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Mao W, Zhou T, Zhang F, Qian M, Xie J, Li Z, Shu Y, Li Y, Xu H. Pan-cancer single-cell landscape of drug-metabolizing enzyme genes. Pharmacogenet Genomics 2024; 34:217-225. [PMID: 38814173 DOI: 10.1097/fpc.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
OBJECTIVE Varied expression of drug-metabolizing enzymes (DME) genes dictates the intensity and duration of drug response in cancer treatment. This study aimed to investigate the transcriptional profile of DMEs in tumor microenvironment (TME) at single-cell level and their impact on individual responses to anticancer therapy. METHODS Over 1.3 million cells from 481 normal/tumor samples across 9 solid cancer types were integrated to profile changes in the expression of DME genes. A ridge regression model based on the PRISM database was constructed to predict the influence of DME gene expression on drug sensitivity. RESULTS Distinct expression patterns of DME genes were revealed at single-cell resolution across different cancer types. Several DME genes were highly enriched in epithelial cells (e.g. GPX2, TST and CYP3A5 ) or different TME components (e.g. CYP4F3 in monocytes). Particularly, GPX2 and TST were differentially expressed in epithelial cells from tumor samples compared to those from normal samples. Utilizing the PRISM database, we found that elevated expression of GPX2, CYP3A5 and reduced expression of TST was linked to enhanced sensitivity of particular chemo-drugs (e.g. gemcitabine, daunorubicin, dasatinib, vincristine, paclitaxel and oxaliplatin). CONCLUSION Our findings underscore the varied expression pattern of DME genes in cancer cells and TME components, highlighting their potential as biomarkers for selecting appropriate chemotherapy agents.
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Affiliation(s)
- Wei Mao
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Tao Zhou
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Feng Zhang
- Center for Precision Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang
| | - Maoxiang Qian
- Institute of Pediatrics and Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai
| | - Jianqiang Xie
- Department of Medicine and Surgery, Sichan Second Veterans Hospital
| | - Zhengyan Li
- Department of Radiology, West China Hospital, Sichuan University
| | - Yang Shu
- Gastric Cancer Center, West China Hospital, Sichuan University
| | - Yuan Li
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Heng Xu
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan
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Bock CA, Medford WG, Coughlin E, Mhaskar R, Sunjic KM. Implementing a Stepwise Shivering Protocol During Targeted Temperature Management. J Pharm Pract 2024; 37:871-879. [PMID: 37551844 DOI: 10.1177/08971900231193533] [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: 08/09/2023]
Abstract
Background: Shivering is often encountered in patients undergoing targeted temperature management (TTM) after cardiac arrest. The most efficient, safe way to prevent shivering during TTM is not clearly defined. Objective: The purpose of this study was to evaluate the impact of shivering management using a stepwise shivering protocol on time to target temperature (TT), medication utilization and nursing confidence. Methods: Single-center, retrospective chart review of all post-cardiac arrest patients who underwent TTM between 2016 and 2021. The primary outcome is a comparison of time to TT pre- and post-protocol implementation. Secondary objectives compared nursing confidence and medication utilization pre- and post-shivering protocol implementation. Results: Fifty-seven patients were included in the pre-protocol group and thirty-seven were in the post-protocol group. The median (IQR) time to TT was 195 (250) minutes and 165 (170), respectively (p = 0.190). The average doses of acetaminophen was 285 mg pre- vs 1994 mg post- (p <0.001, buspirone 47 mg pre- vs 127 mg post- (p < 0.001), magnesium 0.9 g pre-vs 2.8 g post- (p < 0.001), and fentanyl 1564 mcg pre- vs 2286 mcg post- (p=0.023). No difference was seen for midazolam and cisatracurium. Nurses reported feeling confident with his/her ability to manage shivering during TTM 38.5% of the time pre-protocol compared to 60% post-protocol (p = 0.306). Conclusion: Implementation of a stepwise approach to prevent and treat shivering improved time to TT in our institution, although this finding was not statistically significant. The stepwise protocol supported a reduced amount of high-risk medication use and increased nursing confidence in shivering management.
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Affiliation(s)
- Czarina A Bock
- Pharmacy Department, Tampa General Hospital, Tampa, FL, USA
| | - Whitney G Medford
- Pharmacy Department, Tampa General Hospital, Tampa, FL, USA
- Virtual Intensive Care Unit, BayCare Healthcare System, St Petersburg, FL, USA
| | - Emily Coughlin
- Department of Medical Education, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Katlynd M Sunjic
- Pharmacy Department, Tampa General Hospital, Tampa, FL, USA
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida, Taneja College of Pharmacy, Tampa, FL, USA
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Stroe MS, Huang MC, Annaert P, Leys K, Smits A, Allegaert K, Van Bockstal L, Valenzuela A, Ayuso M, Van Ginneken C, Van Cruchten S. Drug Disposition in Neonatal Göttingen Minipigs: Exploring Effects of Perinatal Asphyxia and Therapeutic Hypothermia. Drug Metab Dispos 2024; 52:824-835. [PMID: 38906699 DOI: 10.1124/dmd.124.001677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/25/2024] [Accepted: 05/29/2024] [Indexed: 06/23/2024] Open
Abstract
Asphyxiated neonates often undergo therapeutic hypothermia (TH) to reduce morbidity and mortality. Since both perinatal asphyxia (PA) and TH influence physiology, altered pharmacokinetics (PK) and pharmacodynamics (PD) are expected. Given that TH is the standard of care for PA with moderate to severe hypoxic-ischemic encephalopathy, disentangling the effect of PA versus TH on PK/PD is not possible in clinical settings. However, animal models can provide insights into this matter. The (neonatal) Göttingen Minipig, the recommended strain for nonclinical drug development, was selected as translational model. Four drugs-midazolam (MDZ), fentanyl (FNT), phenobarbital (PHB), and topiramate (TPM)-were intravenously administered under four conditions: control (C), therapeutic hypothermia (TH), hypoxia (H), and hypoxia plus TH (H+TH). Each group included six healthy male neonatal Göttingen Minipigs anesthetized for 24 hours. Blood samples were drawn at 0 (predose) and 0.5, 2, 2.5, 3, 4, 4.5, 6, 8, 12, and 24 hours post drug administration. Drug plasma concentrations were determined using validated bioanalytical assays. The PK parameters were estimated through compartmental and noncompartmental PK analysis. The study showed a statistically significant decrease in FNT clearance (CL; 66% decrease), with an approximately threefold longer half-life (t1/2) in the TH group. The H+TH group showed a 17% reduction in FNT CL, with a 62% longer t1/2 compared with the C group; however, it was not statistically significant. Although not statistically significant, trends toward lower CL and longer t1/2 were observed in the TH and H+TH groups for MDZ and PHB. Additionally, TPM demonstrated a 28% decrease in CL in the H group compared with controls. SIGNIFICANCE STATEMENT: The overarching goal of this study using the neonatal Göttingen Minipig model was to disentangle the effects of systemic hypoxia and TH on PK using four model drugs. Such insights can subsequently be used to inform and develop a physiologically based pharmacokinetic model, which is useful for drug exposure prediction in human neonates.
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Affiliation(s)
- Marina-Stefania Stroe
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Miao-Chan Huang
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Pieter Annaert
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Karen Leys
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Anne Smits
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Karel Allegaert
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Lieselotte Van Bockstal
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Allan Valenzuela
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Miriam Ayuso
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Chris Van Ginneken
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Steven Van Cruchten
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
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Ghia S, Savadjian A, Shin D, Diluozzo G, Weiner MM, Bhatt HV. Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications. J Cardiothorac Vasc Anesth 2023; 37:2634-2645. [PMID: 37723023 DOI: 10.1053/j.jvca.2023.08.139] [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: 06/12/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.
