1
|
Kotani Y, D'Andria Ursoleo J, Murru CP, Landoni G. Blood Pressure Management for Hypotensive Patients in Intensive Care and Perioperative Cardiovascular Settings. J Cardiothorac Vasc Anesth 2024; 38:2089-2099. [PMID: 38918089 DOI: 10.1053/j.jvca.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 06/27/2024]
Abstract
Blood pressure is a critical physiological parameter, particularly in the context of cardiac intensive care and perioperative settings. As a primary indicator of organ perfusion, the maintenance of adequate blood pressure is imperative for the assurance of sufficient tissue oxygen delivery. Among critically ill and major surgery patients, the continuous monitoring of blood pressure is performed as a standard practice for patients. Nonetheless, uncertainties remain regarding blood pressure goals, and there is no consensus regarding blood pressure targets. This review describes the determinants of blood pressure, examine the influence of blood pressure on organ perfusion, and synthesize the current clinical evidence from various intensive care and perioperative settings to provide a concise guidance for daily clinical practice.
Collapse
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Pia Murru
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
2
|
Amer M, Hylander Møller M, Alshahrani M, Shehabi Y, Arabi YM, Alshamsi F, Ingi Sigurðsson M, Rehn M, Chew MS, Kalliomäki ML, Lewis K, Al-Suwaidan FA, Al-Dorzi HM, Al-Fares A, Alsadoon N, Bell CM, Groth CM, Parke R, Mehta S, Wischmeyer PE, Omeri A, Olkkola KT, Alhazzani W. Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Anesth Analg 2024:00000539-990000000-00925. [PMID: 39207913 DOI: 10.1213/ane.0000000000007173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND This Rapid Practice Guideline (RPG) aimed to provide evidence‑based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. METHODS The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. RESULTS Data from 17 randomized clinical trials (n=898) and 9 observational studies (n=1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. CONCLUSION The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.
Collapse
Affiliation(s)
- Marwa Amer
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Yahya Shehabi
- School of Clinical Sciences, Monash University, Clayton Campus, Victoria
- Clinical School of Medicine, University of New South Wales, Randwick Campus, New South Wales, Australia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Martin Ingi Sigurðsson
- Faculty of Medicine, University of Iceland, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Iceland
| | - Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Kimberley Lewis
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Faisal A Al-Suwaidan
- Division of Neurology, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
- Neurology Clinical Lead, Ministry of Health, Saudi Arabia
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Naif Alsadoon
- Alshaya International Trading Company, Riyadh, Saudi Arabia
| | - Carolyn M Bell
- Medical University of South Carolina Hospital Authority, Charleston, SC
- Medical University of South Carolina College of Pharmacy, Charleston, SC
| | | | - Rachael Parke
- School of Nursing University of Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Sangeeta Mehta
- Dept. of Medicine, Mount Sinai Hospital; Interdepartmental Division of Intensive Care Medicine, Toronto, Canada
| | - Paul E Wischmeyer
- Deptartments of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC
| | - Awad Omeri
- Dr Sulaiman Al-Habib Medical Group, Critical Care Department, Riyadh, Saudi Arabia
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Scientific Research Center, Directorate General of Armed Forces Medical Services, Riyadh, Saudi Arabia
| |
Collapse
|
3
|
Karamchandani K, Nasa P, Jarzebowski M, Brewster DJ, De Jong A, Bauer PR, Berkow L, Brown CA, Cabrini L, Casey J, Cook T, Divatia JV, Duggan LV, Ellard L, Ergan B, Jonsson Fagerlund M, Gatward J, Greif R, Higgs A, Jaber S, Janz D, Joffe AM, Jung B, Kovacs G, Kwizera A, Laffey JG, Lascarrou JB, Law JA, Marshall S, McGrath BA, Mosier JM, Perin D, Roca O, Rollé A, Russotto V, Sakles JC, Shrestha GS, Smischney NJ, Sorbello M, Tung A, Jabaley CS, Myatra SN. Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study. Intensive Care Med 2024:10.1007/s00134-024-07578-2. [PMID: 39162823 DOI: 10.1007/s00134-024-07578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/28/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). METHODS An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. RESULTS The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. CONCLUSION Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.
