure-related side effects. Method: Keywords such as ketamine, cesarean section, and spinal anesthesia were searched in databases including Medline, Embase, Web of Science, and Cochrane from 1976 to 2021. Thirteen randomized controlled trials were selected for the meta-analysis. Results: A total of 12 randomized trials involving 2099 participants fulfilled the inclusion criteria. There was no significant association between ketamine and the risk of headaches compared to the placebo (RR = 1.12; 95% CI: 0.53, 2.35; p = 0.77; I² = 62%). There was no significant association between ketamine and nausea compared to the placebo (RR = 0.66; 95% CI: 0.40, 1.09; p = 0.10; I² = 57%). No significant associations between ketamine or the placebo and vomiting were found (RR = 0.94; 95% CI: 0.53, 1.67; p = 0.83; I² = 72%). Conclusion: Intravenous ketamine does not improve the symptoms caused by low intracranial pressure after spinal anesthesia in patients undergoing cesarean section.
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Picetti E, Bouzat P, Cattani L, Taccone FS. Perioperative management of severe brain injured patients. Minerva Anestesiol 2021; 88:380-389. [PMID: 34636222 DOI: 10.23736/s0375-9393.21.15927-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy -
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble Alpes University Hospital, Grenoble, France
| | - Luca Cattani
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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18
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Himmelseher S, Kochs EF. Ready for a "breakthrough" with ketamine? A look at recent pharmacological insights! Curr Opin Anaesthesiol 2021; 34:393-401. [PMID: 34052823 DOI: 10.1097/aco.0000000000001017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To update pharmacological insights on ketamine integrating information from different disciplines for developing steps to "breakthrough" approaches in clinical challenges. RECENT FINDINGS Pharmacokinetic/pharmacodynamic (PK/PD) models have incorporated recirculation, ketamine metabolites, drug-drug interaction, and covariates such as age. Ketamine-induced relief from treatment-resistant depression has been explained by "disinhibition" of gamma-aminobutyric acid-ergic interneurons and synaptogenic mechanisms requiring neurotrophic signals. Neuroimaging/electroencephalographic investigations have shown an increase in gamma spectral power in healthy volunteers and patients with depression, but also opposite changes in functional network connectivity after subanesthetic ketamine. Volunteer data may not be transferable to clinical conditions. Altered states of consciousness induced by subanesthetic ketamine have been described by disruption of resisting-state functional networks and frontoparietal connectivity with preservation of multisensory and sensor-motor networks. This has been interpreted as a "disconnected consciousness". SUMMARY More precise PK/PD models may improve the ketamine use regimen. The findings from research on depression are an important discovery because ketamine's impact on neuronal plasticity and synaptogenesis in human brain disease has directly been documented. Psychic adverse effects with subanesthetic ketamine are related to a "disconnected consciousness". Overall, progress has been made, but the "breakthrough" still has to come.
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Affiliation(s)
- Sabine Himmelseher
- Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
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19
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Khan SM, Carter GT, Aggarwal SK, Holland J. Psychedelics for Brain Injury: A Mini-Review. Front Neurol 2021; 12:685085. [PMID: 34393973 PMCID: PMC8357986 DOI: 10.3389/fneur.2021.685085] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Stroke and traumatic brain injury (TBI) are among the leading causes of disability. Even after engaging in rehabilitation, nearly half of patients with severe TBI requiring hospitalization are left with major disability. Despite decades of investigation, pharmacologic treatment of brain injury is still a field in its infancy. Recent clinical trials have begun into the use of psychedelic therapeutics for treatment of brain injury. This brief review aims to summarize the current state of the science's relevance to neurorehabilitation, and may act as a resource for those seeking to understand the precedence for these ongoing clinical trials. Methods: Narrative mini-review of studies published related to psychedelic therapeutics and brain injury. Results: Recent in vitro, in vivo, and case report studies suggest psychedelic pharmacotherapies may influence the future of brain injury treatment through modulation of neuroinflammation, hippocampal neurogenesis, neuroplasticity, and brain complexity. Conclusions: Historical data on the safety of some of these substances could serve in effect as phase 0 and phase I studies. Further phase II trials will illuminate how these drugs may treat brain injury, particularly TBI and reperfusion injury from stroke.
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Affiliation(s)
- Shariq Mansoor Khan
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Gregory T Carter
- Department of Physical Medicine & Rehabilitation, St. Luke's Rehabilitation Institute, Spokane, WA, United States
| | - Sunil K Aggarwal
- Advanced Integrative Medical Sciences Institute, Seattle, WA, United States
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Abstract
PURPOSE OF REVIEW Anesthetics are known to have immunomodulatory effects. These can be detrimental, inducing immunosuppression and facilitating the development of opportunistic infections, especially when used at high doses, for prolonged periods, or in patients with preexisting immune deficiency; or beneficial, modulating the inflammatory response, particularly in critical illness and systemic hyperinflammatory states. RECENT FINDINGS Anesthetics can have microbicidal properties, and both anti- and pro-inflammatory effects. They can act directly on immune cells as well as modulate immunity through indirect pathways, acting on the neuroimmune stress response, and have recently been described to interact with the gut microbiota. SUMMARY Anesthesiologists should take into consideration the immunomodulatory properties of anesthetic agents in addition to their hemodynamic, neuroprotective, and other impacts. In future, patient stratification according to the perioperative assessment of serum biomarkers associated with postoperative complications may be used to guide anesthetic agent selection based on their immunomodulatory properties.
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Affiliation(s)
- Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Intergrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
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