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Affiliation(s)
- Samit Ghia
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andre Savadjian
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - DaWi Shin
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriele Diluozzo
- Department of Cardiovascular Surgery, Yale School of Medicine, Bridgeport, CT
| | - Menachem M Weiner
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Himani V Bhatt
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Almohaish S, Cook AM, Brophy GM, Rhoney DH. Personalized antiseizure medication therapy in critically ill adult patients. Pharmacotherapy 2023; 43:1166-1181. [PMID: 36999346 DOI: 10.1002/phar.2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/01/2023]
Abstract
Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aaron M Cook
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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Leys K, Stroe MS, Annaert P, Van Cruchten S, Carpentier S, Allegaert K, Smits A. Pharmacokinetics during therapeutic hypothermia in neonates: from pathophysiology to translational knowledge and physiologically-based pharmacokinetic (PBPK) modeling. Expert Opin Drug Metab Toxicol 2023; 19:461-477. [PMID: 37470686 DOI: 10.1080/17425255.2023.2237412] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/13/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Perinatal asphyxia (PA) still causes significant morbidity and mortality. Therapeutic hypothermia (TH) is the only effective therapy for neonates with moderate to severe hypoxic-ischemic encephalopathy after PA. These neonates need additional pharmacotherapy, and both PA and TH may impact physiology and, consequently, pharmacokinetics (PK) and pharmacodynamics (PD). AREAS COVERED This review provides an overview of the available knowledge in PubMed (until November 2022) on the pathophysiology of neonates with PA/TH. In vivo pig models for this setting enable distinguishing the effect of PA versus TH on PK and translating this effect to human neonates. Available asphyxia pig models and methodological considerations are described. A summary of human neonatal PK of supportive pharmacotherapy to improve neurodevelopmental outcomes is provided. EXPERT OPINION To support drug development for this population, knowledge from clinical observations (PK data, real-world data on physiology), preclinical (in vitro and in vivo (minipig)) data, and molecular and cellular biology insights can be integrated into a predictive physiologically-based PK (PBPK) framework, as illustrated by the I-PREDICT project (Innovative physiology-based pharmacokinetic model to predict drug exposure in neonates undergoing cooling therapy). Current knowledge, challenges, and expert opinion on the future directions of this research topic are provided.
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Affiliation(s)
- Karen Leys
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences KU Leuven, Leuven, Belgium
| | - Marina-Stefania Stroe
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | - Steven Van Cruchten
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, GA, Rotterdam, The Netherlands
- Child and Youth Institute, KU Leuven, Leuven, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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Kanji S, Williamson D, Hartwick M. Potential pharmacological confounders in the setting of death determined by neurologic criteria: a narrative review. Can J Anaesth 2023; 70:713-723. [PMID: 37131030 PMCID: PMC10202973 DOI: 10.1007/s12630-023-02415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 05/04/2023] Open
Abstract
Guidelines for the determination of death by neurologic criteria (DNC) require an absence of confounding factors if clinical examination alone is to be used. Drugs that depress the central nervous system suppress neurologic responses and spontaneous breathing and must be excluded or reversed prior to proceeding. If these confounding factors cannot be eliminated, ancillary testing is required. These drugs may be present after being administered as part of the treatment of critically ill patients. While measurement of serum drug concentrations can help guide the timing of assessments for DNC, they are not always available or feasible. In this article, we review sedative and opioid drugs that may confound DNC, along with pharmacokinetic factors that govern the duration of drug action. Pharmacokinetic parameters including a context-sensitive half-life of sedatives and opioids are highly variable in critically ill patients because of the multitude of clinical variables and conditions that can affect drug distribution and clearance. Patient-, disease-, and treatment-related factors that influence the distribution and clearance of these drugs are discussed including end organ function, age, obesity, hyperdynamic states, augmented renal clearance, fluid balance, hypothermia, and the role of prolonged drug infusions in critically ill patients. In these contexts, it is often difficult to predict how long after drug discontinuation the confounding effects will take to dissipate. We propose a conservative framework for evaluating when or if DNC can be determined by clinical criteria alone. When pharmacologic confounders cannot be reversed, or doing so is not feasible, ancillary testing to confirm the absence of brain blood flow should be obtained.
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Affiliation(s)
- Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - David Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal and CIUSSS-Nord-de-l'ile-de-Montreal Research Center, Montreal, QC, Canada
| | - Michael Hartwick
- Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Canada
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Poppe M, Clodi C, Schriefl C, Mueller M, Sunder-Plaßmann R, Reiter B, Rechenmacher M, van Os W, van Hasselt JGC, Holzer M, Herkner H, Schwameis M, Jilma B, Schoergenhofer C, Weiser C. Targeted temperature management after cardiac arrest is associated with reduced metabolism of pantoprazole - A probe drug of CYP2C19 metabolism. Biomed Pharmacother 2021; 146:112573. [PMID: 34959115 DOI: 10.1016/j.biopha.2021.112573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest. METHODS This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling. RESULTS 16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8-4.8 h) in P1, 2.8 h (2.1-6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 - 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3. CONCLUSION CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations.
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Affiliation(s)
- Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Raute Sunder-Plaßmann
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Austria
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9
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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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10
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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11
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Ikejiri K, Akama Y, Ieki Y, Kawamoto E, Suzuki K, Yokoyama K, Ishikura K, Imai H. Veno-arterial extracorporeal membrane oxygenation and targeted temperature management in tricyclic antidepressant-induced cardiac arrest: A case report and literature review. Medicine (Baltimore) 2021; 100:e24980. [PMID: 33655968 PMCID: PMC7939188 DOI: 10.1097/md.0000000000024980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/11/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Cardiotoxicity is a common cause of death in tricyclic antidepressant (TCA) intoxication. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is effective in critically ill poisoned patients who do not respond to conventional therapies, and targeted temperature management (TTM) is associated with improved neurological outcomes and mortality in comatose out-of-hospital cardiac arrest survivors. However, few reports have documented cases of TCA intoxication that required intensive care, including VA-ECMO or TTM. PATIENT CONCERNS A 19-year-old Japanese man with a history of depression was brought to our hospital because he was in a comatose state with a generalized seizure. Before admission, he had taken an unknown amount of amitriptyline. DIAGNOSIS After intubation, the electrocardiogram (ECG) displayed a wide QRS complex tachycardia, and the patient suffered from cardiovascular instability despite intravenous bolus of sodium bicarbonate. At 200 minutes after ingestion, he experienced a TCA-induced cardiac arrest. INTERVENTIONS We initiated VA-ECMO 240 minutes after ingestion. The hemodynamic status stabilized, and the ECG abnormality improved gradually. In addition, we initiated targeted temperature management (TTM) with a target temperature of 34°C. OUTCOMES Twenty seven hours after starting the pump, the patient was weaned off the VA-ECMO. After completing the TTM, his mental status improved, and he was extubated on day 5. He was discharged on day 15 without neurological impairment, and the post-discharge course was uneventful. LESSONS First, VA-ECMO is effective in patients with TCA-induced cardiac arrest. Second, routine ECG screening during VA-ECMO support is useful for assessing the timing to wean off the VA-ECMO, as well as the degree of cardiotoxicity. Third, TTM is safe in comatose survivors of cardiac arrest caused by severe TCA intoxication.