Collapse
Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Prashant Nasa
- Critical Care Medicine, NMC Specialty Hospital, Al Nahda, Dubai, UAE
- Internal Medicine, College of Medicine and Health Sciences, Al Ain, Abu Dhabi, UAE
| | - Mary Jarzebowski
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI, USA
| | - David J Brewster
- Intensive Care Unit, Cabrini Hospital, Melbourne, Australia
- School of Translational Medicine, Monash University, Melbourne, Australia
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - Lauren Berkow
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Lahey Hospital and Medical Center, UMass Chan - Lahey School of Medicine, Burlington, MA, USA
| | - Luca Cabrini
- Department of Biotechnology and Life Sciences, Insubria University, Ospedale di Circolo, Varese, Italy
| | - Jonathan Casey
- Division of Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tim Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Laura V Duggan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - Louise Ellard
- Department of Critical Care, University of Melbourne, Department of Anaesthesia, Austin Health, Victoria, Australia
| | - Begum Ergan
- Division of Critical Care Medicine, Department of Pulmonary and Critical Care, Dokuz Eylul University, Izmir, Turkey
| | - Malin Jonsson Fagerlund
- Department of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden
| | - Jonathan Gatward
- Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Robert Greif
- University of Bern, Bern, Switzerland
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Andy Higgs
- Department of Critical Care Medicine, Warrington Teaching Hospitals, Cheshire, UK
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
| | - David Janz
- Section of Pulmonary and Critical Care Medicine, Tulane School of Medicine, University Medical Center New Orleans, LSU School of Medicine of New Orleans, New Orleans, LA, USA
| | - Aaron M Joffe
- Department of Anesthesiology, Creighton University School of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Boris Jung
- Medical Intensive Care Unit, INSERM PhyMedexp, Montpellier University, Montpellier, France
| | - George Kovacs
- Departments of Emergency Medicine, Anaesthesia, Medical Neurosciences & Continuing Professional Development and Medical Education, Charles V. Keating Emergency and Trauma Centre, Dalhousie University, Halifax, NS, Canada
| | - Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland
| | - Jean-Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, Médecine Intensive Réanimation, UR 4334, 44000, Nantes, France
| | - J Adam Law
- Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Stuart Marshall
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia
| | - Brendan A McGrath
- Anaesthesia and Intensive Care Medicine, Manchester University Hospital, NHS Foundation Trust, Manchester, UK
| | - Jarrod M Mosier
- Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Arizona College of Medicine, Tucson, AZ, USA
| | | | - Oriol Roca
- Servei de Medicina Intensiva, Institut de Recerca Part Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain
| | - Amélie Rollé
- Anesthesia and Intensive Care, University Hospital of La Guadeloupe, University of Les Antilles, Abymes, France
| | - Vincenzo Russotto
- Anesthesia and Intensive Care, University Hospital San Luigi Gonzaga, Orbassano (TO), University of Turin, Turin, Italy
| | - John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Nathan J Smischney
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Massimiliano Sorbello
- UOC Anesthesia and Intensive Care PO Giovanni Paolo II, Ragusa, Italy
- Anaesthesia and Intensive Care, Kore University, Enna, Italy
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Craig S Jabaley
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
4
|
Gao X, Yang X, Tang Y, Fang X, Yuan Y, Qi H, Li R, Shu H, Zou X, Shang Y. Fospropofol disodium versus propofol for long-term sedation during invasive mechanical ventilation: A pilot randomized clinical trial. J Clin Anesth 2024; 95:111442. [PMID: 38493706 DOI: 10.1016/j.jclinane.2024.111442] [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: 11/09/2023] [Revised: 02/26/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
STUDY OBJECTIVE Fospropofol disodium is a propofol prodrug that is water-soluble and has a reduced risk of bacterial contamination and hypertriglyceridemia compared with propofol. Prior to implementing a large randomized trial, we investigated the feasibility, initial efficacy, and safety of fospropofol disodium compared with propofol in long-term mild-to-moderate sedation in intensive care units (ICUs). DESIGN Single-centered, prospective, unblind, randomized, parallel-group clinical trial. SETTING The general ICU of university-affiliated teaching hospital. PATIENTS Adult patients (n = 60) expected to have mechanical ventilation for >24 h were enrolled and randomly assigned to the fospropofol or propofol group. INTERVENTIONS The fospropofol group received continuous fospropofol disodium infusions and the propofol group received continuous propofol infusions. The sedation goal was a score of -3 to 0 on the Richmond Agitation and Sedation Scale (RASS). MEASUREMENTS The primary outcome was the percentage of time spent in the target sedation range without rescue sedation. Safety outcomes were based on adverse events. Blood samples were collected to measure formate concentration in plasma. MAIN RESULTS The median dose was 4.33 (IQR, 3.08-4.94) mg/kg/h in the fospropofol group and 1.96 (IQR, 1.44-2.94) mg/kg/h in the propofol group. The median percentage of time spent in the target RASS range without rescue sedation was identical in both groups, with 83.33% (IQR, 74.43%-100.00%) in the fospropofol group and 83.33% (IQR, 77.45%-100.00%) in the propofol group (p = 0.887). At least one adverse event was identifed in 23 (76.7%) fospropofol patients and 27 (90.0%) propofol patients. The most common adverse events were tachycardia and hypotension. No paresthesia, catheter-related bloodstream infection or propofol infusion syndrome in both groups was reported. Three patients in the fospropofol group had mild hypertriglyceridemia, and nine patients in propofol group had hypertriglyceridemia (mild in eight patients and moderate in one patient) (10% versus 30%, p = 0.104). The formate concentration in plasma was very low, and no significant difference was identified at any time point between the two groups. CONCLUSIONS Fospropofol disodium appears to be a feasible, effective and safe sedative for patients receiving invasive mechanical ventilation with long-term sedation.
