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Upadhyay P, Ichhpujani P, Solanki A. Recent trends in anesthetic agents and techniques for ophthalmic anesthesia. J Anaesthesiol Clin Pharmacol 2023; 39:343-348. [PMID: 38025549 PMCID: PMC10661636 DOI: 10.4103/joacp.joacp_555_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/01/2023] Open
Abstract
Effective and safe ophthalmic anesthesia is essential for the delivery of ophthalmic perioperative care both for children and adults. Recent years have seen a major change in form of smaller incisions for most ophthalmic surgical techniques, thus making them less invasive. Additionally, most ophthalmic surgeries are now day-care surgeries at ambulatory surgical centers. The parallel advancements in the field of anesthesiology have boosted the standard of perioperative care. The purpose of this narrative review was to evaluate current trends in anesthetic agents and techniques for ophthalmic anesthesia primarily centered around deep sedation and general anesthesia as per the concerns of practicing anesthesiologists while briefly acquainting with local anesthesia advances.
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Affiliation(s)
- Prateek Upadhyay
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Parul Ichhpujani
- Department of Ophthalmology, Government Medical College and Hospital, Chandigarh, India
| | - Abhilasha Solanki
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, NY, USA
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Stöhr T, Colin PJ, Ossig J, Pesic M, Borkett K, Winkle P, Struys MMRF, Schippers F. Pharmacokinetic properties of remimazolam in subjects with hepatic or renal impairment. Br J Anaesth 2021; 127:415-423. [PMID: 34246461 DOI: 10.1016/j.bja.2021.05.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 05/13/2021] [Accepted: 05/26/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Remimazolam is a new benzodiazepine for procedural sedation and general anaesthesia. The aim of this study was to characterise its pharmacokinetic properties and safety in renally and hepatically impaired subjects. METHODS Two separate trials were conducted in patients with hepatic (n=11) or renal impairment (n=11) compared with matched healthy subjects (n=9 and n=12, respectively). The hepatic impairment trial was an open-label adaptive 'Reduced Design' trial, using a single bolus of remimazolam 0.1 mg kg-1 i.v., whereas the renal impairment trial was an open-label trial of a single bolus dose of remimazolam 1.5 mg i.v. Remimazolam plasma concentrations over time were analysed by population pharmacokinetic modelling. RESULTS Remimazolam pharmacokinetic properties were adequately described by a three-compartment, recirculatory model. Exposure in subjects with severe hepatic impairment was 38.1% higher (i.e. clearance was 38.1% lower) compared with healthy volunteers. This increase caused a slightly delayed recovery (8.0 min for healthy, 12.1 min for moderate, and 16.7 min for severe hepatic impairment). With renal impairment, plasma clearance was comparable with that measured in healthy subjects. Simulations of Cmax after a bolus dose of 10 mg showed no relevant impact of hepatic or renal impairment. The overall incidence of adverse events was low, and all adverse events were mild. CONCLUSIONS As Cmax after a remimazolam bolus i.v. was not affected by hepatic or renal impairment, no dose adjustments are required. No unexpected adverse events related to remimazolam were seen in subjects with renal or hepatic impairment. CLINICAL TRIAL REGISTRATION Hepatic impairment trial: ClinicalTrials.gov, NCT01790607 (https://clinicaltrials.gov/ct2/show/NCT01790607). Renal impairment trial: EudraCT Number: 2014-004575-23.
