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Haththotuwegama KJ, Bowdle A, Jelacic S, Silliman W. In Response. Anesth Analg 2024; 139:e7-e8. [PMID: 38885405 DOI: 10.1213/ane.0000000000007045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Affiliation(s)
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Seattle, Washington,
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Seattle, Washington
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Sprung J, Deljou A, Schroeder DR, Warner DO, Weingarten TN. Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia: A Retrospective Cohort Study. Anesth Analg 2024; 139:26-34. [PMID: 38381704 DOI: 10.1213/ane.0000000000006906] [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: 02/23/2024]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU). METHODS We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics. RESULTS Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 μg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56). CONCLUSIONS The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.
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Affiliation(s)
- Juraj Sprung
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Atousa Deljou
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | - David O Warner
- From the Departments of Anesthesiology and Perioperative Medicine
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Warner BK, Munhall CC, Nguyen SA, Schlosser RJ, Guldan GJ, Meyer TA. Dexmedetomidine and surgical field visibility in nasal surgery: A systematic review and meta-analysis. J Perioper Pract 2024:17504589241252107. [PMID: 38831613 DOI: 10.1177/17504589241252107] [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: 06/05/2024]
Abstract
INTRODUCTION Nasal and sinus surgery, especially using endoscopy, relies upon adequate haemostasis to be safe and effective. Often other haemostatic methods, such as cautery are not viable, and other methods must be employed. This study examines the effectiveness of dexmedetomidine in controlled hypotension and for surgical field visibility in endoscopic sinus surgery and other nasal surgeries. REVIEW METHODS A literature search was conducted in PubMed, Scopus, CINAHL and Central for randomised controlled trials using dexmedetomidine for controlled hypotension in adult patients undergoing endoscopic sinus surgery or other nasal surgery. Meta-analysis of mean differences and single means were performed. RESULTS Of 935 identified studies, 31 met the inclusion criteria. A statistically significant difference in Fromme-Boezaart surgical field visibility scores was found comparing dexmedetomidine to placebo (p < 0.00001) and propofol (p < 0.0001), but not other agents. A significant difference in intraoperative blood loss volume was found compared with placebo (51.5mL, p < 0.00001) and propofol (13.6mL, p < 0.0001), but not other agents. CONCLUSION Dexmedetomidine demonstrated significantly improved surgical field visibility and blood loss volume compared with placebo and propofol, but not other agents. Dexmedetomidine is viable and useful for controlled hypotension in nasal surgery. Choice of controlled hypotension agent should follow patient and procedure-specific considerations.
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Affiliation(s)
- Brendon K Warner
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - C Cooper Munhall
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - George J Guldan
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Watanabe M, Nikaido Y, Sasaki N. Validation of the anesthetic effect of a mixture of remimazolam, medetomidine, and butorphanol in three mouse strains. Exp Anim 2024; 73:223-232. [PMID: 38246607 DOI: 10.1538/expanim.23-0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
Proper administration of anesthesia is indispensable for the ethical treatment of lab animals in biomedical research. Therefore, selecting an effective anesthesia protocol is pivotal for the design and success of experiments. Hence, continuous development and refinement of anesthetic agents are imperative to improve research outcomes and elevate animal welfare. "Balanced anesthesia" involves using multiple drugs to optimize efficacy while minimizing side effects. The medetomidine, midazolam, and butorphanol, called MMB, and medetomidine, alfaxalone, and butorphanol, called MAB, are popular in Japan. However, the drawbacks of midazolam, including its extended recovery time, and the narrow safety margin of MAB, have prompted research for suitable alternatives. This study replaced midazolam in the MMB combination with remimazolam (RMZ), which is noted for its ultra-short half-life. The resulting combination, called MRB, was effective in providing a wider safety margin compared to MAB while maintaining an anesthesia depth equivalent level to that of MMB in mice. Notably, MRB consistently exhibited better recovery scores after antagonist administration in contrast to MMB. Furthermore, the re-sedation phenomenon observed with MMB was not observed with MRB. The rapid metabolism of RMZ enables reliable anesthesia induction, circumventing the complications linked to MAB. Overall, MRB excelled in providing extended surgical anesthesia and swift post-antagonist recovery. These results highlight the potential of RMZ for broader animal research applications.
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Affiliation(s)
- Masaki Watanabe
- Laboratory of Laboratory Animal Science and Medicine, School of Veterinary Medicine, Kitasato University, 35-1 Higashi-23, Towada, Aomori 034-8628, Japan
| | - Yuko Nikaido
- Laboratory of Laboratory Animal Science and Medicine, School of Veterinary Medicine, Kitasato University, 35-1 Higashi-23, Towada, Aomori 034-8628, Japan
| | - Nobuya Sasaki
- Laboratory of Laboratory Animal Science and Medicine, School of Veterinary Medicine, Kitasato University, 35-1 Higashi-23, Towada, Aomori 034-8628, Japan
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Brosnan RJ, Pypendop BH, Cenani A. Effects of trazodone and dexmedetomidine on fentanyl-mediated reduction of isoflurane minimum alveolar concentration in cats. Vet Anaesth Analg 2024; 51:80-89. [PMID: 37926586 DOI: 10.1016/j.vaa.2023.09.130] [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: 06/26/2023] [Revised: 09/16/2023] [Accepted: 09/30/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To screen modulators of biogenic amine (BA) neurotransmission for the ability to cause fentanyl to decrease isoflurane minimum alveolar concentration (MAC) in cats, and to test whether fentanyl plus a combination of modulators decreases isoflurane MAC more than fentanyl alone. STUDY DESIGN Prospective, experimental study. ANIMALS A total of six adult male Domestic Short Hair cats. METHODS Each cat was anesthetized in three phases with a 1 week washout between studies. In phase 1, anesthesia was induced and maintained with isoflurane, and MAC was measured in duplicate using a tail clamp stimulus and standard bracketing technique. A 21 ng mL-1 fentanyl target-controlled infusion was then administered and MAC measured again. In phase 2, a single cat was administered a single BA modulator (buspirone, haloperidol, dexmedetomidine, pregabalin, ramelteon or trazodone) in a pilot drug screen, and isoflurane MAC was measured before and after fentanyl administration. In phase 3, isoflurane MAC was measured before and after fentanyl administration in cats co-administered trazodone and dexmedetomidine, the two BA modulator drugs associated with fentanyl MAC-sparing in the screen. Isoflurane MAC-sparing by fentanyl alone, trazodone-dexmedetomidine and trazodone-dexmedetomidine-fentanyl was evaluated using paired t tests with p < 0.05 denoting significant effects. RESULTS The MAC of isoflurane was 1.87% ± 0.09 and was not significantly affected by fentanyl administration (p = 0.09). In the BA screen, cats administered trazodone or dexmedetomidine exhibited 26% and 22% fentanyl MAC-sparing, respectively. Trazodone-dexmedetomidine co-administration decreased isoflurane MAC to 1.50% ± 0.14 (p < 0.001), and the addition of fentanyl further decreased MAC to 0.95% ± 0.16 (p < 0.001). CONCLUSIONS AND CLINICAL RELEVANCE Fentanyl alone does not affect isoflurane MAC in cats, but co-administration of trazodone and dexmedetomidine causes fentanyl to significantly decrease isoflurane requirement.
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Affiliation(s)
- Robert J Brosnan
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, USA.
| | - Bruno H Pypendop
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - Alessia Cenani
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, USA
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Kissin I. Antinociceptive Agents as General Anesthetic Adjuncts: Supra-additive and Infra-additive Interactions. Anesth Analg 2023; 137:1198-1207. [PMID: 37851902 DOI: 10.1213/ane.0000000000006737] [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: 10/20/2023]
Abstract
The hypothesis "General anesthesia consists of producing both loss of consciousness and the inhibition of noxious stimuli reaching the brain and causing arousal" was used as a basis for the review of published data on general anesthetic interactions with antinociceptive agents: opioids, α 2 adrenergic agonists, and systemic sodium channel blockers. This review is focused on a specific type of anesthetic interaction-the transformation of antinociceptive agents into general anesthetic adjuncts. The primary aim is to answer 2 questions. First, how does an antinociceptive agent transform the effect of an anesthetic in providing a certain component of anesthesia-hypnosis, immobility, or hemodynamic response to noxious stimulation? Second, does a combination of an anesthetic with an adjunct result in a simple summation of their respective effects or in a supra-additive or infra-additive interaction? The Medline database was searched for data describing the interactions of antinociceptive agents and general anesthetics. The following classes of antinociceptive agents were considered: opioids, α 2 adrenergic agonists, and systemic sodium channel blockers. Drugs used in combination with antinociceptive agents were general anesthetics and benzodiazepines. The following terms related to drug interactions were used: anesthetic interactions, synergy, antagonism, isobolographic analysis, response surface analysis, and fractional analysis. The interactions of antinociceptive agents with general anesthetics result in a decrease of general anesthetic requirements, which differ for each of the components of general anesthesia: hypnosis, immobility, and hemodynamic response to noxious stimulation. Most studies of the nature of anesthetic interactions are related to opioid-general anesthetic combinations, and their conclusions usually confirm supra-additivity.
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Affiliation(s)
- Igor Kissin
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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7
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Gupta A, Laha JK. Growing Utilization of Radical Chemistry in the Synthesis of Pharmaceuticals. CHEM REC 2023; 23:e202300207. [PMID: 37565381 DOI: 10.1002/tcr.202300207] [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: 06/15/2023] [Revised: 07/19/2023] [Indexed: 08/12/2023]
Abstract
Our current unhealthy lifestyle and the exponential surge in the population getting affected by a variety of diseases have made pharmaceuticals or drugs an imperative part of life, making the development of innovative strategies for drug discovery or the introduction of refined, cost-effective and modern technologies for the synthesis of clinically used drugs, a need of the hour. Ever since their discovery, free radicals and radical cations or anions as reactive intermediates have captivated the chemists, resulting in an exceptional utilization of these moieties throughout the field of chemical synthesis, owing to their unprecedented and widespread reactivity. Sticking with the idea of not judging the book by its cover, despite the conventional thought process of radicals being unstable and difficult to control entities, scientists and academicians around the globe have done an appreciable amount of work utilizing both persistent as well as transient radicals for a variety of organic transformations, exemplifying them with the synthesis of significant biologically active pharmaceutical ingredients. This review truly accounts for the organic radical transformations including radical addition, radical cascade cyclization, radical/radical cross-coupling, coupling with metal-complexes and radical cations coupling with nucleophiles, that offers fascinating and unconventional approaches towards the construction of intricate structural frameworks of marketed APIs with high atom- and step-economy; complementing the otherwise employed traditional methods. This tutorial review presents a comprehensive package of diverse methods utilized for radical generation, featuring their reactivity to form critical bonds in pharmaceutical total synthesis or in building key starting materials or intermediates of their synthetic journey, acknowledging their excellence, downsides and underlying mechanisms, which are otherwise poorly highlighted in the literature. Despite great achievements over the past few decades in this area, many challenges and obstacles are yet to be unraveled to shorten the distance between the academics and the industry, which are all discussed in summary and outlook.