Collapse
Affiliation(s)
- Xuehui Gao
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yun Tang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiangzhi Fang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yin Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hong Qi
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| |
Collapse
|
5
|
Remmington C, Camporota L, Meddings C, Hanks F, Taylor D, Sousa A, Sanderson B, Glover G. Clinical use and safety of volatile anaesthetic sedation in mechanically ventilated adult patients: a retrospective single-centre cohort study. Br J Anaesth 2024; 133:208-210. [PMID: 38719698 DOI: 10.1016/j.bja.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 06/17/2024] Open
Affiliation(s)
- Christopher Remmington
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK; Institute of Pharmaceutical Sciences, School of Cancer & Pharmaceutical Sciences, King's College London, London, UK.
| | - Luigi Camporota
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Christopher Meddings
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fraser Hanks
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK; Institute of Pharmaceutical Sciences, School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Daniel Taylor
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Angelo Sousa
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Barnaby Sanderson
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Guy Glover
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
6
|
Kampman JM, Hermanides J, Hollmann MW, Gilhuis CN, Bloem WAH, Schraag S, Pradelli L, Repping S, Sperna Weiland NH. Mortality and morbidity after total intravenous anaesthesia versus inhalational anaesthesia: a systematic review and meta-analysis. EClinicalMedicine 2024; 72:102636. [PMID: 38774674 PMCID: PMC11106536 DOI: 10.1016/j.eclinm.2024.102636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/24/2024] Open
Abstract
Background General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using only intravenous agents, or through inhalational anaesthesia, using volatile anaesthetic agents. The debate on how this affects postoperative patient outcome is ongoing, despite an abundance of published trials. The relevance of this topic has grown by the increasing concern about the contribution of anaesthetic gases to the environmental impact of surgery. We aimed to summarise all available evidence on relevant patient outcomes with total intravenous anaesthesia versus inhalational anaesthesia. Methods In this systematic review and meta-analysis, we searched PubMed/Medline, Embase and Cochrane Central Register of Controlled trials for works published from January 1, 1985 to August 1, 2023 for randomised controlled trials comparing total intravenous anaesthesia using propofol versus inhalational anaesthesia using the volatile anaesthetics sevoflurane, desflurane or isoflurane. Two reviewers independently screened titles, abstracts and full text articles, and assessed risk of bias using the Cochrane Collaboration tool. Outcomes were derived from a recent series of publications on consensus definitions for Standardised Endpoints for Perioperative trials (StEP). Primary outcomes covered mortality and organ-related morbidity. Secondary outcomes were related to anaesthetic and surgical morbidity. This study is registered with PROSPERO (CRD42023430492). Findings We included 317 randomised controlled trials, comprising 51,107 patients. No difference between total intravenous and inhalational anaesthesia was seen in the primary outcomes of in-hospital mortality (RR 1.05, 95% CI 0.67-1.66, 27 trials, 3846 patients), 30-day mortality (RR 0.97, 95% CI 0.70-1.36, 23 trials, 9667 patients) and one-year mortality (RR 1.14, 95% CI 0.88-1.48, 13 trials, 9317 patients). Organ-related morbidity was similar between groups except for the subgroup of elderly patients, in which total intravenous anaesthesia was associated with a lower incidence of postoperative cognitive dysfunction (RR 0.62, 95% CI 0.40-0.97, 11 trials, 3834 patients) and a better score on postoperative cognitive dysfunction tests (standardised mean difference 1.68, 95% CI 0.47-2.88, 9 trials, 4917 patients). In the secondary outcomes, total intravenous anaesthesia resulted in a lower incidence of postoperative nausea and vomiting (RR 0.61, 95% CI 0.56-0.67, 145 trials, 23,172 patients), less emergence delirium (RR 0.40, 95% CI 0.29-0.56, 32 trials, 4203 patients) and a higher quality of recovery score (QoR-40 mean difference 6.45, 95% CI 3.64-9.25, 17 trials, 1835 patients). Interpretation The results indicate that postoperative mortality and organ-related morbidity was similar for intravenous and inhalational anaesthesia. Total intravenous anaesthesia offered advantages in postoperative recovery. Funding Dutch Society for Anaesthesiology (NVA).