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12
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Brady RBE, Poppell WT. Effect of intravenous fluid warming on core body temperature during elective orthopedic procedures. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2020; 61:1080-1084. [PMID: 33012824 PMCID: PMC7488375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The effects of intravenous (IV) fluid warming on core body temperature in a group of dogs undergoing an elective orthopedic procedure was studied. An IV fluid warmer was used alone or in conjunction with forced warmed air to determine the individual or additive effects of IV fluid warming. These effects were compared to those in dogs with no heat support or those with only forced warmed air in a randomized prospective study design. The conclusion was that IV fluid warming had no effect on the maintenance or preservation of core body temperature in this population of dogs, and that, as previous reports have shown, forced warmed air decreased the rate of heat loss during anesthetic procedures. One possible explanation for the lack of benefit is the location of the fluid warmer in relation to the patient. To our knowledge, this is the first study to examine the effects of IV fluid warming on core body temperature in dogs undergoing an elective orthopedic procedure.
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Affiliation(s)
- Robert B E Brady
- Memphis Veterinary Specialists, 555 Trinity Creek Cove, Cordova, Tennessee 38018, USA
| | - William T Poppell
- Memphis Veterinary Specialists, 555 Trinity Creek Cove, Cordova, Tennessee 38018, USA
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13
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Schäfer L, Schmidt P, Schiefer LM, Sareban M, Macholz F, Berger MM. Pharmakologische Eigenschaften von Notfallmedikamenten unter Extrembedingungen. Notf Rett Med 2020. [DOI: 10.1007/s10049-019-00646-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Zusammenfassung
Notfallmedikamente kommen an nahezu allen Orten dieser Erde zum Einsatz. Damit werden sie unterschiedlichsten Umweltbedingungen (Kälte, Hitze, direkte Sonneneinstrahlung) ausgesetzt. Sämtliche Daten zur Pharmakokinetik, Pharmakodynamik, Medikamentensicherheit und -haltbarkeit werden jedoch unter standardisierten Bedingungen erhoben, die sich von den Anwendungsbedingungen in der Notfallmedizin erheblich unterscheiden können. Durch die Kälte bei Wintereinsätzen im Gebirge können ebenso wie bei Einsätzen in großer Hitze und bei direkter Sonnenexposition chemische Reaktionen entstehen, welche die Eigenschaften der Medikamente bis hin zur kompletten Wirkungslosigkeit verändern können. Zusätzlich können Unterkühlung oder Überhitzung des Patienten zu einer Zentralisation bzw. Vasodilatation führen und damit das pharmakologische Verteilungsvolumen erheblich verändern, woraus Unter- bzw. Überdosierungen resultieren können. Gleichzeitig kann durch einen temperaturbedingt veränderten Metabolismus die Konjugation und Elimination von Medikamenten beeinflusst sein und zu einer unvorhersehbaren Verlängerung der Medikamentenwirkung führen. Trotz der erheblichen klinischen Relevanz dieser Thematik existieren bisher kaum Daten zu den konkreten Effekten extremer Umweltbedingungen auf die pharmakologischen Eigenschaften von Notfallmedikamenten. Diese Übersicht soll dazu dienen, den aktuellen Kenntnisstand der notfallmedizinischen Pharmakotherapie unter Extrembedingungen darzustellen.
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14
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Serum GFAP and UCH-L1 for the prediction of neurological outcome in comatose cardiac arrest patients. Resuscitation 2020; 154:61-68. [PMID: 32445783 DOI: 10.1016/j.resuscitation.2020.05.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/17/2020] [Accepted: 05/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Neurological outcome prediction is crucial early after cardiac arrest. Serum biomarkers released from brain cells after hypoxic-ischaemic injury may aid in outcome prediction. The only serum biomarker presently recommended in the European Resuscitation Council prognostication guidelines is neuron-specific enolase (NSE), but NSE has limitations. In this study, we therefore analyzed the outcome predictive accuracy of the serum biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) in patients after cardiac arrest. METHODS Serum GFAP and UCH-L1 were collected at 24, 48 and 72 h after cardiac arrest. The primary outcome was neurological function at 6-month follow-up assessed by the cerebral performance category scale (CPC), dichotomized into good (CPC1-2) and poor (CPC3-5). Prognostic accuracies were tested with receiver-operating characteristics by calculating the area under the receiver-operating curve (AUROC) and compared to the AUROC of NSE. RESULTS 717 patients were included in the study. GFAP and UCH-L1 discriminated between good and poor neurological outcome at all time-points when used alone (AUROC GFAP 0.88-0.89; UCH-L1 0.85-0.87) or in combination (AUROC 0.90-0.91). The combined model was superior to GFAP and UCH-L1 separately and NSE (AUROC 0.75-0.85) at all time-points. At specificities ≥95%, the combined model predicted poor outcome with a higher sensitivity than NSE at 24 h and with similar sensitivities at 48 and 72 h. CONCLUSION GFAP and UCH-L1 predicted poor neurological outcome with high accuracy. Their combination may be of special interest for early prognostication after cardiac arrest where it performed significantly better than the currently recommended biomarker NSE.
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15
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The Effect of Size, Maturation, Global Asphyxia, Cerebral Ischemia, and Therapeutic Hypothermia on the Pharmacokinetics of High-Dose Recombinant Erythropoietin in Fetal Sheep. Int J Mol Sci 2020; 21:ijms21093042. [PMID: 32344930 PMCID: PMC7247678 DOI: 10.3390/ijms21093042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 12/20/2022] Open
Abstract
High-dose human recombinant erythropoietin (rEPO) is a promising potential neuroprotective treatment in preterm and full-term neonates with hypoxic-ischemic encephalopathy (HIE). There are limited data on the pharmacokinetics of high-dose rEPO in neonates. We examined the effects of body weight, gestation age, global asphyxia, cerebral ischemia, hypothermia and exogenous rEPO on the pharmacokinetics of high-dose rEPO in fetal sheep. Near-term fetal sheep on gestation day 129 (0.87 gestation) (full term 147 days) received sham-ischemia (n = 5) or cerebral ischemia for 30 min followed by treatment with vehicle (n = 4), rEPO (n = 8) or combined treatment with rEPO and hypothermia (n = 8). Preterm fetal sheep on gestation day 104 (0.7 gestation) received sham-asphyxia (n = 1) or complete umbilical cord occlusion for 25 min followed by i.v. infusion of vehicle (n = 8) or rEPO (n = 27) treatment. rEPO was given as a loading bolus, followed by a prolonged continuous infusion for 66 to 71.5 h in preterm and near-term fetuses. A further group of preterm fetal sheep received repeated bolus injections of rEPO (n = 8). The plasma concentrations of rEPO were best described by a pharmacokinetic model that included first-order and mixed-order elimination with linear maturation of elimination with gestation age. There were no detectable effects of therapeutic hypothermia, cerebral ischemia, global asphyxia or exogenous treatment on rEPO pharmacokinetics. The increase in rEPO elimination with gestation age suggests that to maintain target exposure levels during prolonged treatment, the dose of rEPO may have to be adjusted to match the increase in size and growth. These results are important for designing and understanding future studies of neuroprotection with high-dose rEPO.
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16
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Sonnier M, Rittenberger JC. State-of-the-art considerations in post-arrest care. J Am Coll Emerg Physicians Open 2020; 1:107-116. [PMID: 33000021 PMCID: PMC7493544 DOI: 10.1002/emp2.12022] [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: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Cardiac arrest has a high rate of morbidity and mortality. Several advances in post-cardiac arrest management can improve outcome, but are time-dependent, placing the emergency physician in a critical role to both recognize the need for and initiate therapy. We present a novel perspective of both the workup and therapeutic interventions geared toward the emergency physician during the first few hours of care. We describe how the immediate care of a post-cardiac arrest patient is resource intensive and requires simultaneous evaluation for the underlying cause and intensive management to prevent further end organ damage, particularly of the central nervous system. The goal of the initial focused assessment is to rapidly determine if any reversible causes of cardiac arrest are present and to intervene when possible. Interventions performed in this acute period are aimed at preventing additional brain injury through optimizing hemodynamics, providing ventilatory support, and by using therapeutic hypothermia when indicated. After the initial phase of care, disposition is guided by available resources and the clinician's judgment. Transfer to a specialized cardiac arrest center is prudent in centers that do not have significant support or experience in the care of these patients.