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Affiliation(s)
| | - Pieter J Colin
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | - Michel M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Modeling the Effect of Excitation on Depth of Anesthesia Monitoring in γ-Aminobutyric Acid Type A Receptor Agonist ABP-700. Anesthesiology 2021; 134:35-51. [PMID: 33064833 DOI: 10.1097/aln.0000000000003590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND γ-Aminobutyric acid type A (GABAA) receptor agonists are known to cause involuntary muscle movements. The mechanism of these movements is not known, and its relationship to depth of anesthesia monitoring is unclear. We have explored the effect of involuntary muscle movement on the pharmacokinetic-pharmacodynamic model for the GABAA receptor agonist ABP-700 and its effects on the Bispectral Index (BIS) as well as the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores. METHODS Observations from 350 individuals (220 men, 130 women) were analyzed, comprising 6,312 ABP-700 concentrations, 5,658 ABP-700 metabolite (CPM-acid) concentrations, 25,745 filtered BIS values, and 6,249 MOAA/S scores, and a recirculatory model developed. Various subject covariates and pretreatment with an opioid or a benzodiazepine were explored as covariates. Relationships between BIS and MOAA/S models and involuntary muscle movements were examined. RESULTS The final model shows that the pharmacokinetics of ABP-700 are characterized by small compartmental volumes and rapid clearance. The BIS model incorporates an effect-site for BIS suppression and a secondary excitatory/disinhibitory effect-site associated with a risk of involuntary muscle movements. The secondary effect-site has a threshold that decreases with age. The MOAA/S model did not show excitatory effects. CONCLUSIONS The GABAA receptor agonist ABP-700 shows the expected suppressive effects for BIS and MOAA/S, but also disinhibitory effects for BIS associated with involuntary muscle movements and reduced by pretreatment. Our model provides information about involuntary muscle movements that may be useful to improve depth of anesthesia monitoring for GABAA receptor agonists. EDITOR’S PERSPECTIVE
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Antkowiak B, Rammes G. GABA(A) receptor-targeted drug development -New perspectives in perioperative anesthesia. Expert Opin Drug Discov 2019; 14:683-699. [DOI: 10.1080/17460441.2019.1599356] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bernd Antkowiak
- Department of Anesthesiology and Intensive Care, Experimental Anesthesiology Section, Eberhard-Karls-University,
Tübingen, Germany
- Department of Anaesthesiology and Intensive Care, Experimental Anaesthesiology Section, Werner Reichardt Center for Integrative Neuroscience, Tübingen,
Germany
| | - Gerhard Rammes
- University Hospital rechts der Isar, Department of Anesthesiology, München,
Germany
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Abstract
Anesthesiology, as a field, has made promising advances in the discovery of novel, safe, effective, and efficient methods to deliver care. This review explores refinement in the technology of soft drug development, unique anesthetic delivery systems, and recent drug and device failures.
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Affiliation(s)
- Mohamed Mahmoud
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Keira P Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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Wang S, Liu Q, Li X, Zhao X, Qiu L, Lin J. Possible binding sites and interactions of propanidid and AZD3043 within the γ-aminobutyric acid type A receptor (GABAAR). J Biomol Struct Dyn 2017; 36:3926-3937. [DOI: 10.1080/07391102.2017.1403959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Shanshan Wang
- School of Chemical and Material Engineering, Jiangnan University, Wuxi 214122, P.R China
- Key Laboratory of Nuclear Medicine, Ministry of Health & Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi 214063, P.R. China
| | - Qingzhu Liu
- Key Laboratory of Nuclear Medicine, Ministry of Health & Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi 214063, P.R. China
| | - Xi Li
- School of Chemical and Material Engineering, Jiangnan University, Wuxi 214122, P.R China
- Key Laboratory of Nuclear Medicine, Ministry of Health & Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi 214063, P.R. China
| | - Xueyu Zhao
- School of Chemical and Material Engineering, Jiangnan University, Wuxi 214122, P.R China
- Key Laboratory of Nuclear Medicine, Ministry of Health & Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi 214063, P.R. China
| | - Ling Qiu
- School of Chemical and Material Engineering, Jiangnan University, Wuxi 214122, P.R China
- Key Laboratory of Nuclear Medicine, Ministry of Health & Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi 214063, P.R. China
| | - Jianguo Lin
- Key Laboratory of Nuclear Medicine, Ministry of Health & Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi 214063, P.R. China
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Feng AY, Kaye AD, Kaye RJ, Belani K, Urman RD. Novel propofol derivatives and implications for anesthesia practice. J Anaesthesiol Clin Pharmacol 2017; 33:9-15. [PMID: 28413268 PMCID: PMC5374837 DOI: 10.4103/0970-9185.202205] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Propofol (2,6-diisopropylphenol) is the most commonly used intravenous agent for induction of anesthesia. It is also used for maintenance of anesthesia and sedation in both Intensive Care Units and outpatient procedural settings. Its success in the clinical setting has been a result of its rapid onset, short duration of action, and minimal side effects despite disadvantages associated with its oil emulsion formulation. Early attempts to alter the standard emulsion or to develop new formulations with cyclodextrins and micelles to resolve issues with pain upon injection, the need for antimicrobial agents, and possible hyperlipidemia have mostly failed. With these challenges in the foreground, attention has now shifted to the use of more prodrugs and exogenous alternatives, the success of which is yet to be determined. These new agents must offer significant clinical advantages over the well-entrenched, generic propofol oil emulsion to justify higher costs and to be well received in the increasingly cost-conscious healthcare marketplace.