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Affiliation(s)
- Anjali Gupta
- Department of Pharmaceutical Technology (Process Chemistry), National Institute of Pharmaceutical Education & Research (NIPER) S.A.S. Nagar, Sahibzada Ajit Singh Nagar, Mohali, 160062, India
| | - Joydev K Laha
- Department of Pharmaceutical Technology (Process Chemistry), National Institute of Pharmaceutical Education & Research (NIPER) S.A.S. Nagar, Sahibzada Ajit Singh Nagar, Mohali, 160062, India
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Heybati K, Zhou F, Baltazar M, Poudel K, Ochal D, Ellythy L, Deng J, Chelf CJ, Welker C, Ramakrishna H. Appraisal of Postoperative Outcomes of Volatile and Intravenous Anesthetics: A Network Meta-Analysis of Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:2215-2222. [PMID: 37573213 DOI: 10.1053/j.jvca.2023.07.011] [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: 06/01/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES To determine the relative efficacy of specific regimens used as primary anesthetics, as well as the potential combination of volatile and intravenous anesthetics among patients undergoing cardiac, thoracic, and vascular surgery. DESIGN This frequentist, random-effects network meta-analysis was registered prospectively (CRD42022316328) and conducted according to the PRISMA-NMA framework. Literature searches were conducted up to April 1, 2022 across relevant databases. Risk of bias (RoB) and confidence of evidence were assessed by RoB-2 and CINeMA, respectively. Pooled treatment effects were compared with propofol monotherapy. SETTING Fifty-three randomized controlled trials (N = 8,085) were included, of which 46 trials (N = 6,604) enrolled patients undergoing cardiac surgery. PARTICIPANTS Trials enrolling adults (≥18) undergoing cardiac, thoracic, and vascular surgery, using the same induction regimens, and comparing volatile and/or total intravenous anesthesia for the maintenance of anesthesia. Given that the majority of trials focused on those undergoing cardiac surgery and the heterogeneity, analyses were restricted to this population. MEASUREMENT AND MAIN RESULTS Outcomes of interest included intensive care unit (ICU) length of stay (LOS), myocardial infarction, in-hospital and 30-day mortality, stroke, and delirium. Across 19 trials (N = 1,821; 9 arms; I2 = 64.5%), sevoflurane combined with propofol decreased ICU LOS (mean difference [MD] -18.26 hours; 95% CI -34.78 to -1.73 hours), whereas midazolam with propofol (MD 17.51 hours; 95% CI 2.78-32.25 hours) was associated with a significant increase in ICU LOS, when compared with propofol monotherapy. Among 27 trials (N = 4,080; 10 arms; I2 = 0%), midazolam was associated with significantly greater risk of myocardial infarction versus propofol (risk ratio 1.94; 95% CI 1.01-3.71). There were no significant differences across other outcomes. CONCLUSION In patients undergoing cardiac surgery, sevoflurane with propofol was associated with decreased ICU LOS compared with propofol monotherapy. Midazolam with propofol increased ICU LOS compared with propofol alone. The combined use of intravenous and volatile anesthetics should be explored further. Future trials in thoracic and vascular surgery are warranted.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN
| | - Fangwen Zhou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Keshav Poudel
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN
| | - Domenic Ochal
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN
| | - Luqman Ellythy
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Carson Welker
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic - Rochester, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic - Rochester, Rochester, MN.
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Watanabe Y, Obara S, Inoue S. Total intravenous anesthesia management with simultaneous use of remimazolam and propofol: A case series of three patients. SAGE Open Med Case Rep 2023; 11:2050313X231204574. [PMID: 37811347 PMCID: PMC10559696 DOI: 10.1177/2050313x231204574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
Remimazolam is an ultra-short-acting benzodiazepine anesthetic agent. Because of pharmacodynamic interactions in the sedation effect between benzodiazepines and propofol, the combination of remimazolam and propofol may allow for a dose reduction of each agent while providing effective sedation for general anesthesia. We experienced three cases in which general anesthesia was induced with remimazolam and maintained with relatively small doses of remimazolam and propofol target-controlled infusion. In all cases, electroencephalogram changes associated with sedation induced by remimazolam were carefully observed during anesthesia induction before administration of propofol. The time required for recovery from anesthesia was 8-13 min. This is the first report in which remimazolam and propofol were concomitantly used for general anesthesia based on the concept of pharmacodynamic interaction. This anesthetic combination may be beneficial in reducing doses of each anesthetic and avoiding delayed recovery from anesthesia, although further study is needed to confirm this.
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Affiliation(s)
| | - Shinju Obara
- Shinju Obara, Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima 960-1295, Japan.
| | - Satoki Inoue
- Department of Anesthesiology, Fukushima Medical University, Fukushima, Japan
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Obert DP, Schneider F, Schneider G, von Dincklage F, Sepulveda P, García PS, Kratzer S, Kreuzer M. Performance of the SEDLine Monitor: Age Dependency and Time Delay. Anesth Analg 2023; 137:887-895. [PMID: 36727845 DOI: 10.1213/ane.0000000000006369] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Devices monitoring the hypnotic component of general anesthesia can help to guide anesthetic management. The main purposes of these devices are the titration of anesthesia dose. While anesthesia at low doses can result in awareness with intraoperative memory formation, excessive administration of anesthetics may be associated with an increased risk of postoperative neurocognitive disorder. We have previously shown for various indices that they are significantly influenced by the patient's age and that the monitors have a significant time delay. Here, we evaluated the influence of patient's age and time delay on the patient state index (PSI) of the SEDLine monitor. METHODS To analyze the influence of the patient's age, we replayed 2 minutes of electroencephalography (EEG) of 141 patients (19-88 years, ASA I-IV) undergoing general anesthesia maintained with desflurane, sevoflurane, or propofol to the SEDLine monitor. We extracted the PSI as well as the spectral edge frequency (SEF) and performed a linear regression analysis. For evaluation of the time delay, we replayed 5 minutes of EEG of stable episodes of adequate anesthesia (PSI between 25 and 50) or light sedation/wake (PSI >70) in different orders to the SEDLine to simulate sudden changes between the states. Time delays were defined as the required time span of the monitor to reach the stable target index. RESULTS PSI and SEF increased significantly with the patient's age. These findings did not depend on the administered anesthetic. The evaluation of the correlation between SEF and PSI showed a strong correlation with Spearman's correlation coefficient of ρ = 0.86 (0.82; 0.89). The time delays depended on the type of transition. We found a median time delay of 54 (Min: 46; Max: 61) seconds for the important transition between adequate anesthesia and awake and 55 (Min: 50; Max: 67) seconds in the other direction. CONCLUSIONS With our analyses, we show that the indices presented on the SEDLine display, the PSI and the SEF, increase with age for patients under general anesthesia. Additionally, a delay of the PSI to react to sudden neurophysiologic changes due to dose of the maintenance anesthetic is of a time course that is clinically significant. These factors should be considered when navigating anesthesia relying on only the proprietary index for the SEDLine monitor.
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Affiliation(s)
- David P Obert
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Frederick Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Falk von Dincklage
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Pablo Sepulveda
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
| | - Stephan Kratzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
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11
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Kennedy RR. Pharmacokinetic and pharmacodynamic drug display and simulation systems in anesthesia practice. Curr Opin Anaesthesiol 2023; 36:407-413. [PMID: 37314166 DOI: 10.1097/aco.0000000000001278] [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: 06/15/2023]
Abstract
PURPOSE OF REVIEW This review explores the use of tools and displays based on pharmacokinetic and pharmacodynamic (PK/PD) modelling of drugs used in anesthesia. The primary focus is on those tools designed to illustrate the interactions between two or more drugs, or classes of drugs, and in particular, their use in a real-time clinical support role. Off-line, educational tools are also explored. RECENT FINDINGS Despite initial promise and encouraging supporting data, the use of real-time display of PK/PD is not common except in target-controlled infusion (TCI) pumps. SUMMARY PK/PD simulation is a useful tool for exposition of the relationship between drug dosing and effect. The initial promise of real-time tools has yet to be realized in routine clinical practice.
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Affiliation(s)
- R Ross Kennedy
- University of Otago: Christchurch, Christchurch, Aotearoa
- Te Whatu Ora, Waitaha, Canterbury, New Zealand
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12
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Liu T, Zhang X, Li A, Liu T, Yang X, Zhang H, Lei Y, Yang Q, Dong H. Effects of intra-operative administration of subanesthetic s-ketamine on emergence from sevoflurane anesthesia: a randomized double-blind placebo-controlled study. BMC Anesthesiol 2023; 23:221. [PMID: 37353750 PMCID: PMC10288804 DOI: 10.1186/s12871-023-02170-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Ketamine is administered in the perioperative period for its benefits in analgesia, anti-agitation and anti-depression when administered at a small dose. However, it is not clear whether the intra-operative administration of ketamine would affect emergence under sevoflurane anesthesia. To investigate this effect, we designed this trial. METHODS In this randomized, double-blind, placebo-controlled study, we enrolled 44 female patients aged 18-60 who were scheduled to elective laparoscopic gynecological surgeries. All patients were randomly assigned to saline or s-ketamine group. In s-ketamine group, patients received 0.125 mg/kg s-ketamine 30 min after the start of surgery. In saline group, patients were administered the same volume of saline. Sevoflurane and remifentanil were used to maintain general anesthesia. The primary outcome was emergence time. We also assessed postoperative agitation, cognitive function, and delirium. In addition, we collected and analyzed prefrontal electroencephalogram (EEG) during and after general anesthesia. RESULTS There were no significant differences in emergence time between s-ketamine group and saline group (10.80 ± 3.77 min vs. 10.00 ± 2.78 min, P = 0.457). Neither postoperative agitation (4 [3, 4] vs. 4 [3, 4], P = 0.835) nor cognitive function (25.84 ± 2.69 vs. 25.55 ± 2.19, P = 0.412) differed between groups. No postoperative delirium was observed in either group. Subanesthetic s-ketamine resulted in active EEG with decreased power of slow (-0.35 ± 1.13 dB vs. -1.63 ± 1.03 dB, P = 0.003), delta (-0.22 ± 1.11 dB vs. -1.32 ± 1.09 dB, P = 0.011) and alpha (-0.31 ± 0.71 dB vs. -1.71 ± 1.34 dB, P = 0.0003) waves and increased power of beta-gamma bands (-0.30 ± 0.89 dB vs. 4.20 ± 2.08 dB, P < 0.0001) during sevoflurane anesthesia, as well as an increased alpha peak frequency (-0.16 ± 0.48 Hz vs. 0.31 ± 0.73 Hz, P = 0.026). EEG patterns did not differ during the recovery period after emergence between groups. CONCLUSION Ketamine administered during sevoflurane anesthesia had no apparent influence on emergence time in young and middle-aged female patients undergoing laparoscopic surgery. Subanesthetic s-ketamine induced an active prefrontal EEG pattern during sevoflurane anesthesia but did not raise neurological side effects after surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2100046479 (date: 16/05/2021).
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Affiliation(s)
- Tiantian Liu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Xinxin Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Ao Li
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Tingting Liu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Xue Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Huanhuan Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Yanling Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Qianzi Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China.
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China.