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Affiliation(s)
| | - Jon C. Rittenberger
- Guthrie Robert Packer HospitalSayrePennsylvania
- Geisinger Commonwealth Medical CollegeScrantonPennsylvania
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17
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Bhagat I, Sarkar S. Multiple Organ Dysfunction During Therapeutic Cooling of Asphyxiated Infants. Neoreviews 2019; 20:e653-e660. [PMID: 31676739 DOI: 10.1542/neo.20-11-e653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The main purpose of therapeutic cooling is neuroprotection of asphyxiated infants with significant hypoxic-ischemic encephalopathy. However, to improve the overall outcome, it is necessary to properly manage the full range of multiple organ system complications found in asphyxiated infants undergoing therapeutic cooling. Every physiologic process in an asphyxiated infant can potentially be affected by the cooling treatment. The purpose of this review is to discuss the effect of cooling on neonatal physiology in the current recommended cooling range and the management thereof.
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Affiliation(s)
- Indira Bhagat
- Division of Neonatal-Perinatal Medicine, Wayne State University, Children's Hospital of Michigan, Detroit, MI
| | - Subrata Sarkar
- Division of Neonatal-Perinatal Medicine, University of Michigan Health System, Ann Arbor, MI
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18
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Raffaeli G, Pokorna P, Allegaert K, Mosca F, Cavallaro G, Wildschut ED, Tibboel D. Drug Disposition and Pharmacotherapy in Neonatal ECMO: From Fragmented Data to Integrated Knowledge. Front Pediatr 2019; 7:360. [PMID: 31552205 PMCID: PMC6733981 DOI: 10.3389/fped.2019.00360] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/27/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving support technology for potentially reversible neonatal cardiac and/or respiratory failure. As the survival and the overall outcome of patients rely on the treatment and reversal of the underlying disease, effective and preferentially evidence-based pharmacotherapy is crucial to target recovery. Currently limited data exist to support the clinicians in their every-day intensive care prescribing practice with the contemporary ECMO technology. Indeed, drug dosing to optimize pharmacotherapy during neonatal ECMO is a major challenge. The impact of the maturational changes of the organ function on both pharmacokinetics (PK) and pharmacodynamics (PD) has been widely established over the last decades. Next to the developmental pharmacology, additional non-maturational factors have been recognized as key-determinants of PK/PD variability. The dynamically changing state of critical illness during the ECMO course impairs the achievement of optimal drug exposure, as a result of single or multi-organ failure, capillary leak, altered protein binding, and sometimes a hyperdynamic state, with a variable effect on both the volume of distribution (Vd) and the clearance (Cl) of drugs. Extracorporeal membrane oxygenation introduces further PK/PD perturbation due to drug sequestration and hemodilution, thus increasing the Vd and clearance (sequestration). Drug disposition depends on the characteristics of the compounds (hydrophilic vs. lipophilic, protein binding), patients (age, comorbidities, surgery, co-medications, genetic variations), and circuits (roller vs. centrifugal-based systems; silicone vs. hollow-fiber oxygenators; renal replacement therapy). Based on the potential combination of the above-mentioned drug PK/PD determinants, an integrated approach in clinical drug prescription is pivotal to limit the risks of over- and under-dosing. The understanding of the dose-exposure-response relationship in critically-ill neonates on ECMO will enable the optimization of dosing strategies to ensure safety and efficacy for the individual patient. Next to in vitro and clinical PK data collection, physiologically-based pharmacokinetic modeling (PBPK) are emerging as alternative approaches to provide bedside dosing guidance. This article provides an overview of the available evidence in the field of neonatal pharmacology during ECMO. We will identify the main determinants of altered PK and PD, elaborate on evidence-based recommendations on pharmacotherapy and highlight areas for further research.
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Affiliation(s)
- Genny Raffaeli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Pavla Pokorna
- Department of Pediatrics—ICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Enno D. Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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Urits I, Jones MR, Orhurhu V, Sikorsky A, Seifert D, Flores C, Kaye AD, Viswanath O. A Comprehensive Update of Current Anesthesia Perspectives on Therapeutic Hypothermia. Adv Ther 2019; 36:2223-2232. [PMID: 31301055 PMCID: PMC6822844 DOI: 10.1007/s12325-019-01019-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Indexed: 12/16/2022]
Abstract
Normal thermal regulation is a result of the integration of afferent sensory, central control, and efferent responses to temperature change. Therapeutic hypothermia (TH) is a technique utilized during surgery to protect vital organs from ischemia; however, in doing so leads to other physiological changes. Indications for inducing hypothermia have been described for neuroprotection, coronary artery bypass graft (CABG) surgery, surgical repair of thoracoabdominal and intracranial aneurysms, pulmonary thromboendarterectomy, and arterial switch operations in neonates. Initially it was thought that induced hypothermia worked exclusively by a temperature-dependent reduction in metabolism causing a decreased demand for oxygen and glucose. Induced hypothermia exerts its neuroprotective effects through multiple underlying mechanisms including preservation of the integrity and survival of neurons through a reduction of extracellular levels of excitatory neurotransmitters dopamine and glutamate, therefore reducing central nervous system hyperexcitability. Risks of hypothermia include increased infection risk, altered drug pharmacokinetics, and systemic cardiovascular changes. Indications for TH include ischemia-inducing surgeries and diseases. Two commonly used methods are used to induce TH, surface cooling and endovascular cooling. Core body temperature monitoring is essential during induction of TH and rewarming, with central venous temperature as the gold standard. The aim of this review is to highlight current literature discussing perioperative considerations of TH including risks, benefits, indications, methods, and monitoring.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Mark R Jones
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew Sikorsky
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Danica Seifert
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Catalina Flores
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Creighton University School of Medicine, Omaha, NE, USA
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20
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Kovacs K, Szakmar E, Meder U, Szakacs L, Cseko A, Vatai B, Szabo AJ, McNamara PJ, Szabo M, Jermendy A. A Randomized Controlled Study of Low-Dose Hydrocortisone Versus Placebo in Dopamine-Treated Hypotensive Neonates Undergoing Hypothermia Treatment for Hypoxic-Ischemic Encephalopathy. J Pediatr 2019; 211:13-19.e3. [PMID: 31155392 DOI: 10.1016/j.jpeds.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/10/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate whether hydrocortisone supplementation increases blood pressure and decreases inotrope requirements compared with placebo in cooled, asphyxiated neonates with volume-resistant hypotension. STUDY DESIGN A double-blind, randomized, placebo-controlled clinical trial was conducted in a Level III neonatal intensive care unit in 2016-2017. Thirty-five asphyxiated neonates with volume-resistant hypotension (defined as a mean arterial pressure [MAP] < gestational age in weeks) were randomly assigned to receive 0.5 mg/kg/6 hours of hydrocortisone or placebo in addition to standard dopamine treatment during hypothermia. RESULTS More patients reached the target of at least 5-mm Hg increment of MAP in 2 hours after randomization in the hydrocortisone group, compared with the placebo group (94% vs 58%, P = .02, intention-to-treat analysis). The duration of cardiovascular support (P = .001) as well as cumulative (P < .001) and peak inotrope dosage (P < .001) were lower in the hydrocortisone group. In a per-protocol analysis, regression modeling predicted that a 4-mm Hg increase in MAP in response to hydrocortisone treatment was comparable with the effect of 15 μg/kg/min of dopamine in this patient population. Serum cortisol concentrations were low before randomization in both the hydrocortisone and placebo groups (median 3.5 and 3.3 μg/dL, P = .87; respectively), suggesting inappropriate adrenal function. Short-term clinical outcomes were similar in the 2 groups. CONCLUSIONS Hydrocortisone administration was effective in raising the blood pressure and decreasing inotrope requirement in asphyxiated neonates with volume-resistant hypotension during hypothermia treatment. TRIAL REGISTRATION ClinicalTrials.gov: NCT02700828.