Collapse
Affiliation(s)
- Jasper M. Kampman
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | | | | | - Sjoerd Repping
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Healthcare Evaluation and Appropriate Use, National Healthcare Institute, Diemen, the Netherlands
| | - Nicolaas H. Sperna Weiland
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands
| |
Collapse
|
7
|
Guichard L, Bhatia M. Volatile Anesthetic Agents Are Preferred Over Total Intravenous Anesthesia in Cardiac Surgery Under Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00366-5. [PMID: 38937175 DOI: 10.1053/j.jvca.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Lauriane Guichard
- Department of Anesthesiology, University of North Carolina at Chapel Hill.
| | - Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| |
Collapse
|
8
|
Milne B, John M, Evans R, Robertson S, Ó Scanaill P, Murphy GJ, Landoni G, Marber M, Clayton T, Kunst G. Comparison between propofol and total inhalational anaesthesia on cardiovascular outcomes following on-pump cardiac surgery in higher-risk patients: a randomised controlled pilot and feasibility study. Open Heart 2024; 11:e002630. [PMID: 38724266 PMCID: PMC11086547 DOI: 10.1136/openhrt-2024-002630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/14/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES Myocardial revascularisation and cardiopulmonary bypass (CPB) can cause ischaemia-reperfusion injury, leading to myocardial and other end-organ damage. Volatile anaesthetics protect the myocardium in experimental studies. However, there is uncertainty about whether this translates into clinical benefits because of the coadministration of propofol and its detrimental effects, restricting myocardial protective processes. METHODS In this single-blinded, parallel-group randomised controlled feasibility trial, higher-risk patients undergoing elective coronary artery bypass graft (CABG) surgery with an additive European System for Cardiac Operative Risk Evaluation ≥5 were randomised to receive either propofol or total inhalational anaesthesia as single agents for maintenance of anaesthesia. The primary outcome was the feasibility of recruiting and randomising 50 patients across two cardiac surgical centres, and secondary outcomes included the feasibility of collecting the planned perioperative data, clinically relevant outcomes and assessments of effective patient identification, screening and recruitment. RESULTS All 50 patients were recruited within 11 months in two centres, allowing for a 13-month hiatus in recruitment due to the COVID-19 pandemic. Overall, 50/108 (46%) of eligible patients were recruited. One patient withdrew before surgery and one patient did not undergo surgery. All but one completed in-hospital and 30-day follow-up. CONCLUSIONS It is feasible to recruit and randomise higher-risk patients undergoing CABG surgery to a study comparing total inhalational and propofol anaesthesia in a timely manner and with high acceptance and completion rates. TRIAL REGISTRATION NUMBER NCT04039854.
Collapse
Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Therapy, King's College Hospital NHS Foundation Trust, London, UK
| | - Martin John
- Department of Anaesthesia, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Richard Evans
- London School of Hygiene and Tropical Medicine, Medical Statistics, 1 Keppel Street, London WC1E 7HT, UK
| | - Steven Robertson
- London School of Hygiene and Tropical Medicine, Medical Statistics, 1 Keppel Street, London WC1E 7HT, UK
| | - Pádraig Ó Scanaill
- Department of Anaesthetics and Pain Therapy, King's College Hospital NHS Foundation Trust, London, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michael Marber
- School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Tim Clayton
- London School of Hygiene and Tropical Medicine, Medical Statistics, 1 Keppel Street, London WC1E 7HT, UK
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Therapy, King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| |
Collapse
|
9
|
Fuchs VF, Simon HV, Soldinger N, Volk T, Meiser A. Neuropsychological follow-up of isoflurane sedated intensive care patients: a substudy of a randomized trial. Minerva Anestesiol 2024; 90:377-385. [PMID: 38482637 DOI: 10.23736/s0375-9393.24.17834-0] [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: 05/22/2024]
Abstract
BACKGROUND Inhaled sedation of intensive care unit (ICU) patients ventilated >24 hours may have long term effects. We hypothesized that isoflurane has a better neuropsychological outcome in a one-year follow-up compared to propofol sedation. METHODS All 66 patients included by the coordinating center of the ISOCONDA study (EudraCT#: 2016-004551-67) took part in this substudy (DRKS00020240). A delirium test (CAM-ICU) was performed 24 hours after end of sedation. Sedation-, ventilator-, ICU- and delirium-free days within 30 days were calculated. Patients were sent five questionnaires one, three and twelve months after ICU discharge: ICU-Memory-tool (ICU-MT), Short-Form-36-Health-survey (SF-36), Posttraumatic-Stress-Scale-14 (PTSS-14), WHO-Five-Well-Being-Index (WHO-5) and Hospital-Anxiety-Depression-Scale (HADS). RESULTS CAM-ICU was positive in 17% of patients, however 68% showed signs of delirium during the ICU stay (no group differences). Mortality was lower after isoflurane (30-days: 1/33 versus 7/33, P=0.024; One-year: 9/33 versus 14/33, P=0.156). Isoflurane led to significantly more sedation- (median [IQR]: 28[25-29] versus 24[21-29], P=0.016), ventilator- (28[24-29] versus 22[4-28], P=0.011), ICU- (23[13-26] versus 11[0-25], P=0.044) and delirium-free days (25[21-29] versus 20[12-28], P=0.031). Return rate of questionnaires was high (87/128). In the ICU-MT, isoflurane patients recalled significantly more factual memories after one year. Generally, the psychological tests suggested a poor quality of life (SF-36), high rates of post-traumatic-stress-disorder (PTSS-14: 38%) and depression (WHO-5: 54%, HADS: 43%), without significant group differences. CONCLUSIONS Isoflurane sedation leads to more delirium free days during the ICU treatment and more factual memories of the ICU stay one year after the ICU stay. However long-term outcome of ventilated ICU patients is poor, and there were no differences between isoflurane and propofol sedation.