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Ostović H, Šimac B, Pražetina M, Bradić N, Peršec J. The Effect of Intravenous Lidocaine, Ketamine, and Lidocaine-Ketamine Combination in Colorectal Cancer Surgery: A Randomized Controlled Trial. Anesth Analg 2023; Publish Ahead of Print:00000539-990000000-00586. [PMID: 37224065 DOI: 10.1213/ane.0000000000006555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Colorectal resections are associated with a pronounced inflammatory response, severe postoperative pain, and postoperative ileus. The aim of this study was to evaluate the main effects of lidocaine and ketamine, and their interaction in colorectal cancer (CRC) patients after open surgery. The interaction could be additive if the effect of 2 drugs given in combination equals the sum of their individual effects, or multiplicative if their combined effect exceeds the sum of their individual effects. We hypothesized that the combination of lidocaine and ketamine might reduce the inflammatory response additively or synergistically. METHODS Eighty-two patients undergoing elective open colorectal resection were randomized to receive either lidocaine or placebo and either ketamine or placebo in a 2 × 2 factorial design. After induction of general anesthesia, all subjects received an intravenous bolus (lidocaine 1.5 mg/kg and/or ketamine 0.5 mg/kg and/or a matched saline volume) followed by a continuous infusion (lidocaine 2 mg·kg-1·h-1 and/or ketamine 0.2 mg·kg-1·h-1 and/or a matched saline volume) until the end of surgery. Primary outcomes were serum levels of white blood cell (WBC) count, interleukins (IL-6, IL-8), and C-reactive protein (CRP) measured at 2 time points: 12 and 36 hours after surgery. Secondary outcomes included intraoperative opioid consumption; visual analog scale (VAS) pain scores at 2, 4, 12, 24, 36, and 48 hours postoperatively; cumulative analgesic consumption within 48 hours after surgery; and time to first bowel movement. We assessed the main effects of each of lidocaine and ketamine and their interaction on the primary outcomes using linear regression analyses. A Bonferroni-adjusted significance level was set at .05/8 = .00625 for primary analyses. RESULTS No statistically significant differences were observed with either lidocaine or ketamine intervention in any of the measured inflammatory markers. No multiplicative interaction between the 2 treatments was confirmed at 12 or 36 hours after surgery: WBC count, P = .870 and P = .393, respectively; IL-6, P = .892 and P = .343, respectively; IL-8, P = .999 and P = .996, respectively; and CRP, P = .014 and P = .445, respectively. With regard to inflammatory parameters, no evidence of additive interactions was found. Lidocaine and ketamine, either together or alone, significantly reduced intraoperative opioid consumption versus placebo, and, except for lidocaine alone, improved pain scores. Neither intervention significantly influenced gut motility. CONCLUSIONS Our study results do not support the use of an intraoperative combination of lidocaine and ketamine in patients undergoing open surgery for CRC.
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Affiliation(s)
- Helena Ostović
- From the Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Brankica Šimac
- Clinical Department of Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
| | - Marko Pražetina
- From the Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Nikola Bradić
- From the Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- Department of Biomedical Sciences, University North, Varaždin, Croatia
| | - Jasminka Peršec
- From the Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia
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14
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Oh J, Park SY, Lee GY, Park JH, Joe HB. Effective dose of remimazolam co-administered with remifentanil to facilitate I-gel insertion without neuromuscular blocking agents: an up-and-down sequential allocation trial. BMC Anesthesiol 2023; 23:81. [PMID: 36927413 PMCID: PMC10018909 DOI: 10.1186/s12871-023-02041-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Remimazolam is a new anesthetic drug developed and is an ultra-short-acting agent with rapid onset and offset. The pharmacology of this drug seems to be ideal for short surgeries eligible for I-gel insertion. Therefore, this study aimed to determine the optimal bolus dose of remimazolam for I-gel insertion when co-administered with remifentanil without neuromuscular blocking agents (NMBAs). METHODS Patients aged 19-65 years with American Society of Anesthesiologists physical status I or II scheduled for general anesthesia were enrolled. The first dose of remimazolam was 0.15 mg/kg and remifentanil was co-administered at an effect-site concentration (Ce) of 3.0 ng/mL. The dose of remimazolam for the following patient was decreased or increased by 0.05 mg/kg depending on the success or failure of I-gel insertion in the previous patient. RESULTS The remimazolam bolus dose required for successful I-gel insertion in 50% of adult patients using modified Dixon's up-and-down method with remifentanil Ce 3.0 ng/mL and no NMBAs was 0.280 ± 0.048 mg/kg. Isotonic regression analysis showed that the 50% and 95% effective doses were 0.244 (83% confidence interval [CI] 0.213-0.313) mg/kg and 0.444 (95% CI 0.436-0.448) mg/kg, respectively. The mean time to loss of consciousness (Modified Observer's Assessment of Alertness/Sedation score < 2) was 52.2 s. Three patients (12.0%) showed a reduction in systolic blood pressure of more than 30% from baseline. CONCLUSIONS Selecting the appropriate dose of remimazolam/remifentanil without NMBAs makes it feasible to insert the I-gel. TRIAL REGISTRATION This study protocol was registered at http://cris.nih.go.kr (KCT0007801, 12th, October, 2022).
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Affiliation(s)
- Juyeon Oh
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea
| | - Ga Yun Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea
| | - Ji Hyun Park
- Office of Biostatics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea
| | - Han Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea.
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15
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Chen H, Yang H, Li M, Peng H, Guo W, Li M. Effect of oral administration of gabapentin on the minimum alveolar concentration of isoflurane in cats. Front Vet Sci 2023; 10:1117313. [PMID: 36865443 PMCID: PMC9972096 DOI: 10.3389/fvets.2023.1117313] [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: 12/06/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Objective To determine if oral gabapentin decreases the minimum alveolar concentration (MAC) of isoflurane in cats. Study design Prospective, randomized, blinded, crossover, and experimental study. Animals A total of six healthy adult cats (three male, three female) aged 18-42 months, weighing 3.31 ± 0.26 kg. Methods Cats were randomly given oral gabapentin (100 mg cat-1) or placebo 2 h before starting MAC determination, with the crossover treatment given at least 7 days apart. Anesthesia was induced and maintained with isoflurane in oxygen. Isoflurane MAC was determined in duplicate using an iterative bracketing technique and tail clamp method. Hemodynamic and other vital variables were recorded at each stable isoflurane concentration and were compared between gabapentin and placebo treatments at lowest end-tidal isoflurane concentration when cats did not respond to tail clamping. A paired t-test was used to compare normally distributed data, and a Wilcoxon signed-rank test was applied for non-normally distributed data. Significance was set at p < 0.05. Data are mean ± standard deviation. Results Isoflurane MAC in the gabapentin treatment was 1.02 ± 0.11%, which was significantly lower than that in the placebo treatment (1.49 ± 0.12%; p < 0.001), decreasing by 31.58 ± 6.94%. No significant differences were found in cardiovascular and other vital variables between treatments. Conclusion and clinical relevance Oral administration of gabapentin 2 h before starting MAC determination had a significant isoflurane MAC-sparing effect in cats with no observed hemodynamic benefit.
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Affiliation(s)
- Hangbin Chen
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Huan Yang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Mengqing Li
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Haojie Peng
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Weibin Guo
- Ainuo Blessing Veterinary Hospital, Guangzhou, Guangdong, China
| | - Meng Li
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China,*Correspondence: Meng Li ✉
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16
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Liou JY, Kuo IT, Chang WK, Ting CK, Tsou MY. Pharmacodynamic modeling of moderate sedation and rationale for dosing using midazolam, propofol and alfentanil. BMC Pharmacol Toxicol 2023; 24:3. [PMID: 36647160 PMCID: PMC9843845 DOI: 10.1186/s40360-023-00642-5] [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: 07/01/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Regulations have broadened to allow moderate sedation administration for gastrointestinal endoscopy by non-anesthesia personnel. The line between moderate and deep sedation is ambiguous. Deep sedation offers patient comfort as well as greater safety concerns. Unintended deep sedation can occur if drug interactions are overlooked. We present a pharmacodynamic model for moderate sedation using midazolam, alfentanil and propofol. The model is suitable for training and devising rationales for appropriate dosing. METHODS The study consists of two parts: modeling and validation. In modeling, patients scheduled for esophagogastroduodenoscopy (EGD) or colonoscopy sedation are enrolled. The modified observer's assessment of alertness/sedation (MOAA/S) score < 4 is defined as loss of response to represent moderate sedation. Two patient groups receiving bronchoscopy or endoscopic retrograde cholangiopancreatography (ERCP) are used for validation. Model performance is assessed by receiver operating characteristic (ROC) curves and area under the curve (AUC). Simulations are performed to demonstrate how the model is used to rationally determine drug regimen for moderate sedation. RESULTS Interaction between propofol and alfentanil is stronger than the other pairwise combinations. Additional synergy is observed with three drugs. ROC AUC is 0.83 for the modeling group, and 0.96 and 0.93 for ERCP and bronchoscopy groups respectively. Model simulation suggests that 1 mg midazolam, 250 µg alfentanil and propofol maximally benefits from drug interactions and suitable for moderate sedation. CONCLUSION We demonstrate the accurate prediction of a three-drug response surface model for moderate sedation and simulation suggests a rational dosing strategy for moderate sedation with midazolam, alfentanil and propofol.
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Affiliation(s)
- Jing-Yang Liou
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - I-Ting Kuo
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Weng-Kuei Chang
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mei-Yung Tsou
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
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Krause M, Nguyen A, O'Brien O, Khoche S, Schmidt U. A Randomized Pilot Study Assessing if SEDLine Monitoring During Induction of Surgical Patients is Associated With Reduced Dosage of Administered Induction Agents. Semin Cardiothorac Vasc Anesth 2022; 26:260-265. [PMID: 36198482 DOI: 10.1177/10892532221130660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Intubations, especially in emergent settings, carry a high risk of hemodynamic instability with potentially catastrophic outcomes. Weight-based dosing of induction drugs can be inappropriately high for elective or emergent intubations and lead to hemodynamic instability. We hypothesized that monitoring the patient state index of SEDLine monitors (Masimo, Irvine, CA) would decrease the dose of induction drugs in the operating room during elective intubations.Methods. In this randomized study, SEDLine monitoring was provided to the intervention group but not to the control group during the induction of anesthesia in the operating room. Anesthesia providers in the intervention group were advised to titrate induction drugs to a Patient State Index of <50 before proceeding with intubation. The primary outcome was the induction dose of propofol and etomidate per kilogram normalized to propofol dose equivalents. Secondary outcomes included supplemental doses of ketamine, midazolam, fentanyl, phenylephrine, and ephedrine per kg, time from induction to intubation, administration of additional propofol or vasopressors after induction, mean arterial pressure ≥ or <65 mmHg, and lowest mean arterial pressure post-induction.Results. We found no significant difference in propofol equivalents between groups (P = .41). Using a SEDLine decreased the odds that a patient would require vasopressors during induction (odds ratio of .39 [95% confidence interval, .15-.98]).Conclusion. SEDLine monitoring during induction did not decrease dosing of the induction drugs etomidate and propofol but decreased the odds of receiving vasopressors. Further studies are warranted to assess the utility of processed electroencephalography in emergent intubations outside of the operating room.
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Affiliation(s)
- Martin Krause
- Department of Anesthesiology, 8784University of California San Diego, San Diego, CA, USA
| | - Albert Nguyen
- Division of Critical Care Medicine, 24341Providence Santa Rosa Memorial Hospital, Santa Rosa, CA, USA
| | - Orestes O'Brien
- Department of Anesthesiology, 8784University of California San Diego, San Diego, CA, USA
| | - Swapnil Khoche
- Department of Anesthesiology, 8784University of California San Diego, San Diego, CA, USA
| | - Ulrich Schmidt
- Department of Anesthesiology, 8784University of California San Diego, San Diego, CA, USA
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18
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Simulation-Based Gastrointestinal Endoscopy Sedations: A Novel Validation to Multidrug Pharmacodynamic Modeling. Pharmaceutics 2022; 14:pharmaceutics14102056. [PMID: 36297491 PMCID: PMC9610933 DOI: 10.3390/pharmaceutics14102056] [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] [Received: 08/21/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Pharmacodynamic models have described the interactions between anesthetics. Applying the models to clinical practice is still problematic due to inherent limitations: 1. modeling conditions are different from practice. 2. One model can only describe one endpoint. To tackle these, we propose a new method of model validation for recovery and intraprocedural sedation adequacy with a three-drug pharmacodynamic model using six published clinical studies that contain midazolam, opioid, and propofol. Mean drug dose, intraprocedural sedation level, procedure, and recovery time are extracted from each study. Simulated drug regimens are designed to best approximate study conditions. A published deep sedation model is used for simulation. Model-predicted recovery time and intraprocedural sedation scores are compared with the original clinical study outcomes. The model successfully predicted recovery times in eight out of nine regimens. Lower doses of midazolam are associated with faster recovery. Model prediction of intraprocedural sedation level was compatible with the clinical studies in five out of seven regimens. The three-drug pharmacodynamic model describes the course of gastrointestinal endoscopy sedations from clinical studies well. Model predictions are consistent with the results from clinical studies. The approach implies that large scale validation can be performed repeatedly.