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Affiliation(s)
- Kata Kovacs
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Eniko Szakmar
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Unoke Meder
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | | | - Anna Cseko
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Barbara Vatai
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabo
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary; MTA-SE Pediatric and Nephrology Research Group, Budapest, Hungary
| | | | - Miklos Szabo
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Agnes Jermendy
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary.
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21
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Eyileten C, Soplinska A, Pordzik J, Siller‐Matula JM, Postuła M. Effectiveness of Antiplatelet Drugs Under Therapeutic Hypothermia: A Comprehensive Review. Clin Pharmacol Ther 2019; 106:993-1005. [DOI: 10.1002/cpt.1492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Ceren Eyileten
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Aleksandra Soplinska
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Justyna Pordzik
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | | | - Marek Postuła
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
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Miyazaki R, Hoka S, Yamaura K. Visceral fat, but not subcutaneous fat, is associated with lower core temperature during laparoscopic surgery. PLoS One 2019; 14:e0218281. [PMID: 31188877 PMCID: PMC6561588 DOI: 10.1371/journal.pone.0218281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/29/2019] [Indexed: 01/14/2023] Open
Abstract
Background Previous studies suggest that lower BMI is a risk factor for intraoperative core hypothermia. Adipose tissue has a high insulation effect and is one of the major explanatory factors of core hypothermia. Accordingly, determining the respective influence of visceral and subcutaneous fat on changes in core temperature during laparoscopic surgery is of considerable interest. Methods We performed a prospective study of 104 consecutive donors who underwent laparoscopic nephrectomy. Temperature data were collected from anesthesia records. Visceral and subcutaneous fat were calculated by computed tomography (CT) or ultrasound. For ultrasound measurements, preperitoneal fat thickness was used as an index of visceral fat. Multiple linear regression analysis was performed at 30, 60, and 120 minutes after the surgical incision to identify the predictive factors of body temperature change. The potential explanatory valuables were age, sex, BMI, visceral fat, and subcutaneous fat. Results BMI (β = 0.010, 95%CI: 0.001–0.019, p = 0.033) and waist-to-hip ratio (β = 0.424, 95%CI: 0.065–0.782, p = 0.021) were associated with increased core temperature at 30 minutes after the surgical incision. Ultrasound measured-preperitoneal fat was significantly associated with increased core temperature at 30 and 60 minutes after the surgical incision (β = 0.012, 95%CI: 0.003–0.021, p = 0.009 and β = 0.013, 95%CI: 0.002–0.024, p = 0.026). CT-measured visceral fat was also associated with increased core temperature at 30 minutes after the surgical incision (β = 0.005, 95%CI: 0.000–0.010, p = 0.046). Conversely, subcutaneous fat was not associated with intraoperative core temperature. Male sex and younger age were associated with lower intraoperative core temperature. Conclusions Visceral fat protects against core temperature decrease during laparoscopic donor nephrectomy.
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Affiliation(s)
- Ryohei Miyazaki
- Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
- * E-mail:
| | - Sumio Hoka
- International University of Health and Welfare, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Shafaeiyan M, Ghods F, Rahbar F, Daneshi Z, Sadati L, Mashak B, Moradi J, Torkmandi H. The Effect of Warm Intravenous Fluid on Postoperative Pain: A Double-Blind Clinical Trial. PREVENTIVE CARE IN NURSING AND MIDWIFERY JOURNAL 2019. [DOI: 10.29252/pcnm.8.4.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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24
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Favié LMA, Groenendaal F, van den Broek MPH, Rademaker CMA, de Haan TR, van Straaten HLM, Dijk PH, van Heijst A, Dudink J, Dijkman KP, Rijken M, Zonnenberg IA, Cools F, Zecic A, van der Lee JH, Nuytemans DHGM, van Bel F, Egberts TCG, Huitema ADR. Pharmacokinetics of morphine in encephalopathic neonates treated with therapeutic hypothermia. PLoS One 2019; 14:e0211910. [PMID: 30763356 PMCID: PMC6375702 DOI: 10.1371/journal.pone.0211910] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/22/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Morphine is a commonly used drug in encephalopathic neonates treated with therapeutic hypothermia after perinatal asphyxia. Pharmacokinetics and optimal dosing of morphine in this population are largely unknown. The objective of this study was to describe pharmacokinetics of morphine and its metabolites morphine-3-glucuronide and morphine-6-glucuronide in encephalopathic neonates treated with therapeutic hypothermia and to develop pharmacokinetics based dosing guidelines for this population. STUDY DESIGN Term and near-term encephalopathic neonates treated with therapeutic hypothermia and receiving morphine were included in two multicenter cohort studies between 2008-2010 (SHIVER) and 2010-2014 (PharmaCool). Data were collected during hypothermia and rewarming, including blood samples for quantification of morphine and its metabolites. Parental informed consent was obtained for all participants. RESULTS 244 patients (GA mean (sd) 39.8 (1.6) weeks, BW mean (sd) 3,428 (613) g, male 61.5%) were included. Morphine clearance was reduced under hypothermia (33.5°C) by 6.89%/°C (95% CI 5.37%/°C- 8.41%/°C, p<0.001) and metabolite clearance by 4.91%/°C (95% CI 3.53%/°C- 6.22%/°C, p<0.001) compared to normothermia (36.5°C). Simulations showed that a loading dose of 50 μg/kg followed by continuous infusion of 5 μg/kg/h resulted in morphine plasma concentrations in the desired range (between 10 and 40 μg/L) during hypothermia. CONCLUSIONS Clearance of morphine and its metabolites in neonates is affected by therapeutic hypothermia. The regimen suggested by the simulations will be sufficient in the majority of patients. However, due to the large interpatient variability a higher dose might be necessary in individual patients to achieve the desired effect. TRIAL REGISTRATION www.trialregister.nl NTR2529.
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Affiliation(s)
- Laurent M. A. Favié
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcel P. H. van den Broek
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Carin M. A. Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Timo R. de Haan
- Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Peter H. Dijk
- Department of Neonatology, Groningen University Medical Centre, Groningen, the Netherlands
| | - Arno van Heijst
- Department of Neonatology, Radboud university medical center-Amalia Children’s Hospital, Nijmegen, the Netherlands
| | - Jeroen Dudink
- Department of Pediatrics, Division of Neonatology, Erasmus Medical Centre-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Koen P. Dijkman
- Department of Neonatology, Máxima Medical Center Veldhoven, Veldhoven, the Netherlands
| | - Monique Rijken
- Department of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Inge A. Zonnenberg
- Department of Neonatology, VU University Medical Center, Amsterdam, the Netherlands
| | - Filip Cools
- Department of Neonatology, UZ Brussel—Vrije Universiteit Brussel, Brussels, Belgium
| | - Alexandra Zecic
- Department of Neonatology, University Hospital Gent, Gent, Belgium
| | - Johanna H. van der Lee
- Paediatric Clinical Research Office, Emma Children’s Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Toine C. G. Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Alwin D. R. Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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Pisani F, Spagnoli C. Diagnosis and Management of Acute Seizures in Neonates. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00007-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Boylan GB, Kharoshankaya L, Mathieson SR. Diagnosis of seizures and encephalopathy using conventional EEG and amplitude integrated EEG. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:363-400. [PMID: 31324321 DOI: 10.1016/b978-0-444-64029-1.00018-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Seizures are more common in the neonatal period than at any other time of life, partly due to the relative hyperexcitability of the neonatal brain. Brain monitoring of sick neonates in the NICU using either conventional electroencephalography or amplitude integrated EEG is essential to accurately detect seizures. Treatment of seizures is important, as evidence increasingly indicates that seizures damage the brain in addition to that caused by the underlying etiology. Prompt treatment has been shown to reduce seizure burden with the potential to ameliorate seizure-mediated damage. Neonatal encephalopathy most commonly caused by a hypoxia-ischemia results in an alteration of mental status and problems such as seizures, hypotonia, apnea, and feeding difficulties. Confirmation of encephalopathy with EEG monitoring can act as an important adjunct to other investigations and the clinical examination, particularly when considering treatment strategies such as therapeutic hypothermia. Brain monitoring also provides useful early prognostic indicators to clinicians. Recent use of machine learning in algorithms to continuously monitor the neonatal EEG, detect seizures, and grade encephalopathy offers the exciting prospect of real-time decision support in the NICU in the very near future.