Collapse
Affiliation(s)
- Verena F Fuchs
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
- Department of General Pediatrics and Neonatology, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Henrik V Simon
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany -
| | - Nina Soldinger
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| |
Collapse
|
10
|
Bernat M, Boyer A, Roche M, Richard C, Bouvet L, Remacle A, Antonini F, Poirier M, Pastene B, Hammad E, Fond G, Bruder N, Leone M, Zieleskiewicz L. Reducing the carbon footprint of general anaesthesia: a comparison of total intravenous anaesthesia vs. a mixed anaesthetic strategy in 47,157 adult patients. Anaesthesia 2024; 79:309-317. [PMID: 38205529 DOI: 10.1111/anae.16221] [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] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
Global warming is a major public health concern. Volatile anaesthetics are greenhouse gases that increase the carbon footprint of healthcare. Modelling studies indicate that total intravenous anaesthesia is less carbon intensive than volatile anaesthesia, with equivalent quality of care. In this observational study, we aimed to apply the findings of previous modelling studies to compare the carbon footprint per general anaesthetic of an exclusive TIVA strategy vs. a mixed TIVA-volatile strategy. This comparative retrospective study was conducted over 2 years in two French hospitals, one using total intravenous anaesthesia only and one using a mixed strategy including both intravenous and inhalation anaesthetic techniques. Based on pharmacy procurement records, the quantity of anaesthetic sedative drugs was converted to carbon dioxide equivalents. The primary outcome was the difference in carbon footprint of hypnotic drugs per intervention between the two strategies. From 1 January 2021 to 31 December 2022, 25,137 patients received general anaesthesia in the hospital using the total intravenous anaesthesia strategy and 22,020 in the hospital using the mixed strategy. The carbon dioxide equivalent footprint of hypnotic drugs per intervention in the hospital using the total intravenous anaesthesia strategy was 20 times lower than in the hospital using the mixed strategy (emissions of 2.42 kg vs. 48.85 kg carbon dioxide equivalent per intervention, respectively). The total intravenous anaesthesia strategy significantly reduces the carbon footprint of hypnotic drugs in general anaesthesia in adult patients compared with a mixed strategy. Further research is warranted to assess the risk-benefit ratio of the widespread adoption of total intravenous anaesthesia.
Collapse
Affiliation(s)
- M Bernat
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - A Boyer
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - M Roche
- Pharmacy Department, Service Central des Opérations Pharmaceutiques, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - C Richard
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - L Bouvet
- Department of Anesthesia and Critical Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - A Remacle
- Departement of Medical Information, Hôpital Nord, Marseille, France
| | - F Antonini
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - M Poirier
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - B Pastene
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - E Hammad
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - G Fond
- CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, Marseille, France
| | - N Bruder
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - M Leone
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - L Zieleskiewicz
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| |
Collapse
|
11
|
Jia L, Li H, Li T. Efficacy of Sevoflurane and Propofol Anesthesia on Perioperative Adverse Cardiovascular Events and Hemodynamics in Elderly Patients With Diabetes. Clin Ther 2024; 46:246-251. [PMID: 38350756 DOI: 10.1016/j.clinthera.2024.01.006] [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: 07/12/2023] [Revised: 12/05/2023] [Accepted: 01/18/2024] [Indexed: 02/15/2024]
Abstract
PURPOSE This study was undertaken to compare the effects of sevoflurane and propofol anesthesia on perioperative hemodynamics and perioperative adverse cardiovascular events (PACE) in elderly patients with diabetes undergoing general anesthesia for noncardiac surgery. METHODS According to the random number table (n = 40), 80 patients with diabetes undergoing noncardiac general anesthesia were divided into a control group and an observation group. In the control group, the patients were given propofol 4 to 6 mg/(kg·h), continuously pumped to maintain anesthesia. In the observation group, the patients were given maintained concentration of sevoflurane for 1 to 1.5 minimum alveolar concentration (MAC) for continuous inhalation, while