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Brennan J, Jain L, Garman S, Donnelly AE, Wright ES, Jamieson K. Sample-efficient identification of high-dimensional antibiotic synergy with a normalized diagonal sampling design. PLoS Comput Biol 2022; 18:e1010311. [PMID: 35849634 PMCID: PMC9333450 DOI: 10.1371/journal.pcbi.1010311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/28/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022] Open
Abstract
Antibiotic resistance is an important public health problem. One potential solution is the development of synergistic antibiotic combinations, in which the combination is more effective than the component drugs. However, experimental progress in this direction is severely limited by the number of samples required to exhaustively test for synergy, which grows exponentially with the number of drugs combined. We introduce a new metric for antibiotic synergy, motivated by the popular Fractional Inhibitory Concentration Index and the Highest Single Agent model. We also propose a new experimental design that samples along all appropriately normalized diagonals in concentration space, and prove that this design identifies all synergies among a set of drugs while only sampling a small fraction of the possible combinations. We applied our method to screen two- through eight-way combinations of eight antibiotics at 10 concentrations each, which requires sampling only 2,560 unique combinations of antibiotic concentrations. Antibiotic resistance is a growing public health concern, and there is an increasing need for methods to combat it. One potential approach is the development of synergistic antibiotic combinations, in which a mixture of drugs is more effective than any individual component. Unfortunately, the search for clinically beneficial drug combinations is severely restricted by the pace at which drugs can be screened. To date, most studies of combination therapies have been limited to testing only pairs or triples of drugs. These studies have identified primarily antagonistic drug interactions, in which the combination is less effective than the individual components. There is an acute need for methodologies that enable screening of higher-order drug combinations, both to identify synergies among many drugs and to understand the behavior of higher-order combinations. In this work we introduce a new paradigm for combination testing, the normalized diagonal sampling design, that makes identifying interactions among eight or more drugs feasible for the first time. Screening d drugs at m different combinations requires m ⋅ 2d samples under our design as opposed to md under exhaustive screening, while provably identifying all synergies under mild assumptions about antibiotic behavior. Scientists can use our design to quickly screen for antibiotic interactions, accelerating the pace of combination therapy development.
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Affiliation(s)
- Jennifer Brennan
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, Washington, United States of America
| | - Lalit Jain
- Foster School of Business, University of Washington, Seattle, Washington, United States of America
| | - Sofia Garman
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ann E. Donnelly
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Erik Scott Wright
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Pittsburgh Center for Evolutionary Biology and Medicine, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| | - Kevin Jamieson
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, Washington, United States of America
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Thermodynamic Interpretation of a Machine-Learning-Based Response Surface Model and Its Application to Pharmacodynamic Synergy between Propofol and Opioids. MATHEMATICS 2022. [DOI: 10.3390/math10101651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Propofol and fentanyl are commonly used agents for the induction of anesthesia, and are often associated with hemodynamic disturbances. Understanding pharmacodynamic impacts is vital for parasympathetic and sympathetic tones during the anesthesia induction period. Inspired by the thermodynamic interaction between drug concentrations and effects, we established a machine-learning-based response surface model (MLRSM) to address this predicament. Then, we investigated and modeled the biomedical phenomena in the autonomic nervous system. Our study prospectively enrolled 60 patients, and the participants were assigned to two groups randomly and equally. Group 1 received propofol first, followed by fentanyl, and the drug sequence followed an inverse procedure in Group 2. Then, we extracted and analyzed the spectrograms of electrocardiography (ECG) and pulse photoplethysmography (PPG) signals after induction of propofol and fentanyl. Eventually, we utilized the proposed MLRSM to evaluate the relationship between anesthetics and the integrity/balance of sympathetic and parasympathetic activity by employing the power of high-frequency (HF) and low-frequency (LF) bands and PPG amplitude (PPGA). It is worth emphasizing that the proposed MLRSM exhibits a similar mathematical form to the conventional Greco model, but with better computational performance. Furthermore, the MLRSM has a theoretical foundation and flexibility for arbitrary numbers of drug combinations. The modeling results are consistent with the previous literature. We employed the bootstrap algorithm to inspect the results’ consistency and measure the various statistical fluctuations. Then, the comparison between the modeling and the bootstrapping results was used to validate the statistical stability and the feasibility of the proposed MLRSM.
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Harbell MW, Dumitrascu C, Bettini L, Yu S, Thiele CM, Koyyalamudi V. Anesthetic Considerations for Patients on Psychotropic Drug Therapies. Neurol Int 2021; 13:640-658. [PMID: 34940748 PMCID: PMC8708655 DOI: 10.3390/neurolint13040062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
Psychotropic drugs are used in the treatment of psychiatric and non-psychiatric conditions. Many patients who are on psychotropic medications may present for procedures requiring anesthesia. Psychotropic medications can have dangerous interactions with drugs commonly used in anesthesia, some of which can be life-threatening. In this review, we describe the current anesthetic considerations for patients on psychotropic drug therapies, including antidepressants, antipsychotics, mood stabilizers, anxiolytics, and stimulants. The pharmacology, side effects, and potential drug interactions of the commonly prescribed psychotropic drug therapies with anesthetic agents are described. Further, we highlight the current recommendations regarding the cessation and continuation of these medications during the perioperative period.
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Affiliation(s)
- Monica W. Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
- Correspondence:
| | - Catalina Dumitrascu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
| | - Layne Bettini
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
| | - Soojie Yu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
| | | | - Veerandra Koyyalamudi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
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22
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Seangrung R, Pasutharnchat K, Injampa S, Kumdang S, Komonhirun R. Comparison of the hemodynamic response of dexmedetomidine versus additional intravenous lidocaine with propofol during tracheal intubation: a randomized controlled study. BMC Anesthesiol 2021; 21:265. [PMID: 34717532 PMCID: PMC8557037 DOI: 10.1186/s12871-021-01484-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/23/2021] [Indexed: 11/14/2022] Open
Abstract
Background Laryngoscopy and tracheal intubation are strong stimuli that cause a reflex increase in blood pressure (BP), heart rate (HR), and serum catecholamine level. These can lead to myocardial infarction or cerebrovascular accidents. The purpose of this study is to compare the efficacy of dexmedetomidine and lidocaine combined with propofol in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation. Methods This study was a randomized controlled study and adhered to the CONSORT guidelines. One-hundred and six patients undergoing elective general anesthesia with endotracheal intubation were divided randomly into two groups. Group D received dexmedetomidine (1 μg kg− 1) before induction. Group LP received lidocaine (1.5 mg kg− 1) before induction with additional propofol (0.5 mg kg− 1) before laryngoscopy. The primary endpoint was hemodynamic including systolic (S) BP, diastolic (D) BP, mean arterial blood pressure (MAP) and HR measured before and after induction and ≤ 10 min after intubation. Secondary outcome was complications/adverse effects. Results After induction, the mean SBP, DBP, MAP and HR decreased significantly from baseline in both groups except for mean HR in group LP at 1 min. Differences in mean values of SBP, DBP, and MAP were significantly lower in group D after intubation at 4–10 min (P < 0.05). Group LP had a non-inferior effect in blunting BP at all time points except 1 and 2 min after induction, and 2 min after intubation. The mean difference in HR in group D was significantly lower than that in group LP at all time points (P < 0.001). Group D had significantly more episodes of bradycardia (18.87% vs. 0%, P = 0.001) and hypotension (52.83% vs. 15.09%, P < 0.001) than did group LP. Conclusion Lidocaine (1.5 mg kg− 1) with additional propofol (0.5 mg kg− 1) had a non-inferior effect compared with dexmedetomidine (1 μg kg− 1) in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation, and had fewer adverse effects. Trial registration Thai Clinical Trial Registry, (TRTC20190206002). Retrospectively registered 4 February 2019.
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Affiliation(s)
- Rattaphol Seangrung
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand.
| | - Koravee Pasutharnchat
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
| | - Subundit Injampa
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
| | - Sirima Kumdang
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
| | - Rojnarin Komonhirun
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
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Shanker A, Abel JH, Narayanan S, Mathur P, Work E, Schamberg G, Sharkey A, Bose R, Rangasamy V, Senthilnathan V, Brown EN, Subramaniam B. Perioperative Multimodal General Anesthesia Focusing on Specific CNS Targets in Patients Undergoing Cardiac Surgeries: The Pathfinder Feasibility Trial. Front Med (Lausanne) 2021; 8:719512. [PMID: 34722563 PMCID: PMC8551571 DOI: 10.3389/fmed.2021.719512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Multimodal general anesthesia (MMGA) is a strategy that utilizes the well-known neuroanatomy and neurophysiology of nociception and arousal control in designing a rational and clinical practical paradigm to regulate the levels of unconsciousness and antinociception during general anesthesia while mitigating side effects of any individual anesthetic. We sought to test the feasibility of implementing MMGA for seniors undergoing cardiac surgery, a high-risk cohort for hemodynamic instability, delirium, and post-operative cognitive dysfunction. Twenty patients aged 60 or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries were enrolled in this non-randomized prospective observational feasibility trial, wherein we developed MMGA specifically for cardiac surgeries. Antinociception was achieved by a combination of intravenous remifentanil, ketamine, dexmedetomidine, and magnesium together with bupivacaine administered as a pecto-intercostal fascial block. Unconsciousness was achieved by using electroencephalogram (EEG)-guided administration of propofol along with the sedative effects of the antinociceptive agents. EEG-guided MMGA anesthesia was safe and feasible for cardiac surgeries, and exploratory analyses found hemodynamic stability and vasopressor usage comparable to a previously collected cohort. Intraoperative EEG suppression events and postoperative delirium were found to be rare. We report successful use of a total intravenous anesthesia (TIVA)-based MMGA strategy for cardiac surgery and establish safety and feasibility for studying MMGA in a full clinical trial. Clinical Trial Number: www.clinicaltrials.gov; identifier NCT04016740 (https://clinicaltrials.gov/ct2/show/NCT04016740).
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Affiliation(s)
- Akshay Shanker
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - John H. Abel
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Shilpa Narayanan
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Pooja Mathur
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Erin Work
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Gabriel Schamberg
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ruma Bose
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Valluvan Rangasamy
- Department of Anesthesia, Critical Care, and Pain Medicine, Riley Hospital for Children, Indiana University, Indianapolis, IN, United States
| | - Venkatachalam Senthilnathan
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Emery N. Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Abstract
Barbiturate overdose as a method of euthanasia is becoming unacceptable. This has made alternative methods of euthanasia very important. Gunshot or captive bolt euthanasia is among methods that are acceptable, but they may not be esthetically acceptable. This has led to the use of other methods of euthanasia. Inducing anesthesia prior to euthanasia offers an easier method of control. Adjunctive techniques using intravenous potassium or magnesium salts administered intravenously and intracardiac administration of potassium chloride or intrathecal lidocaine offer alternatives that work well and are more environmentally safer than barbiturates. Pithing and exsanguination are also environmentally safer but may not be as esthetically acceptable as the other methods.