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Affiliation(s)
- Geraldine B Boylan
- Department of Paediatrics and Child Health, Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Liudmila Kharoshankaya
- Department of Paediatrics and Child Health, Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Sean R Mathieson
- Department of Paediatrics and Child Health, Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
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What is the predictor of the intraoperative body temperature in abdominal surgery? J Anesth 2018; 33:67-73. [PMID: 30498930 DOI: 10.1007/s00540-018-2585-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 11/17/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Inadvertent hypothermia is a relatively common intraoperative complication. Few studies have investigated predictors of body temperature change or the effect of the blanket type used with a forced-air warming device during the intraoperative period. We investigated the predictive factors of intraoperative body temperature change in scheduled abdominal surgery. METHODS We retrospectively reviewed the data from 2574 consecutive adult patients who underwent scheduled abdominal surgery in the supine position. Temperature data were collected from anesthesia records. Multiple regression analysis was performed at 60, 120, and 180 min after the surgical incision to identify the factors influencing body temperature change. We conducted nonlinear regression analysis using the equation ΔT = α (e-γt-1) + βt, where ΔT represented the change in intraoperative core temperature (°C), t represented the surgical duration (minutes), and α, β, and γ were constants. RESULTS The intraoperative core temperature change was explained by the equation ΔT = 0.59 (e- 0.018t - 1) + 0.0043t. Younger age, higher body mass index (BMI), male sex, laparoscopic surgery, and use of an underbody blanket were associated with increased core temperature at 1 or 2 h after surgical incision. Male sex and an underbody blanket remained strong predictive variables even 3 h after surgical incision, whereas BMI had little explanatory power at this timepoint. The difference in the heating effect of an underbody versus an overbody blanket was 0.0012 °C per minute. CONCLUSIONS The blanket type of the forced-air warmer, age, sex, laparoscopic surgery, and BMI are predictors of intraoperative core temperature change.
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Ryu S, Novak JJ, Patel R, Yates P, Di L. The impact of low temperature on fraction unbound for plasma and tissue. Biopharm Drug Dispos 2018; 39:437-442. [DOI: 10.1002/bdd.2160] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/01/2018] [Accepted: 10/20/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Sangwoo Ryu
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc.; Groton CT 06340 USA
| | - Jonathan J. Novak
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc.; Groton CT 06340 USA
| | - Roshan Patel
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc.; Groton CT 06340 USA
| | - Phillip Yates
- Early Clinical Development, Pfizer Inc.; Cambridge MA 02139 USA
| | - Li Di
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc.; Groton CT 06340 USA
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Sathyanarayanan G, Haapala M, Kiiski I, Sikanen T. Digital microfluidic immobilized cytochrome P450 reactors with integrated inkjet-printed microheaters for droplet-based drug metabolism research. Anal Bioanal Chem 2018; 410:6677-6687. [PMID: 30073515 PMCID: PMC6132693 DOI: 10.1007/s00216-018-1280-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/27/2018] [Accepted: 07/17/2018] [Indexed: 01/23/2023]
Abstract
We report the development and characterization of digital microfluidic (DMF) immobilized enzyme reactors (IMERs) for studying cytochrome P450 (CYP)-mediated drug metabolism on droplet scale. The on-chip IMERs consist of porous polymer (thiol-ene) monolith plugs prepared in situ by photopolymerization and functionalized with recombinant CYP1A1 isoforms (an important detoxification route for many drugs and other xenobiotics). The DMF devices also incorporate inexpensive, inkjet-printed microheaters for on-demand regio-specific heating of the IMERs to physiological temperature, which is crucial for maintaining the activity of the temperature-sensitive CYP reaction. For on-chip monitoring of the CYP activity, the DMF devices were combined with a commercial well-plate reader, and a custom fluorescence quantification method was developed for detection of the chosen CYP1A1 model activity (ethoxyresorufin-O-deethylation). The reproducibility of the developed assay was examined with the help of ten parallel CYP-IMERs. All CYP-IMERs provided statistically significant difference (in fluorescence response) compared to any of the negative controls (including room-temperature reactions). The average (n = 10) turnover rate was 20.3 ± 9.0 fmol resorufin per minute. Via parallelization, the concept of the droplet-based CYP-IMER developed in this study provides a viable approach to rapid and low-cost prediction of the metabolic clearance of new chemical entities in vitro.
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Affiliation(s)
- Gowtham Sathyanarayanan
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, P.O. Box 56, 00014, Helsinki, Finland
| | - Markus Haapala
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, P.O. Box 56, 00014, Helsinki, Finland
| | - Iiro Kiiski
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, P.O. Box 56, 00014, Helsinki, Finland
| | - Tiina Sikanen
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, P.O. Box 56, 00014, Helsinki, Finland.
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Chevin M, Guiraut C, Sébire G. Effect of hypothermia on interleukin-1 receptor antagonist pharmacodynamics in inflammatory-sensitized hypoxic-ischemic encephalopathy of term newborns. J Neuroinflammation 2018; 15:214. [PMID: 30060742 PMCID: PMC6066954 DOI: 10.1186/s12974-018-1258-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
Background Hypothermia is increasingly tested in several neurological conditions, such as neonatal encephalopathy, stroke, traumatic brain injury, subarachnoid hemorrhage, spinal cord injury, and neurological outcomes of cardiac arrest. Current studies aim to increase benefits of hypothermia with new add-on therapies including immunomodulatory agents. Hypothermia has been shown to affect the metabolism of commonly used drugs, including those acting on neuroimmune pathways. Objective This study focuses on the effect of hypothermia on interleukin-1 receptor antagonist pharmacodynamics in a model of neonatal encephalopathy. Methods The effect of hypothermia on (i) the tissue concentration of the interleukin-1 receptor antagonist, (ii) the interleukin-1 inflammatory cascade, and (iii) the neuroprotective potential of interleukin-1 receptor antagonist has been assessed on our rat model of neonatal encephalopathy resulting from inflammation induced by bacterial compound plus hypoxia-ischemia. Results Hypothermia reduced the surface of core and penumbra lesions, as well as alleviated the brain weight loss induced by LPS+HI exposure. Hypothermia compared to normothermia significantly increased (range 50–65%) the concentration of the interleukin-1 receptor antagonist within the central nervous system. Despite this increase of intracerebral interleukin-1 receptor antagonist concentration, the intracerebral interleukin-1-induced tumor necrosis factor-alpha cascade was upregulated. In hypothermic condition, the known neuroprotective effect of interleukin-1 receptor antagonist was neutralized (50 mg/kg/12 h for 72 h) or even reversed (200 mg/kg/12 h for 72 h) as compared to normothermic condition. Conclusion Hypothermia interferes with the pharmacodynamic parameters of the interleukin-1 receptor antagonist, through a bioaccumulation of the drug within the central nervous system and a paradoxical upregulation of the interleukin-1 pathway. These effects seem to be at the origin of the loss of efficiency or even toxicity of the interleukin-1 receptor antagonist when combined with hypothermia. Such bioaccumulation could happen similarly with the use of other drugs combined to hypothermia in a clinical context.