remifentanil with volume fraction of 0.05 to 1 µg/(kg·min) was given for continuous pumping in both groups. The heart rate (HR) and mean arterial pressure (MAP) of the patients were recorded, and the serum creatine kinase-MB (CK-MB) and cardiac troponin I (cTnI) contents before anesthesia (T0), immediately after surgery (T3), and 24 hours later (T4) as well as the blood glucose levels at T0 and T3 were compared between the two groups. The occurrence of PACE in the two groups was compared during the perioperative period. FINDINGS The HR and MAP 5 minutes after intubation (T1), 1 hour after skin incision (T2), and at T3 in the two groups were significantly lower than those of T0 (P < 0.05), whereas the MAP and HR of T1, T2, and T3 in the observation group were significantly higher than those of the control group (P < 0.05). The T3 blood glucose levels were significantly higher in the two groups than that in T0 (P < 0.05), and the T3 blood glucose levels in the observation group were significantly lower than that in the control group (P < 0.05). CK-MB and cTnI in the two groups were significantly higher at T3 and T4 than T0 (P < 0.05), whereas CK-MB and cTnI in the observation group were significantly lower than in the control group at T3 and T4 (P < 0.05). The incidence of hypotension and PACE was significantly lower in the observation group than in the control group (P < 0.05). IMPLICATIONS Compared with propofol IV general anesthesia, sevoflurane inhalation anesthesia can improve perioperative hemodynamics stability and reduce the incidence of PACE in elderly patients with diabetes undergoing noncardiac surgery.
Collapse
Affiliation(s)
- Liling Jia
- Department of Anesthesiology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Hongfeng Li
- Department of Anesthesiology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Tuping Li
- Department of Anesthesiology, The Second Hospital of Shanxi Medical University, Taiyuan, China.
| |
Collapse
|
12
|
Kotani Y, Semler MW, Lee TC, Landoni G. Authors response: "Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials". J Crit Care 2024; 79:154411. [PMID: 37690922 DOI: 10.1016/j.jcrc.2023.154411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan.
| | - Matthew W Semler
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, United States; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, United States
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
13
|
Slingerland-Boot R, Kummerow M, Arbous SM, van Zanten ARH. Association between first-week propofol administration and long-term outcomes of critically ill mechanically ventilated patients: A retrospective cohort study. Clin Nutr 2024; 43:42-51. [PMID: 38000194 DOI: 10.1016/j.clnu.2023.10.029] [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: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND & AIM Propofol is commonly used in ICUs, but its long-term effects have not been thoroughly studied. In vitro studies suggest it may harm mitochondrial function, potentially affecting clinical outcomes. This study aimed to investigate the association between substantial propofol sedation and clinical outcomes in critically ill patients. METHODS We conducted a single-centre cohort study of critically ill, mechanically ventilated (≥7 days) adults to compare patients who received a substantial dose of propofol (cumulative >500 mg) during the first week of ICU admission with those who did not. The primary outcome was the association between substantial propofol administration and 6-month mortality, adjusted for relevant covariates. Subanalyses were performed for administration in the early (day 1-3) and late (day 4-7) acute phases of critical illness due to the metabolic changes in this period. Secondary outcomes included tracheostomy need and duration, length of ICU and hospital stay (LOS), discharge destinations, ICU, hospital, and 3-month mortality. RESULTS A total of 839 patients were enrolled, with 73.7 % receiving substantial propofol administration (substantial propofol dose group). Six-month all-cause mortality was 32.4 %. After adjusting for relevant variables, we found no statistically significant difference in 6-month mortality between both groups. There were also no significant differences in secondary outcomes. CONCLUSION Our study suggests that substantial propofol administration during the first week of ICU stay in the least sick critically ill, mechanically ventilated adult patients is safe, with no significant associations found with 6-month mortality, ICU or hospital LOS, differences in discharge destinations or need for tracheostomy.
Collapse
Affiliation(s)
- Rianne Slingerland-Boot
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands
| | - Maren Kummerow
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Sesmu M Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands.