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Brosnan RJ, Pypendop BH. Evaluation of whether acepromazine maleate causes fentanyl to decrease the minimum alveolar concentration of isoflurane in cats. Am J Vet Res 2021; 82:352-357. [PMID: 33904805 DOI: 10.2460/ajvr.82.5.352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether isoflurane-anesthetized cats with demonstrated resistance to the immobilizing effects of fentanyl would exhibit naltrexone-reversible sparing of the minimum alveolar concentration (MAC) of isoflurane when fentanyl was coadministered with the centrally acting catecholamine receptor antagonist acepromazine. ANIMALS 5 healthy male purpose-bred cats. PROCEDURES Anesthesia was induced and maintained with isoflurane in oxygen. Baseline isoflurane MAC was measured by use of a standard tail clamp stimulus and bracketing study design. Afterward, fentanyl was administered IV to achieve a plasma concentration of 100 ng/mL by means of target-controlled infusion, and isoflurane MAC was remeasured. Next, acepromazine maleate (0.1 mg/kg) was administered IV, and isoflurane MAC was remeasured. Finally, isoflurane concentration was equilibrated at 70% of the baseline MAC. Movement of cats in response to tail clamping was tested before and after IV bolus administration of naltrexone. Physiologic responses were compared among treatment conditions. RESULTS Isoflurane MAC did not differ significantly between baseline and fentanyl infusion (mean ± SD, 1.944 ± 0.111% and 1.982 ± 0.126%, respectively). Acepromazine with fentanyl significantly decreased isoflurane MAC to 1.002 ± 0.056% of 1 atm pressure. When isoflurane was increased to 70% of the baseline MAC, no cats moved in response to tail clamping before naltrexone administration, but all cats moved after naltrexone administration. CONCLUSIONS AND CLINICAL RELEVANCE Acepromazine caused fentanyl to decrease the isoflurane MAC in cats that otherwise did not exhibit altered isoflurane requirements with fentanyl alone. Results suggested that opioid-mediated increases in brain catecholamine concentrations in cats counteract the opioid MAC-sparing effect.
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Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
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Hayes JA, Aljuhani T, De Oliveira K, Johnston BC. Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:979-992. [PMID: 32665470 DOI: 10.1213/ane.0000000000004967] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Drugs such as propofol and ketamine are used alone or in combination to provide sedation for medical procedures in children. The purpose of this systematic review was to compare the safety and effectiveness of propofol and ketamine to other drug regimens. METHODS We searched Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Web of Science, and the grey literature (meta-Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar) for randomized controlled studies comparing intravenous propofol and ketamine to any other single or combination drug regimen administered to children undergoing diagnostic or therapeutic procedures. Meta-analyses were performed for primary (hemodynamic and respiratory adverse events) and secondary outcomes using RevMan 5.3. We assessed the risk of bias and the certainty (quality) evidence for all outcomes using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS Twenty-nine studies were included for analysis. Based on low-to-moderate quality evidence, we concluded that the use of propofol and ketamine may result in a slight-to-small reduction in the risk of hypotension, bradycardia, and apnea, and a slight increase in the risk of tachycardia, hypertension, and other respiratory adverse events, such as cough or laryngospasm. The ratio of propofol to ketamine and comparator drug regimen subgroups effects were important for desaturation and some secondary outcomes. CONCLUSIONS The use of propofol and ketamine had a minimal effect on the incidence of adverse events and other secondary outcomes. Large-scale studies are required to more accurately estimate adverse event rates and the effects of propofol and ketamine on patient-important outcomes.
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Affiliation(s)
- Jason A Hayes
- From the Department of Anesthesia and Pain Medicine, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Talal Aljuhani
- Pediatric Anesthesia Department, King Abdullah Specialized Children Hospital (KASCH), Riyadh, Saudi Arabia
| | - Kyle De Oliveira
- From the Department of Anesthesia and Pain Medicine, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bradley C Johnston
- Department of Nutrition, Texas A&M University, College Station, Texas.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Abstract
Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether. Dosing is carried out using the minimal alveolar concentration (MAC) concept. The pharmacokinetic properties of the various inhalational anesthetics are governed by the specific distribution coefficients. Mechanisms of action include specific modulations of various receptors of the central nervous system as well as an unspecific interaction with the cell membrane. Organ toxicity of modern inhalational anesthetics is considered to be minimal. The role of inhalational anesthetics in the context of postoperative nausea and vomiting (PONV) has been reassessed in recent years. The superiority of inhalational anesthetics over intravenous hypnotics with respect to intraoperative awareness is undisputed. The organ protective mechanism of preconditioning is an exclusive property of inhalational anesthetics among all the currently available hypnotics.
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Affiliation(s)
- Jan Jedlicka
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland.
| | - Philipp Groene
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Julia Linhart
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Elisabeth Raith
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Da Vy Mu Stapha
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Peter Conzen
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
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Lidocaine combined with magnesium sulfate preserved hemodynamic stability during general anesthesia without prolonging neuromuscular blockade: a randomized, double-blind, controlled trial. BMC Anesthesiol 2021; 21:91. [PMID: 33773580 PMCID: PMC8004390 DOI: 10.1186/s12871-021-01311-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/21/2021] [Indexed: 12/05/2022] Open
Abstract
Background Lidocaine and magnesium sulfate have become increasingly utilized in general anesthesia. The present study evaluated the effects of these drugs, isolated or combined, on hemodynamic parameters as well as on the cisatracurium-induced neuromuscular blockade (NMB). Methods At a university hospital, 64 patients, ASA physical status I and II, undergoing elective surgery with similar pain stimuli were randomly assigned to four groups. Patients received a bolus of lidocaine and magnesium sulfate before the tracheal intubation and a continuous infusion during the operation as follows: 3 mg.kg− 1 and 3 mg.kg− 1.h− 1 (lidocaine - L group), 40 mg.kg− 1 and 20 mg.kg− 1.h− 1 (magnesium - M group), equal doses of both drugs (magnesium plus lidocaine - ML group), and an equivalent volume of isotonic solution (control - C group). Hemodynamic parameters and neuromuscular blockade features were continuously monitored until spontaneous recovery of the train of four (TOF) ratio (TOFR > 0.9). Results The magnesium sulfate significantly prolonged all NMB recovery features, without changing the speed of onset of cisatracurium. The addition of lidocaine to Magnesium Sulfate did not influence the cisatracurium neuromuscular blockade. A similar finding was observed when this drug was used alone, with a significantly smaller fluctuation of mean arterial pressure (MAP) and heart rate (HR) measures during anesthesia induction and maintenance. Interestingly, the percentage of patients who achieved a TOFR of 90% without reaching T1–95% was higher in the M and ML groups. Than in the C and L groups. There were no adverse events reported in this study. Conclusion Intravenous lidocaine plays a significant role in the hemodynamic stability of patients under general anesthesia without exerting any additional impact on the NMB, even combined with magnesium sulfate. Aside from prolonging all NMB recovery characteristics without altering the onset speed, magnesium sulfate enhances the TOF recovery rate without T1 recovery. Our findings may aid clinical decisions involving the use of these drugs by encouraging their association in multimodal anesthesia or other therapeutic purposes. Trial registration NCT02483611 (registration date: 06-29-2015). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01311-y.
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Aragon IV, Boyd A, Abou Saleh L, Rich J, McDonough W, Koloteva A, Richter W. Inhibition of cAMP-phosphodiesterase 4 (PDE4) potentiates the anesthetic effects of Isoflurane in mice. Biochem Pharmacol 2021; 186:114477. [PMID: 33609559 DOI: 10.1016/j.bcp.2021.114477] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/26/2022]
Abstract
Despite major advances, there remains a need for novel anesthetic drugs or drug combinations with improved efficacy and safety profiles. Here, we show that inhibition of cAMP-phosphodiesterase 4 (PDE4), while not inducing anesthesia by itself, potently enhances the anesthetic effects of Isoflurane in mice. Treatment with several distinct PAN-PDE4 inhibitors, including Rolipram, Piclamilast, Roflumilast, and RS25344, significantly delayed the time-to-righting after Isoflurane anesthesia. Conversely, treatment with a PDE3 inhibitor, Cilostamide, or treatment with the potent, but non-brain-penetrant PDE4 inhibitor YM976, had no effect. These findings suggest that potentiation of Isoflurane hypnosis is a class effect of brain-penetrant PDE4 inhibitors, and that they act by synergizing with Isoflurane in inhibiting neuronal activity. The PDE4 family comprises four PDE4 subtypes, PDE4A to PDE4D. Genetic deletion of any of the four PDE4 subtypes in mice did not affect Isoflurane anesthesia per se. However, PDE4D knockout mice are largely protected from the effect of pharmacologic PDE4 inhibition, suggesting that PDE4D is the predominant, but not the sole PDE4 subtype involved in potentiating Isoflurane anesthesia. Pretreatment with Naloxone or Propranolol alleviated the potentiating effect of PDE4 inhibition, implicating opioid- and β-adrenoceptor signaling in mediating PDE4 inhibitor-induced augmentation of Isoflurane anesthesia. Conversely, stimulation or blockade of α1-adrenergic, α2-adrenergic or serotonergic signaling did not affect the potentiation of Isoflurane hypnosis by PDE4 inhibition. We further show that pretreatment with a PDE4 inhibitor boosts the delivery of bacteria into the lungs of mice after intranasal infection under Isoflurane, thus providing a first example that PDE4 inhibitor-induced potentiation of Isoflurane anesthesia can critically impact animal models and must be considered as a factor in experimental design. Our findings suggest that PDE4/PDE4D inhibition may serve as a tool to delineate the exact molecular mechanisms of Isoflurane anesthesia, which remain poorly understood, and may potentially be exploited to reduce the clinical doses of Isoflurane required to maintain hypnosis.
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Affiliation(s)
- Ileana V Aragon
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Abigail Boyd
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Lina Abou Saleh
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Justin Rich
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Will McDonough
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Anna Koloteva
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Wito Richter
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA.
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Wolf A, Selpien H, Haberl H, Unterberg M. Does a combined intravenous-volatile anesthesia offer advantages compared to an intravenous or volatile anesthesia alone: a systematic review and meta-analysis. BMC Anesthesiol 2021; 21:52. [PMID: 33588751 PMCID: PMC7883423 DOI: 10.1186/s12871-021-01273-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In anesthesia, additive drug interactions are used for reducing dose and dose-dependent side-effects. The combination of propofol with volatile anesthetics is rather unusual but might have advantages compared to the single use regarding PONV, time to extubation, movement during surgery and postoperative pain perception. METHODS We searched PubMed, Scopus, Web of Science, and CENTRAL for relevant studies comparing combined intravenous volatile anesthesia with total intravenous or balanced anesthesia. The studies identified were summarized in a meta-analysis with the standardized mean difference or risk ratio as the effect size. RESULTS Ten studies provided data. The risk for PONV in the recovery room was significantly reduced for a combined anesthesia compared to a balanced anesthesia (RR 0.657, CI 0.502-0.860, p-value 0.002). There was no significant difference detected either in the time to extubation or in pain perception. Movement during surgery was significantly reduced for a combined compared to a total intravenous anesthesia (RR 0.241, CI 0.135-0.428, p-value 0.000). CONCLUSIONS The combination of propofol and volatiles may have some advantages in the early occurrence of PONV compared to a balanced anesthesia. To sufficiently evaluate potential advantages of a combination of volatiles and propofol further high-quality trials are needed. TRIAL REGISTRATION PROSPERO CRD42019126627 .
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Affiliation(s)
- Alexander Wolf
- Ruhr University Bochum, Bochum, Germany.