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Affiliation(s)
- Mathilde Chevin
- Department of Pediatrics, McGill University, Research Institute of the McGill University Health Centre, 1001 Decarie Boulevard, (Glen site, Block E, M0.3211), Montreal, Quebec, H4A 3J1, Canada
| | - Clémence Guiraut
- Department of Pediatrics, McGill University, Research Institute of the McGill University Health Centre, 1001 Decarie Boulevard, (Glen site, Block E, M0.3211), Montreal, Quebec, H4A 3J1, Canada
| | - Guillaume Sébire
- Department of Pediatrics, McGill University, Research Institute of the McGill University Health Centre, 1001 Decarie Boulevard, (Glen site, Block E, M0.3211), Montreal, Quebec, H4A 3J1, Canada.
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Wang W, Hua T, Li H, Wu X, Bradley J, Peberdy MA, Ornato JP, Tang W. Decreased cAMP Level and Decreased Downregulation of β 1-Adrenoceptor Expression in Therapeutic Hypothermia-Resuscitated Myocardium Are Associated With Improved Post-Resuscitation Myocardial Function. J Am Heart Assoc 2018; 7:JAHA.117.006573. [PMID: 29572320 PMCID: PMC5907536 DOI: 10.1161/jaha.117.006573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Epinephrine administered during cardiopulmonary resuscitation (CPR) is associated with severe post‐resuscitation myocardial dysfunction. We previously demonstrated that therapeutic hypothermia reduced the severity of post‐resuscitation myocardial dysfunction caused by epinephrine; however, the relationship between myocardial adrenoceptor expression and myocardial protective effects by hypothermia remains unclear. Methods and Results Rats weighing between 450 and 550 g were randomized into 5 groups: (1) normothermic placebo, (2) normothermic epinephrine, (3) hypothermic placebo, (4) hypothermic epinephrine, and (5) sham (not subject to cardiac arrest and resuscitation). Ventricular fibrillation was induced and untreated for 8 minutes for all other groups. Hypothermia was initiated coincident with the start of CPR and maintained at 33±0.2°C for 4 hours. Placebo or epinephrine was administered 5 minutes after the start of CPR and 3 minutes before defibrillation. Post‐resuscitation ejection fraction was measured hourly for 4 hours then hearts were harvested. Epinephrine increased coronary perfusion pressure during CPR (27±6 mm Hg versus 21±2 mm Hg P<0.05). Post‐resuscitation myocardial function was impaired in the normothermic epinephrine group compared with other groups. The concentration of myocardial cAMP doubled in the normothermic epinephrine group (655.06±447.63 μmol/L) compared with the hypothermic epinephrine group (302.51±97.98 μmol/L; P<0.05). Myocardial β1‐adrenoceptor expression decreased with normothermia cardiac arrest but not with hypothermia regardless of epinephrine. Conclusions Epinephrine, administered during normothermic CPR, increased the severity of post‐resuscitation myocardial dysfunction. This adverse effect was inhibited by intra‐arrest hypothermia resuscitation. Declined cAMP with more preserved β1‐adrenoceptors in hypothermia‐resuscitated myocardium is associated with improved post‐resuscitated myocardial function in vivo.
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Affiliation(s)
- Wei Wang
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA
| | - Tianfeng Hua
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA
| | - Hao Li
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA
| | - Xiaobo Wu
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA
| | - Jennifer Bradley
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA
| | - Mary Ann Peberdy
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA.,Departments of Internal Medicine and Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - Joseph P Ornato
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA.,Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA .,Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA.,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Figueroa SA, Blissitt PA, Livesay S, Wavra T, Guanci MM. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2017; 7:231-234. [PMID: 29058528 DOI: 10.1089/ther.2017.29037.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stephen A Figueroa
- 2 Division of Neurocritical Care, The University of Texas Southwestern Medical Center , Dallas, Texas
| | - Patricia A Blissitt
- 3 Harborview Medical Center and Swedish Medical Center, Clinical Faculty, University of Washington School of Nursing , Seattle, Washington
| | - Sarah Livesay
- 4 College of Nursing, Rush University , Chicago, Illinois
| | - Teresa Wavra
- 5 Cardiovascular CNS, Mission Hospital , Mission Viejo, California
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Abstract
Neonatal seizures constitute the most frequent presenting neurologic sign encountered in the neonatal intensive care unit. Despite limited efficacy and safety data, phenobarbital continues to be used near-universally as the first-line anti-seizure drug (ASD) in neonates. The choice of second-line ASDs varies by provider and institution, and is still not supported by sufficient scientific evidence. In this review, we discuss the available evidence supporting the efficacy, mechanism of action, potential adverse effects, key pharmacokinetic characteristics such as interaction with therapeutic hypothermia, logistical issues, and rationale for use of neonatal ASDs. We describe the widely used neonatal ASDs, namely phenobarbital, phenytoin, midazolam, and levetiracetam, in addition to potential ASDs, including lidocaine, topiramate, and bumetanide.
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Affiliation(s)
- Mohamed El-Dib
- Neonatal Neurocritical Care, Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Wei W, Xie Y, Lai SC, Liu BF, He YR, Hu H, Cao Y. Benefits of anti-inflammatory therapy in the treatment of ischemia/reperfusion injury in the renal microvascular endothelium of rats with return of spontaneous circulation. Mol Med Rep 2017; 15:4231-4238. [DOI: 10.3892/mmr.2017.6548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 02/14/2017] [Indexed: 11/05/2022] Open
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Dosing antibiotic prophylaxis during cardiopulmonary bypass-a higher level of complexity? A structured review. Int J Antimicrob Agents 2017; 49:395-402. [PMID: 28254373 DOI: 10.1016/j.ijantimicag.2016.12.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/01/2016] [Accepted: 12/17/2016] [Indexed: 12/30/2022]
Abstract
In highly invasive procedures such as open heart surgery, the risk of post-operative infection is particularly high due to exposure of the surgical field to multiple foreign devices. Adequate antibiotic prophylaxis is an essential intervention to minimise post-operative morbidity and mortality. However, there is a lack of clear understanding on the adequacy of traditional prophylactic dosing regimens, which are rarely supported by data. The aim of this structured review is to describe the relevant pharmacokinetic/pharmacodynamic (PK/PD) considerations for optimal antibiotic prophylaxis for major cardiac surgery including cardiopulmonary bypass (CPB). A structured review of the relevant published literature was performed and 45 relevant studies describing antibiotic pharmacokinetics in patients receiving extracorporeal CPB as part of major cardiac surgery were identified. Some of the studies suggested marked PK alterations in the peri-operative period with increases in volume of distribution (Vd) by up to 58% and altered drug clearances of up to 20%. Mechanisms proposed as causing the PK changes included haemodilution, hypothermia, retention of the antibiotic within the extracorporeal circuit, altered physiology related to a systemic inflammatory response, and maldistribution of blood flow. Of note, some studies reported no or minimal impact of the CPB procedure on antibiotic pharmacokinetics. Given the inconsistent data, ongoing research should focus on clarifying the influence of CPB procedure and related clinical covariates on the pharmacokinetics of different antibiotics during cardiac surgery. Traditional prophylactic dosing regimens may need to be re-assessed to ensure sufficient drug exposures that will minimise the risk of surgical site infections.