| |
Collapse
|
14
|
Dost B, Turunc E, Sarikaya Ozel E, Aydın ME, Karapinar YE, Beldagli M, De Cassai A. Myocardial Protection in Cardiac Surgery: Exploring the Influence of Anesthetic Agents. Eurasian J Med 2023; 55:138-141. [PMID: 38752865 PMCID: PMC11075016 DOI: 10.5152/eurasianjmed.2023.23376] [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: 11/24/2023] [Accepted: 12/26/2023] [Indexed: 05/19/2024] Open
Abstract
This review assesses the efficacy of inhalation anesthetics and propofol in cardiac surgery, primarily focusing on their impact on myocardial protection and subsequent clinical outcomes. The review provides a concise summary of the current scientific information regarding the protective efects of inhalation anesthetics and propofol, particularly in the context of ischemia-reperfusion injury during cardiac surgery. The review delves into the mechanisms of action and discusses clinical studies comparing the 2 anesthetic strategies regarding mortality, complication rates, and length of hospital stay. Inhalation anesthetics exhibit cardioprotective properties through many mechanisms, such as preconditioning, scavenging of free radicals, and stabilizing mitochondria. Propofol demonstrates certain protective benefits but does not possess the preconditioning capability of inhalation medications. Clinical investigations yield contradictory findings, as several studies indicate enhanced outcomes with inhalation anesthetics, while others observe no substantial disparity between the 2 approaches. The cardioprotective efcacy of propofol against ischemia-reperfusion injury remains limited. While its inherent antioxidant properties ofer direct myocardial protection, propofol demonstrably lacks the preconditioning-mediated signaling pathways triggered by inhalation anesthetics. As a result, propofol's protective efect may be slightly inferior to preconditioning strategies, and its potential to inhibit organ-protective impact of other interventions needs further investigation. The question of which anesthetic approach ofers superior myocardial protection remains debatable. Current evidence is inconclusive, potentially due to patient heterogeneity, surgical complexity, and methodological limitations of existing studies. Future research, including pharmacogenetic studies and large, welldesigned, randomized controlled trials, are necessary to provide definitive guidance on anesthetic selection for optimal myocardial protection in cardiac surgery.
Collapse
Affiliation(s)
- Burhan Dost
- Department of Anaesthesiology and Reanimation, Ondokuz Mayıs University Faculty of Medicine, Samsun, Türkiye
| | - Esra Turunc
- Department of Anaesthesiology and Reanimation, Ondokuz Mayıs University Faculty of Medicine, Samsun, Türkiye
| | - Elif Sarikaya Ozel
- Department of Anaesthesiology and Reanimation, Ondokuz Mayıs University Faculty of Medicine, Samsun, Türkiye
| | - Muhammed Enes Aydın
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Türkiye
| | - Yunus Emre Karapinar
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Türkiye
| | - Muzeyyen Beldagli
- Department of Anesthesiology and Reanimation, Samsun Training and Research Hospital Faculty of Medicine, Samsun, Türkiye
| | - Alessandro De Cassai
- UOC Anesthesia and Intensive Care Unit “Sant’Antonio”, University Hospital of Padua, Padua, Italy
| |
Collapse
|
15
|
Marcos-Vidal JM, González R, Merino M, Higuera E, García C. Sedation for Patients with Sepsis: Towards a Personalised Approach. J Pers Med 2023; 13:1641. [PMID: 38138868 PMCID: PMC10744994 DOI: 10.3390/jpm13121641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.
Collapse
Affiliation(s)
- José Miguel Marcos-Vidal
- Department of Anesthesiology and Critical Care, Universitary Hospital of Leon, 24071 Leon, Spain; (R.G.); (M.M.); (E.H.); (C.G.)
| | | | | | | | | |
Collapse
|
16
|
Kempenaers S, Hansen TG, Van de Velde M. Remimazolam and serious adverse events: A scoping review. Eur J Anaesthesiol 2023; 40:841-853. [PMID: 37727906 DOI: 10.1097/eja.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Remimazolam is anticipated to be an interesting anaesthetic and sedative. It combines the pharmacodynamic properties of midazolam with pharmacokinetic properties similar to remifentanil. However, worrisome case reports of anaphylaxis, delayed emergence and re-sedation have emerged recently and necessitate further investigation.PubMed (including MEDLINE) and EMBASE were searched for all studies reporting serious adverse events where remimazolam was administered for sedation or anaesthesia.Thirty-six case reports and 73 trials were identified, involving a total of 6740 patients who received remimazolam. Hypotension was reported in 911 cases, delayed emergence in 68 cases, anaphylaxis in 10 cases and re-sedation in 8 cases. The incidence of hypotension seems to be lower compared with other anaesthetics, even in high-risk patients.Delayed emergence might be related to the metabolism of remimazolam through carboxylesterase 1 (CES1), a tissue esterase predominant in the liver. There is significant interindividual variation, and it is inhibited by flavonoids, fatty acids and alcohol. Individual benzodiazepine sensitivity has also been reported. A higher BMI, older age and low plasma albumin concentration are risk factors for delayed emergence. Anaphylaxis might be related to a non-IgE-mediated effect of the excipient dextran-40 or a partially IgE-mediated reaction to remimazolam itself. Resedation has been reported after flumazenil reversal and is explained by the specific pharmacokinetic properties of flumazenil and remimazolam. Reversal by flumazenil should be reserved for and used carefully in patients with delayed emergence. VISUAL ABSTRACT http://links.lww.com/EJA/A864 .