- Department of Anesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, In der Schornau 23 - 25, 44892, Bochum, Germany.
| | - Helene Selpien
- Ruhr University Bochum, Bochum, Germany
- Department of Anesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, In der Schornau 23 - 25, 44892, Bochum, Germany
| | - Helge Haberl
- Ruhr University Bochum, Bochum, Germany
- Department of Anesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, In der Schornau 23 - 25, 44892, Bochum, Germany
| | - Matthias Unterberg
- Ruhr University Bochum, Bochum, Germany
- Department of Anesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, In der Schornau 23 - 25, 44892, Bochum, Germany
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Velázquez-Delgado PI, Gutierrez-Blanco E, Torres-Acosta FDJ, Ortega-Pacheco A, Aguilar-Caballero AJ, Dzikiti BT. Comparison of Propofol or Isoflurane Anesthesia Maintenance, Combined with a Fentanyl-Lidocaine-Ketamine Constant-Rate Infusion in Goats Undergoing Abomasotomy. Animals (Basel) 2021; 11:ani11020492. [PMID: 33668487 PMCID: PMC7918233 DOI: 10.3390/ani11020492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/24/2021] [Accepted: 02/11/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary General anesthesia in small ruminants is still a challenge under field conditions. Propofol is an injectable short-acting anesthetic used to provide induction and/or anesthesia maintenance. Isoflurane is the inhaled anesthetic more widely used for providing general anesthesia; however, it requires an expensive equipment for its administration, and high doses may produce environmental pollution. Both anesthetics produce dose-related cardiovascular depressant effects. This study aimed to compare the effects of propofol or isoflurane, combined with a constant-rate infusion of fentanyl–lidocaine–ketamine (total [total intravenous anesthesia (TIVA)] and partial intravenous anesthesia [PIVA], respectively) in goats undergoing abomasotomy. Our results showed that both TIVA and PIVA protocols produced a satisfactory quality of anesthesia during surgery, with minimal changes in cardiopulmonary parameters. However, recovery from anesthesia induced by propofol fentanyl–lidocaine–ketamine might be of poor quality. Abstract This study aimed to compare, first, the anesthetic and cardiopulmonary effects of propofol or isoflurane anesthetic maintenance in goats receiving a fentanyl–lidocaine–ketamine infusion undergoing abomasotomy and, secondly, to compare the quality of the recovery from anesthesia. Two groups were used: propofol (TIVA) and isoflurane (PIVA). Goats were premedicated with fentanyl (10 μg/kg intravenously [IV]), lidocaine (2 mg/kg, IV), and ketamine (1.5 mg/kg, IV). Anesthesia was induced with propofol and maintenance consisted of fentanyl (10 μg/kg/h, IV), lidocaine (50 μg/kg/min, IV), and ketamine (50 μg/kg/min, IV) as constant-rate infusions (CRIs), combined with either CRI of propofol at initial dose of 0.3 mg/kg/min, IV (TIVA), or isoflurane with initial end-tidal (FE’Iso) concentration of 1.2% partial intravenous anesthesia (PIVA). The mean effective propofol dose for maintenance was 0.44 ± 0.07 mg/kg/min, while the mean FE’Iso was 0.81 ± 0.2%. Higher systolic arterial pressure (SAP) values were observed in total intravenous anesthesia (TIVA) during some time points. Recovery was smooth in PIVA, while restlessness, vocalizations, and paddling were observed in TIVA. Both protocols produced a satisfactory quality of anesthesia during surgery, with minimal impact on cardiopulmonary function. Nevertheless, recovery after anesthesia in TIVA might be of poor quality.
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Affiliation(s)
- Perla I. Velázquez-Delgado
- Department of Animal Health and Preventive Medicine, Autonomous University of Yucatan, 97000 Merida, Mexico; (P.I.V.-D.); (F.d.J.T.-A.); (A.O.-P.); (A.J.A.-C.)
| | - Eduardo Gutierrez-Blanco
- Department of Animal Health and Preventive Medicine, Autonomous University of Yucatan, 97000 Merida, Mexico; (P.I.V.-D.); (F.d.J.T.-A.); (A.O.-P.); (A.J.A.-C.)
- Correspondence: ; Tel.: +52-99-9942-3200
| | - Felipe de J. Torres-Acosta
- Department of Animal Health and Preventive Medicine, Autonomous University of Yucatan, 97000 Merida, Mexico; (P.I.V.-D.); (F.d.J.T.-A.); (A.O.-P.); (A.J.A.-C.)
| | - Antonio Ortega-Pacheco
- Department of Animal Health and Preventive Medicine, Autonomous University of Yucatan, 97000 Merida, Mexico; (P.I.V.-D.); (F.d.J.T.-A.); (A.O.-P.); (A.J.A.-C.)
| | - Armando J. Aguilar-Caballero
- Department of Animal Health and Preventive Medicine, Autonomous University of Yucatan, 97000 Merida, Mexico; (P.I.V.-D.); (F.d.J.T.-A.); (A.O.-P.); (A.J.A.-C.)
| | - Brighton T. Dzikiti
- Department of Large Animal Clinical Science, School of Veterinary Medicine, Ross University, KN0111 Basseterre, Saint Kitts and Nevis;
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Taharabaru S, Tamura T, Higashi M, Matsuda N, Satomoto M, Adachi YU, Sato AB, Okuda M. JM-1232(-) and propofol, a new combination of hypnotics with short-acting and non-cumulative preferable properties. Exp Anim 2021; 70:101-107. [PMID: 33071272 PMCID: PMC7887627 DOI: 10.1538/expanim.20-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/10/2020] [Indexed: 10/31/2022] Open
Abstract
Drug interactions are significant in anesthesiology because drug combinations can potentially possess novel properties. The pharmacological advantages of a new combination of the benzodiazepine receptor agonist JM-1232(-) and propofol were investigated in mice. Male adult mice were administered JM-1232(-) or propofol or combinations of the two drugs intravenously. Loss of the righting reflex was evaluated as achieving hypnosis, and the time until recovery of the reflex was measured as hypnosis time. After determining the ED50, doses double and triple the ED50 of propofol were injected with JM-1232(-) to compare hypnosis time. The injections were repeated four times, and the hypnosis times were compared. Flumazenil was administered separately immediately after the last dose was injected. The ED50 values ([95% confidence interval]) for hypnosis were 3.76 [3.36-4.10] for JM-1232(-) and 9.88 [8.03-11.58] mg kg-1 for propofol. Co-administration of 0.5 and 1 mg kg-1 JM-1232(-) reduced the ED50 values of propofol to 1.76 [1.21-2.51] and 1.00 [0.46-1.86] mg kg-1, respectively. The drug combination for hypnosis produced a supra-additive interaction. Hypnosis time was significantly shorter in the groups given the mixtures compared to each hypnotic administered alone. After repeated injections, hypnosis time with the mixtures showed smaller prolongation than that with the hypnotic alone. Flumazenil completely restored the recovery time after anesthesia. The combination of JM-1232(-) and propofol showed a supra-additive interaction, and the reduced hypnotic dose contributed to a faster recovery even after multiple injections.
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Affiliation(s)
- Saori Taharabaru
- Department of Anesthesia, Nishio Municipal Hospital, Nishio Municipal Hospital, 6 Kamiawahara, Kumami-cho, Nishio, Aichi 4458510, Japan
- Department of Anesthesiology, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 4658651, Japan
| | - Takahiro Tamura
- Department of Surgical Intensive Care Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Michiko Higashi
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Naoyuki Matsuda
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Maiko Satomoto
- Department of Anesthesiology, Toho University School of Medicine, Toho University Medical Center, Ohmori Hospital, 6-11-1 Ohmori-Nishi, Ohta-ku, Tokyo 1438541, Japan
| | - Yushi U Adachi
- Department of Anesthesia and Intensive Care Medicine, International University of Health and Welfare, 537-3 Iguchi, Nasushiobara, Tochigi 3292763, Japan
| | - Aiji Boku Sato
- Department of Anesthesiology, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 4658651, Japan
| | - Masahiro Okuda
- Department of Anesthesiology, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 4658651, Japan
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New Evidence of Receptor-based Pharmacology Underlying a Volatile Anesthetic Effect. Anesthesiology 2020; 133:973-975. [PMID: 32936873 DOI: 10.1097/aln.0000000000003559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kops MS, Pesic M, Petersen KU, Schmalix WA, Stöhr T. Impact of concurrent remifentanil on the sedative effects of remimazolam, midazolam and propofol in cynomolgus monkeys. Eur J Pharmacol 2020; 890:173639. [PMID: 33065095 DOI: 10.1016/j.ejphar.2020.173639] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/02/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
Drug-drug interactions can substantially change pharmacological effects of the individual substances involved. For the use of sedatives or anaesthetics, having knowledge of the extent and characteristics of such interactions is crucial for ensuring the proper protection of patients undergoing any kind of sedation. Remimazolam is a new ultra-short acting benzodiazepine that is currently under development for intravenous use in procedural sedation and general anaesthesia. It exhibits a fast onset and fast offset which enables a more rapid recovery than currently available drugs in that class, such as midazolam. The purpose of this study was to more closely investigate the sedative properties and pharmacodynamic drug-drug interaction potential of remimazolam with the opioid analgesic remifentanil and compare it with other commonly used sedatives - midazolam and propofol. For this purpose, six Cynomolgus monkeys received escalating doses of remimazolam, propofol, and midazolam intravenously without or with concurrent remifentanil. Sedation was evaluated using a general sedation scale that included monitoring exploratory and avoidance behaviour, responses to sensory stimuli, posture and gait, and eyelid position as endpoints. Based on the results, sedative doses were calculated to allow evaluation of pharmacological drug-drug interaction with remifentanil. Remimazolam induced dose-dependent and consistent sedative effects in each endpoint tested and showed a high degree of synergism with remifentanil. Midazolam showed a comparable synergism while the interaction between propofol and remifentanil was less pronounced.
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Affiliation(s)
- Maren S Kops
- PAION Deutschland GmbH, Martinstr. 10-12, 52062, Aachen, Germany.
| | - Marija Pesic
- PAION Deutschland GmbH, Martinstr. 10-12, 52062, Aachen, Germany
| | - Karl-Uwe Petersen
- Medizinische Fakultät, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | | | - Thomas Stöhr
- PAION Deutschland GmbH, Martinstr. 10-12, 52062, Aachen, Germany
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Raue JF, Tünsmeyer J, Kästner SBR. Effects of isoflurane, remifentanil and dexmedetomidine on selected EEG parameters derived from a Narcotrend Monitor before and after nociceptive stimulation at different MAC multiples in cats. BMC Vet Res 2020; 16:332. [PMID: 32928231 PMCID: PMC7489203 DOI: 10.1186/s12917-020-02532-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this prospective and complete cross-over study was to evaluate the effects of isoflurane, remifentanil and dexmedetomidine on EEG parameters derived from the Narcotrend® Monitor before and after nociceptive stimulation at different isoflurane MAC (minimal alveolar concentration) multiples. Seven adult European Domestic Short Hair cats were used. Each cat went through 3 experimental treatments. Group I received isoflurane, group IR received isoflurane and a constant rate infusion (CRI) of remifentanil (18 μg/kg/h IV), and group ID received isoflurane and a CRI of dexmedetomidine (3 μg/kg/h IV). The isoflurane MAC in each group was determined via supramaximal electrical stimulation. The EEG parameters were derived by a Narcotrend Monitor at specific time points before and after nociceptive stimulation at 0.75, 1.0 and 1.5 MAC. The depth of anaesthesia was also assessed by a clinical score. Results The mean MAC sparing effects in group IR and group ID were 9.8 and 55.2%, respectively. The best correlation of EEG and MAC multiples was found for the Narcotrend Index (NI) in group I (r = − 0.67). The NI was also able to differentiate between 0.75 MAC and 1.5 MAC in group IR. Spectral edge frequency had a lower correlation with MAC multiples in group I (r = − 0.62) but was able to differentiate between 0.75 MAC and 1.5 MAC in groups I and IR, and between 1.0 MAC and 1.5 MAC in group IR. Narcotrend Index, SEF 95 and MF increased significantly after nociceptive stimulation at 1.0 MAC in group I, and SEF 95 increased significantly at 0.75 MAC in group ID. The clinical score correlated closer than any of the EEG parameters with MAC in all groups, with highest correlation values in group I (r = − 0.89). Noxious stimulation led to a significant increase of the clinical score at 0.75 MAC and 1.0 MAC in group I. Conclusions The EEG parameters derived from the Narcotrend Monitor show correlation to isoflurane MAC multiples in cats, but the anaesthetic protocol and especially the addition of dexmedetomidine have great influence on the reliability. The Narcotrend Monitor can be used as an additional tool to assess anesthetic depth in cats.