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Affiliation(s)
- Aiden Y Feng
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan D Kaye
- Department of Anesthesiology and Pharmacology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Rachel J Kaye
- Department of Anesthesiology and Pharmacology, Louisiana State University Health Sciences Center, New Orleans, LA, USA.,Department of Biochemistry, Bowdoin College, Brunswick, ME, USA
| | - Kumar Belani
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Sear JW, Egan TD. David (Propofol Wannabes) Versus Goliath (Propofol): AZD-3043 Goes Up Against the Giant! Anesth Analg 2015; 121:849-851. [PMID: 26378696 DOI: 10.1213/ane.0000000000000904] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- John W Sear
- From the Nuffield Department of Anaesthetics, University of Oxford, Oxford, United Kingdom; and Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
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Kalman S, Koch P, Ahlén K, Kanes SJ, Barassin S, Björnsson MA, Norberg Å. First Human Study of the Investigational Sedative and Anesthetic Drug AZD3043: A Dose-Escalation Trial to Assess the Safety, Pharmacokinetics, and Efficacy of a 30-Minute Infusion in Healthy Male Volunteers. Anesth Analg 2015; 121:885-893. [PMID: 26111262 DOI: 10.1213/ane.0000000000000831] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AZD3043 is a positive allosteric modulator of the γ-aminobutyric acid type A receptor that is rapidly metabolized to an inactive metabolite by esterases present in blood and liver. Preclinical results suggest that AZD3043 has the potential as a short-acting IV sedative/anesthetic drug with rapid and predictable recovery characteristics and a favorable safety and tolerability profile. METHODS Our primary objective in this phase 1, single-center, open-label study was to evaluate the safety and tolerability of AZD3043 after IV infusion and to estimate the maximal tolerated dose. Secondary objectives included the evaluation of AZD3043 pharmacokinetics, pharmacodynamics, and efficacy. Sequential ascending-dose cohorts of 5 or 6 healthy male volunteers aged 18 to 45 years received a single 30-minute IV infusion of AZD3043. Assessments included adverse events, vital signs, blood gases, laboratory values, clinical signs of sedation/anesthesia, and bispectral index. RESULTS Fifty-three subjects received AZD3043 in infusion rate cohorts of 1, 3, 6, 12, 18, 27, 36, 54, and 81 mg/kg/h. There were no discontinuations, and dose escalation was stopped on reaching the predefined exposure limit. Adverse events occurring in >1 subject were headache (n = 4), erythema (n = 3), chest discomfort (n = 2), nausea (n = 2), and dyspnea (n = 2). The frequency and character of adverse events appeared unrelated to dose. There were no spontaneous reports of pain on injection and no clinically relevant changes in respiratory rate or arterial blood pressure. However, heart rate increased dose-dependently at infusion rates >18 mg/kg/h. Occurrence of sedation/anesthesia corresponded with dose; the lowest applied infusion rate to induce anesthesia according to clinical signs of sedation/anesthesia at predefined time points was 12 mg/kg/h (1 of 6 subjects anesthetized), and all subjects in the 3 highest dose groups were anesthetized. The onset of anesthesia ranged from 4 minutes in the highest infusion rate group to 29 minutes in the 12-mg/kg/h infusion rate group. Return of response to oral command occurred at 3 minutes after the end of infusion in the single subject who was anesthetized in the 12-mg/kg/h group and median 25 minutes in the 81-mg/kg/h group. Involuntary movements ranging from minor twitches to extensive movements were accompanied by increased muscle tone. CONCLUSIONS AZD3043 was well tolerated in this first human study and seems to exhibit rapid onset and recovery, indicating potential use as a short-acting drug for anesthesia and sedation.
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Affiliation(s)
- Sigridur Kalman
- From the Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm at Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Huddinge, Sweden; AstraZeneca R&D, Södertälje, Sweden; AstraZeneca US, Wilmington, Delaware; and Department of Clinical Pharmacology and Pharmacometrics, AstraZeneca R&D, Södertälje, Sweden
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