Collapse
Affiliation(s)
- Sander Kempenaers
- From the Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium (SK), Department of Anaesthesia and Intensive Care, Akershus University Hospital, Lorenskog (TGH), Faculty of Medicine, Institute of Clinical Medicine, Oslo University, Oslo, Norway (TGH), Department of Cardiovascular Sciences, KU Leuven (MVdV) and Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium (MVdV)
| | | | | |
Collapse
|
17
|
Dietrich M, Bernhard M, Beynon C, Fiedler MO, Hecker A, Jungk C, Nusshag C, Michalski D, Schmitt FCF, Brenner T, Weigand MA, Reuß CJ. [Focus on sepsis and general intensive care medicine : Summary of selected intensive care studies]. DIE ANAESTHESIOLOGIE 2023; 72:821-830. [PMID: 37672061 DOI: 10.1007/s00101-023-01334-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/07/2023]
Affiliation(s)
- M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Neurochirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - F C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| |
Collapse
|
18
|
Kotani Y, Pruna A, Landoni G. Mechanisms of Action of the Detrimental Effects of Propofol on Survival. J Cardiothorac Vasc Anesth 2023; 37:2176-2180. [PMID: 37586953 DOI: 10.1053/j.jvca.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023]
Abstract
Due to its favorable pharmacologic features, propofol is the most commonly used hypnotic agent in perioperative and intensive care settings. However, it also has adverse effects like propofol infusion syndrome and an increased risk of infection. Growing evidence suggests that propofol may worsen clinical outcomes by inhibiting the organ-protective properties of other interventions, such as volatile anesthetics or remote ischemic preconditioning. This editorial describes possible mechanisms underlying the detrimental effects of propofol, and provides an overview of the results of clinical trials evaluating the effects of propofol in various settings.
Collapse
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
19
|
Bellgardt M, Onyeche F, Sackey P, Bracht H. Authors response: "ICU- and ventilator-free days with isoflurane or propofol as a primary sedative - A post-hoc analysis of a randomized controlled trial". J Crit Care 2023; 77:154372. [PMID: 37453836 DOI: 10.1016/j.jcrc.2023.154372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Martin Bellgardt
- Department of Anaesthesiology and Intensive Care Medicine, St.-Josef-Hospital, University Hospital of Ruhr-University of Bochum, Germany.
| | - Fabian Onyeche
- Department of Anaesthesiology and Intensive Care Medicine, St.-Josef-Hospital, University Hospital of Ruhr-University of Bochum, Germany
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden.
| | - Hendrik Bracht
- University Hospital Ulm, Department of Emergency Medicine, Ulm, Germany.
| |
Collapse
|
20
|
Kotani Y, Pruna A, Belletti A, Lee TC, Landoni G. Authors' reply to the comment from Glass et al. Crit Care 2023; 27:334. [PMID: 37644558 PMCID: PMC10464268 DOI: 10.1186/s13054-023-04599-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy.
| |
Collapse
|
21
|
Glass A, McCall P, Shelley B. Comment on Propofol and survival: an updated meta-analysis of randomized clinical trials. Crit Care 2023; 27:281. [PMID: 37434188 PMCID: PMC10337079 DOI: 10.1186/s13054-023-04550-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/25/2023] [Indexed: 07/13/2023] Open
Affiliation(s)
- Adam Glass
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
| | - Philip McCall
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Ben Shelley
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| |
Collapse
|
22
|
Vincent JL. Harmful effects of propofol? The Editor's standpoint. Crit Care 2023; 27:279. [PMID: 37430324 DOI: 10.1186/s13054-023-04559-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium.
| |
Collapse
|
23
|
Kotani Y, Pruna A, Lee TC, Roth D, Landoni G. Comment to: "Propofol and survival: an updated meta-analysis of randomized clinical trials": authors' reply. Crit Care 2023; 27:237. [PMID: 37322553 PMCID: PMC10273723 DOI: 10.1186/s13054-023-04528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-Cho, Kamogawa, Chiba, 296-8602, Japan
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy.
| |
Collapse
|
24
|
Hansel J. Propofol versus the world: The whole is not always greater than the sum of its parts. Crit Care 2023; 27:208. [PMID: 37254187 DOI: 10.1186/s13054-023-04450-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Jan Hansel
- University of Manchester, Manchester, UK.
| |
Collapse
|
25
|
Gutierrez MAG, Meade-Aguilar JA, Martinez DE. Reply to "Propofol and survival: an updated meta‑analysis of randomized clinical trials". Crit Care 2023; 27:192. [PMID: 37198651 DOI: 10.1186/s13054-023-04484-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/19/2023] Open
|