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Affiliation(s)
- Jonathan F Raue
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Julia Tünsmeyer
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Sabine B R Kästner
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.,Center for Systems Neuroscience Hannover, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
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Competitive Interactions between Halothane and Isoflurane at the Carotid Body and TASK Channels. Anesthesiology 2020; 133:1046-1059. [DOI: 10.1097/aln.0000000000003520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background
The degree to which different volatile anesthetics depress carotid body hypoxic response relates to their ability to activate TASK potassium channels. Most commonly, volatile anesthetic pairs act additively at their molecular targets. We examined whether this applied to carotid body TASK channels.
Methods
We studied halothane and isoflurane effects on hypoxia-evoked rise in intracellular calcium (Ca2+i, using the indicator Indo-1) in isolated neonatal rat glomus cells, and TASK single-channel activity (patch clamping) in native glomus cells and HEK293 cell line cells transiently expressing TASK-1.
Results
Halothane (5%) depressed glomus cell Ca2+i hypoxic response (mean ± SD, 94 ± 4% depression; P < 0.001 vs. control). Isoflurane (5%) had a less pronounced effect (53 ± 10% depression; P < 0.001 vs. halothane). A mix of 3% isoflurane/1.5% halothane depressed cell Ca2+i response (51 ± 17% depression) to a lesser degree than 1.5% halothane alone (79 ± 15%; P = 0.001), but similar to 3% isoflurane alone (44 ± 22%; P = 0.224), indicating subadditivity. Halothane and isoflurane increased glomus cell TASK-1/TASK-3 activity, but mixes had a lesser effect than that seen with halothane alone: 4% halothane/4% isoflurane yielded channel open probabilities 127 ± 55% above control, versus 226 ± 12% for 4% halothane alone (P = 0.009). Finally, in HEK293 cell line cells, progressively adding isoflurane (1.5 to 5%) to halothane (2.5%) reduced TASK-1 channel activity from 120 ± 38% above control, to 88 ± 48% (P = 0.034).
Conclusions
In all three experimental models, the effects of isoflurane and halothane combinations were quantitatively consistent with the modeling of weak and strong agonists competing at a common receptor on the TASK channel.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Yano M, Matsuda A, Natsume T, Ogawa S, Awaga Y, Hayashi I, Hama A, Takamatsu H. Pain-related behavior and brain activation in cynomolgus macaques with naturally occurring endometriosis. Hum Reprod 2020; 34:469-478. [PMID: 30597044 DOI: 10.1093/humrep/dey383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 11/22/2018] [Accepted: 12/04/2018] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION Can pain be objectively assessed in macaques with naturally occurring endometriosis? SUMMARY ANSWER Behavioral, pharmacological and in vivo brain imaging findings indicate that pain can be quantified in macaques with endometriosis. WHAT IS KNOWN ALREADY Endometriosis is characterized by abdominopelvic hypersensitity. The mechanism by which endometriosis evokes pain is largely unknown, as currently available analgesics offer limited pain relief. Thus, there is a need for both greater understanding of the in vivo mechanism of endometriosis-associated pain and better methods of testing novel therapeutics. STUDY DESIGN, SIZE, DURATION Pain-related behavior and brain activation were assessed in five cynomolgus macaques with endometriosis. Three healthy female macaques served as controls. PARTICIPANTS/MATERIALS, SETTING, METHODS Abdominopelvic sensitivity to force was assessed with an algometer. Activation of brain areas using block design force stimulation and the effects of a single dose of the analgesic drug morphine and 2-month treatment with the progestin dienogest on brain activation were observed via functional magnetic resonance imaging. MAIN RESULTS AND THE ROLE OF CHANCE Pain response thresholds in macaques with endometriosis were significantly less than that of healthy macaques (P = 0.0003). In addition, non-noxious force activated the insula and thalamus, which was reduced with morphine and 2-month dienogest treatment. LIMITATIONS, REASONS FOR CAUTION The specific role of cysts, such as peritoneal cysts, in endometriosis pain was not explored. While non-noxious stimulation activated the insula and thalamus, macaques were sedated during fMRI scans. Current findings need further confirmation in a larger cohort. WIDER IMPLICATIONS OF THE FINDINGS The current study demonstrated central sensitization and related pain behavior in macaques with naturally occurring endometriosis. Altered functioning of the central nervous system could be the focus of future mechanistic studies and for the development of novel therapeutics. STUDY FUNDING/COMPETING INTEREST(S) Supported by a grant from the Shizuoka Industrial Foundation. All authors are employees of Hamamatsu Pharma Research, Inc.
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Affiliation(s)
- Mizuho Yano
- Animal Care, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
| | - Akihisa Matsuda
- Animal Care, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
| | - Takahiro Natsume
- Pharmacology, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
| | - Shin'ya Ogawa
- Pharmacology, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
| | - Yūji Awaga
- Pharmacology, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
| | - Ikuo Hayashi
- Hamamatsu Pharma Research USA, Inc., San Diego, CA, US
| | - Aldric Hama
- Pharmacology, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
| | - Hiroyuki Takamatsu
- Pharmacology, Hamamatsu Pharma Research, Inc., Hamamatsu, Shizuoka, Japan
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Peker K, Akçaboy ZN, Aydın G, Gençay I, Şahin AT, Koçak YF, Peker SA. The Effect of Erector Spinae Plane Block on Laparoscopic Cholecystectomy Anesthesia: Analysis of Opioid Consumption, Sevoflurane Consumption, and Cost. J Laparoendosc Adv Surg Tech A 2020; 30:725-729. [DOI: 10.1089/lap.2019.0809] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Kevser Peker
- Anesthesiology and Critical Care, Kırıkkale University Medical Faculty Hospital, Kırıkkale, Turkey
| | - Zeynep Nur Akçaboy
- Anesthesiology and Critical Care, Kırıkkale University Medical Faculty Hospital, Kırıkkale, Turkey
| | - Gülçin Aydın
- Anesthesiology and Critical Care, Kırıkkale University Medical Faculty Hospital, Kırıkkale, Turkey
| | - Işın Gençay
- Anesthesiology and Critical Care, Kırıkkale University Medical Faculty Hospital, Kırıkkale, Turkey
| | - Ahmet Tuğrul Şahin
- Anesthesiology and Critical Care, Kırıkkale University Medical Faculty Hospital, Kırıkkale, Turkey
| | - Yahya Fatih Koçak
- Anesthesiology and Critical Care, Kırıkkale University Medical Faculty Hospital, Kırıkkale, Turkey
| | - Seydi Ali Peker
- Medical Biochemistry, Kırıkkale Yuksek Ihtisas Hospital, Kırıkkale, Turkey
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[Effects of remifentanil on awakening of propofol sedated patients submitted to upper gastrointestinal endoscopy: a randomized clinical trial]. Rev Bras Anestesiol 2020; 70:262-270. [PMID: 32482355 DOI: 10.1016/j.bjan.2020.03.004] [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: 02/05/2019] [Revised: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Sedation for endoscopic procedures aims to provide high quality sedation, lower risks, short recovery time, superior recovery quality and absence of side effects, seeking high patient level of satisfaction. The goal of the study was to assess administration of remifentanil combined with propofol regarding the effects of the drug association during sedation and recovery for patients submitted to upper GI diagnostic endoscopy. METHOD One hundred and five patients were assessed, randomly divided into three groups of 35 patients. The Control Group was sedated with propofol alone. Study Group 1 was sedated with a fixed dose of 0.2 μg.kg-1 remifentanil combined with propofol. Study Group 2 was sedated with 0.3 μg.kg-1 remifentanil combined with propofol. We assessed the quality of sedation, hemodynamic parameters, incidence of significant hypoxemia, time for spontaneous eye opening, post-anesthetic recovery time, quality of post-anesthetic recovery, presence of side effects and patient satisfaction. RESULTS Study Group 1 showed better quality of sedation. The groups in which remifentanil was administered combined with propofol showed shorter eye-opening time and shorter post-anesthetic recovery time compared to the control group. The three groups presented hemodynamic changes at some of the moments assessed. The incidence of significant hypoxemia, the quality of post-anesthetic recovery, the incidence of side effects and patient satisfaction were similar in the three groups. CONCLUSIONS The combination of propofol with remifentanil at a dose of 0.2 μg.kg-1 was effective in improving the quality of sedation, and at doses of 0.2 μg.kg-1 and 0.3 μg.kg-1 reduced the time to spontaneous eye opening and post-anesthetic recovery in comparison to sedation with propofol administered alone.
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Sauter ER. Cancer prevention and treatment using combination therapy with natural compounds. Expert Rev Clin Pharmacol 2020; 13:265-285. [PMID: 32154753 DOI: 10.1080/17512433.2020.1738218] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Naturally occurring compounds play an essential role in the prevention and treatment of various cancers. There are more than 100 plant and animal based natural compounds currently in clinical use.Areas covered: 1) The importance of natural products combinations in the prevention and treatment of cancer, 2) the need to maximize efficacy while minimizing side effects when using natural product combinations, and 3) specifics related to plant and animal derived natural products, as well as agents derived from natural products. Therapies using natural compounds that have been investigated, their rationale, mechanism of action and findings are reviewed. When the data warrant it, combined interventions that appear to increase efficacy (compared with monotherapy) while minimizing toxicity have been highlighted. Pubmed was used to search for relevant publications.Expert opinion: Combination therapy with natural compounds has the potential to be more effective than single agent therapy. Similar to pharmacologic agents, the goal is to maximize efficacy while mimimizing potential side effects. There is an increasing research focus on the development of agents derived from natural products, with notable successes already achieved from the effort.
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Affiliation(s)
- Edward R Sauter
- Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
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Rosati M, Bramante S, Conti F, Frattari A, Rizzi M, Roman RA. Operative Gynecological Laparoscopy Under Conscious Sedation. JSLS 2020; 24:e2020.00020. [PMID: 32612345 PMCID: PMC7316526 DOI: 10.4293/jsls.2020.00020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Operative laparoscopy is generally performed under general anesthesia. Local anesthesia and conscious sedation may be useful in select short procedures. In the present study, we evaluated safety and efficacy of operative laparoscopy under conscious sedation. METHODS Retrospective observational study evaluating patients undergoing gynecologic laparoscopy. Laparoscopy under conscious sedation was performed for each patient with umbilical direct insertion of a 12-mm port, followed by 2 ancillary ports at 1 cm medially to the anterior superior iliac spine. Conversion to conventional laparoscopy or laparotomy was recorded. Conscious sedation was obtained using Remifentanil and Propofol, administered by an infusion system based on pharmacokinetic and pharmacodynamic models. Local anesthesia was administered at port insertion sites and for paracervical block. Pain intensity was evaluated with the Visual Analog Scale (VAS). Adverse events and drug concentrations throughout the procedure were retrieved. RESULTS Our study population included 166 patients. They underwent laparoscopic unilateral versus bilateral salpingo-oophorectomy, ovarian cystectomy, bilateral salpingo-oophorectomy and omentectomy for a borderline ovarian tumor, myomectomy; or underwent surgery for unexplained infertility evaluation, pelvic pain, staging of ovarian cancer. Mean duration of pneumoperitoneum was 22.3 ± 7.2 min. Rate of conversion to laparoscopy under general anesthesia was 17/166 (10.2%) and there were only 3 cases of patients with low tolerability to the procedure. No severe adverse events occurred. Hospital discharge occurred in all unconverted cases after 6 to 18 h. CONCLUSIONS Operative laparoscopy under conscious sedation and local anesthesia appears to be a feasible technique in gynecologic surgery with no adverse patient outcomes.
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Affiliation(s)
- Maurizio Rosati
- Unit of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
| | - Silvia Bramante
- Unit of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
| | - Fiorella Conti
- Unit of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
| | - Antonella Frattari
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Pescara, Italy
| | - Maria Rizzi
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Pescara, Italy
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Abstract
The science of transitional states of consciousness is reviewed. Despite intensive study, determining the subjective experience of animals during transitional states of consciousness remains inherently limited. Until better assessment tools become available, behavior-based observations, such as loss of righting reflex/loss of posture, remain among our most useful guides to the onset of unconsciousness in animals. To minimize potential animal suffering and to ensure a truly unconscious state is unambiguously achieved, a state of general anesthesia relying on gamma amino butyric acid type A agonists or N-methyl-d-aspartate antagonist agents continues to be a necessary component of the companion animal euthanasia process.
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Affiliation(s)
- Robert E Meyer
- Veterinary Anesthesiology, College of Veterinary Medicine, PO Box 6100, Campus Mailstop 9825, 240 Wise Center Drive, Mississippi State, MS 39762-6100, USA.
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An J, Lee JH, Kim E, Woo K, Kim H, Lee D. Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: A prospective randomized study. Medicine (Baltimore) 2020; 99:e19130. [PMID: 32049831 PMCID: PMC7035047 DOI: 10.1097/md.0000000000019130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sugammadex reverses rocuronium-induced neuromuscular blockade quickly and effectively. This study compared efficacy of sugammadex and pyridostigmine for reversal of rocuronium-induced light block or minimal block in children scheduled for elective entropion surgery. METHODS A prospective randomized study was conducted on 60 pediatric patients aged 1 to 11 years and scheduled for entropion surgery under sevoflurane anesthesia. Neuromuscular blockade was achieved by administration of 0.6 mg/kg rocuronium and assessed using train-of-four (TOF) ulnar nerve stimulation. Patients were randomly assigned to 2 groups receiving sugammadex 2 mg/kg or pyridostigmine 0.2 mg/kg plus glycopyrrolate 0.01 mg/kg. Primary outcomes were time from reversal agents administration to TOF ratio 0.9 and time from reversal agent administration to TOF ratio 1.0. Time from TOF ratio 0.9 to extubation, time from TOF ratio 1.0 to extubation, and postoperative adverse events were also recorded. RESULTS There were no substantial differences in demographic variables. Time from reversal agents administration to TOF ratio 0.9 and time from reversal agents to TOF ratio 1.0 were significantly faster in sugammadex group: 1.30 ± 0.84 versus 3.53 ± 2.73 minutes (P < .001) and 2.75 ± 1.00 versus 5.73 ± 2.83 minutes (P < .001). Extubation time was shorter in sugammadex group. Incidence of skin rash, nausea, vomiting, and postoperative residual neuromuscular blockade (airway obstruction) was not statistically different between groups. Incidence of patients agitation in recovery room was lower in sugammadex group. CONCLUSION Sugammadex provided more rapid reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing surgery lasting 30 to 60 minutes than did pyridostigmine plus glycopyrrolate, with no differences in incidence of adverse events between groups.
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Shionoya Y, Nakamura E, Goi T, Nakamura K, Sunada K. Intravenous Sedation in Arnold-Chiari Malformation With Respiratory Failure. Anesth Prog 2020; 66:37-41. [PMID: 30883227 DOI: 10.2344/anpr-66-01-06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Type II Arnold-Chiari malformation (ACM) is an abnormality in which the cerebellum, pons, and medulla oblongata are displaced downward into the spinal cord. Type II ACM is often complicated by respiratory depression, sleep-disordered breathing, and deglutition disorder as a result of medullary dysfunction and impairment of the lower cranial nerves. Bending and stretching of the neck is restricted, and anesthetic management is problematic in patients with the disorder. We performed dental treatment twice under intravenous sedation in a patient with intellectual disability with type II ACM complicated by hypercapnic respiratory failure. Propofol was used for the first sedation procedure. Repeated bouts of respiratory depression occurred on that occasion, so the airway was managed manually by lifting the jaw. However, aspiration pneumonitis occurred postoperatively. A combination of dexmedetomidine and midazolam was used for sedation on the second occasion, and the intervention was completed uneventfully without any respiratory depression. Our experience with this patient highlights the need for selection of an agent for intravenous sedation that does not require neck extension and has minimal effect on respiration in patients with type II ACM, who are at high risk of respiratory depression and pulmonary aspiration.
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Affiliation(s)
- Yoshiki Shionoya
- Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan
| | - Eishi Nakamura
- Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan
| | - Takahiro Goi
- Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan
| | - Kiminari Nakamura
- Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan
| | - Katsuhisa Sunada
- Department of Dental Anesthesiology, Nippon Dental University School of Life Dentistry, Tokyo, Japan
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Kent DE, Savechenkov PY, Bruzik KS, Miller KW. Binding site location on GABA A receptors determines whether mixtures of intravenous general anaesthetics interact synergistically or additively in vivo. Br J Pharmacol 2019; 176:4760-4772. [PMID: 31454409 DOI: 10.1111/bph.14843] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/24/2019] [Accepted: 08/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND PURPOSE General anaesthetics can act on synaptic GABAA receptors by binding to one of three classes of general anaesthetic sites. Canonical drugs that bind selectively to only one class of site are etomidate, alphaxalone, and the mephobarbital derivative, R-mTFD-MPAB. We tested the hypothesis that the general anaesthetic potencies of mixtures of such site-selective agents binding to the same or to different sites would combine additively or synergistically respectively. EXPERIMENTAL APPROACH The potency of general anaesthetics individually or in combinations to cause loss of righting reflexes in tadpoles was determined, and the results were analysed using isobolographic methods. KEY RESULTS The potencies of combinations of two or three site-selective anaesthetics that all acted on a single class of site were strictly additive, regardless of which single site was involved. Combinations of two or three site-selective anaesthetics that all bound selectively to different sites always interacted synergistically. The strength of the synergy increased with the number of separate sites involved such that the percentage of each agent's EC50 required to cause anaesthesia was just 35% and 14% for two or three sites respectively. Propofol, which binds non-selectively to the etomidate and R-mTFD-MPAB sites, interacted synergistically with each of these agents. CONCLUSIONS AND IMPLICATIONS The established pharmacology of the three anaesthetic binding sites on synaptic GABAA receptors was sufficient to predict whether a mixture of anaesthetics interacted additively or synergistically to cause loss of righting reflexes in vivo. The principles established here have implications for clinical practice.
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Affiliation(s)
- Daniel E Kent
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts.,Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | | | - Karol S Bruzik
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, Illinois
| | - Keith W Miller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
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Pharmacodynamic Interaction of Remifentanil and Dexmedetomidine on Depth of Sedation and Tolerance of Laryngoscopy. Anesthesiology 2019; 131:1004-1017. [PMID: 31425170 DOI: 10.1097/aln.0000000000002882] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dexmedetomidine is a sedative with modest analgesic efficacy, whereas remifentanil is an opioid analgesic with modest sedative potency. Synergy is often observed when sedative-hypnotics are combined with opioid analgesics in anesthetic practice. A three-phase crossover trial was conducted to study the pharmacodynamic interaction between remifentanil and dexmedetomidine. METHODS After institutional review board approval, 30 age- and sex- stratified healthy volunteers were studied. The subjects received consecutive stepwise increasing target-controlled infusions of dexmedetomidine, remifentanil, and remifentanil with a fixed dexmedetomidine background concentration. Drug effects were measured using binary (yes or no) endpoints: no response to calling the subject by name, tolerance of shaking the patient while shouting the name ("shake and shout"), tolerance of deep trapezius squeeze, and tolerance of laryngoscopy. The drug effect was measured using the electroencephalogram-derived "Patient State Index." Pharmacokinetic-pharmacodynamic modeling related the administered dexmedetomidine and remifentanil concentration to these observed effects. RESULTS The binary endpoints were correlated with dexmedetomidine concentrations, with increasing concentrations required for increasing stimulus intensity. Estimated model parameters for the dexmedetomidine EC50 were 2.1 [90% CI, 1.6 to 2.8], 9.2 [6.8 to 13], 24 [16 to 35], and 35 [23 to 56] ng/ml, respectively. Age was inversely correlated with dexmedetomidine EC50 for all four stimuli. Adding remifentanil did not increase the probability of tolerance of any of the stimuli. The cerebral drug effect as measured by the Patient State Index was best described by the Hierarchical interaction model with an estimated dexmedetomidine EC50 of 0.49 [0.20 to 0.99] ng/ml and remifentanil EC50 of 1.6 [0.87 to 2.7] ng/ml. CONCLUSIONS Low dexmedetomidine concentrations (EC50 of 0.49 ng/ml) are required to induce sedation as measured by the Patient State Index. Sensitivity to dexmedetomidine increases with age. Despite falling asleep, the majority of subjects remained arousable by calling the subject's name, "shake and shout," or a trapezius squeeze, even when reaching supraclinical concentrations. Adding remifentanil does not alter the likelihood of response to graded stimuli.
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Perioperative use of opioids: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2019; 33:341-351. [DOI: 10.1016/j.bpa.2019.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
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Abstract
Balanced general anesthesia, the most common management strategy used in anesthesia care, entails the administration of different drugs together to create the anesthetic state. Anesthesiologists developed this approach to avoid sole reliance on ether for general anesthesia maintenance. Balanced general anesthesia uses less of each drug than if the drug were administered alone, thereby increasing the likelihood of its desired effects and reducing the likelihood of its side effects. To manage nociception intraoperatively and pain postoperatively, the current practice of balanced general anesthesia relies almost exclusively on opioids. While opioids are the most effective antinociceptive agents, they have undesirable side effects. Moreover, overreliance on opioids has contributed to the opioid epidemic in the United States. Spurred by concern of opioid overuse, balanced general anesthesia strategies are now using more agents to create the anesthetic state. Under these approaches, called “multimodal general anesthesia,” the additional drugs may include agents with specific central nervous system targets such as dexmedetomidine and ones with less specific targets, such as magnesium. It is postulated that use of more agents at smaller doses further maximizes desired effects while minimizing side effects. Although this approach appears to maximize the benefit-to-side effect ratio, no rational strategy has been provided for choosing the drug combinations. Nociception induced by surgery is the primary reason for placing a patient in a state of general anesthesia. Hence, any rational strategy should focus on nociception control intraoperatively and pain control postoperatively. In this Special Article, we review the anatomy and physiology of the nociceptive and arousal circuits, and the mechanisms through which commonly used anesthetics and anesthetic adjuncts act in these systems. We propose a rational strategy for multimodal general anesthesia predicated on choosing a combination of agents that act at different targets in the nociceptive system to control nociception intraoperatively and pain postoperatively. Because these agents also decrease arousal, the doses of hypnotics and/or inhaled ethers needed to control unconsciousness are reduced. Effective use of this strategy requires simultaneous monitoring of antinociception and level of unconsciousness. We illustrate the application of this strategy by summarizing anesthetic management for 4 representative surgeries.
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