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Sung IK. Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy in Newborn Infants. NEONATAL MEDICINE 2017. [DOI: 10.5385/nm.2017.24.4.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- In Kyung Sung
- Department of Pediatrics, Collge of Medicine, The Catholic University of Korea, Seoul, Korea
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Witcher R, Dzierba AL, Kim C, Smithburger PL, Kane-Gill SL. Adverse drug reactions in therapeutic hypothermia after cardiac arrest. Ther Adv Drug Saf 2016; 8:101-111. [PMID: 28382198 DOI: 10.1177/2042098616679813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) improves survival and neurologic function in comatose survivors of cardiac arrest. Many medications used to support TH have altered pharmacokinetics and pharmacodynamics during this treatment. It is unknown if or at what frequency the medications used during TH cause adverse drug reactions (ADRs). METHODS A retrospective chart review was conducted for patients admitted to an intensive care unit (ICU) after cardiac arrest and treated with TH from January 2009 to June 2012 at two urban, university-affiliated, tertiary-care medical centres. Medications commonly used during TH were screened for association with significant ADRs (grade 3 or greater per Common Terminology Criteria for Adverse Events) using three published ADR detection instruments. RESULTS A total of 229 patients were included, the majority being males with median age of 62 presenting with an out-of-hospital cardiac arrest in pulseless electrical activity or asystole. The most common comorbidities were hypertension, coronary artery disease, and diabetes mellitus. There were 670 possible ADRs and 69 probable ADRs identified. Of the 670 possible ADRs, propofol, fentanyl, and acetaminophen were the most common drugs associated with ADRs. Whereas fentanyl, insulin, and propofol were the most common drugs associated with a probable ADR. Patients were managed with TH for a median of 22 hours, with 38% of patients surviving to hospital discharge. CONCLUSIONS Patients undergoing TH after cardiac arrest frequently experience possible adverse reactions associated with medications and the corresponding laboratory abnormalities are significant. There is a need for judicious use and close monitoring of drugs in the setting of TH until recommendations for dose adjustments are available to help prevent ADRs.
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Affiliation(s)
- Robert Witcher
- New York University Langone Medical Centre, New York, NY, USA
| | | | - Catherine Kim
- University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA Department of Pharmacy, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Pamela L Smithburger
- University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA Department of Pharmacy, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Sandra L Kane-Gill
- School of Pharmacy, University of Pittsburgh, 918 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA
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Seder DB, Lord C, Gagnon DJ. The Evolving Paradigm of Individualized Postresuscitation Care After Cardiac Arrest. Am J Crit Care 2016; 25:556-564. [PMID: 27802958 DOI: 10.4037/ajcc2016496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The postresuscitation period after a cardiac arrest is characterized by a wide range of physiological derangements. Variations between patients include preexisting medical problems, the underlying cause of the cardiac arrest, presence or absence of hemodynamic and circulatory instability, severity of the ischemia-reperfusion injury, and resuscitation-related injuries such as pulmonary aspiration and rib or sternal fractures. Although protocols can be applied to many elements of postresuscitation care, the widely disparate clinical condition of cardiac arrest survivors requires an individualized approach that stratifies patients according to their clinical profile and targets specific treatments to patients most likely to benefit. This article describes such an individualized approach, provides a practical framework for evaluation and triage at the bedside, and reviews concerns specific to all members of the interprofessional postresuscitation care team.
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Affiliation(s)
- David B. Seder
- David B. Seder is director of neurocritical care at Maine Medical Center, Portland, Maine, and an associate professor of medicine at Tufts University School of Medicine, Boston, Massachusetts. Christine Lord is a staff nurse and the unit-based educator for the cardiac intensive care unit at Maine Medical Center. David J. Gagnon is a critical care pharmacist at Maine Medical Center and a clinical assistant professor of medicine at Tufts University School of Medicine
| | - Christine Lord
- David B. Seder is director of neurocritical care at Maine Medical Center, Portland, Maine, and an associate professor of medicine at Tufts University School of Medicine, Boston, Massachusetts. Christine Lord is a staff nurse and the unit-based educator for the cardiac intensive care unit at Maine Medical Center. David J. Gagnon is a critical care pharmacist at Maine Medical Center and a clinical assistant professor of medicine at Tufts University School of Medicine
| | - David J. Gagnon
- David B. Seder is director of neurocritical care at Maine Medical Center, Portland, Maine, and an associate professor of medicine at Tufts University School of Medicine, Boston, Massachusetts. Christine Lord is a staff nurse and the unit-based educator for the cardiac intensive care unit at Maine Medical Center. David J. Gagnon is a critical care pharmacist at Maine Medical Center and a clinical assistant professor of medicine at Tufts University School of Medicine
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Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest. Best Pract Res Clin Anaesthesiol 2016; 29:435-50. [PMID: 26670815 DOI: 10.1016/j.bpa.2015.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 09/22/2015] [Indexed: 12/16/2022]
Abstract
The approach to sedation, analgesia, and neuromuscular blockade during targeted temperature management (TTM) remains largely unstudied, forcing clinicians to adapt previous research from other patient environments. During TTM, very little data guide drug selection, doses, and specific therapeutic goals. Sedation should be deep enough to prevent awareness during neuromuscular blockade, but titration is complex as metabolism and clearance are delayed for almost all drugs during hypothermia. Deeper sedation is associated with prolonged intensive care unit (ICU) and ventilator therapy, increased delirium and infection, and delayed wakening which can confound early critical neurological assessments, potentially resulting in erroneous prognostication and inappropriate withdrawal of life support. We review the potential therapeutic goals for sedation, analgesia, and neuromuscular blockade during TTM; the adverse events associated with that treatment; data suggesting that TTM and organ dysfunction impair drug metabolism; and controversies and potential benefits of specific monitoring. We also highlight the areas needing better research to guide our therapy.
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Anderson KB, Poloyac SM, Kochanek PM, Empey PE. Effect of Hypothermia and Targeted Temperature Management on Drug Disposition and Response Following Cardiac Arrest: A Comprehensive Review of Preclinical and Clinical Investigations. Ther Hypothermia Temp Manag 2016; 6:169-179. [PMID: 27622966 DOI: 10.1089/ther.2016.0003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Targeted temperature management (TTM) has been shown to reduce mortality and improve neurological outcomes in out-of-hospital cardiac arrest (CA) patients and in neonates with hypoxic-ischemic encephalopathy (HIE). TTM has also been associated with adverse drug events in the critically ill patient due to its effect on drug pharmacokinetics (PKs) and pharmacodynamics (PDs). We aim to evaluate the current literature on the effect of TTM on drug PKs and PDs following CA. MEDLINE/PubMed databases were searched for publications, which include the MeSH terms hypothermia, drug metabolism, drug transport, P450, critical care, cardiac arrest, hypoxic-ischemic encephalopathy, pharmacokinetics, and pharmacodynamics between July 2006 and October 2015. Twenty-three studies were included in this review. The studies demonstrate that hypothermia impacts PK parameters and increases concentrations of cytochrome-P450-metabolized drugs in the cooling and rewarming phase. Furthermore, the current data demonstrate a combined effect of CA and hypothermia on drug PK. Importantly, these effects can last greater than 4-5 days post-treatment. Limited evidence suggests hypothermia-mediated changes in the Phase II metabolism and the Phase III transport of drugs. Hypothermia also has been shown to potentially decrease the effect of specific drugs at the receptor level. Therapeutic hypothermia, as commonly deployed/applied during TTM, alters PK, and elevates concentrations of several commonly used medications. Hypothermia-mediated effects are an important factor when dosing and monitoring patients undergoing TTM treatment.
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Affiliation(s)
- Kacey B Anderson
- 1 Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Samuel M Poloyac
- 1 Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 2 Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Philip E Empey
- 3 Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
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Coppler PJ, Sawyer KN, Youn CS, Choi SP, Park KN, Kim YM, Reynolds JC, Gaieski DF, Lee BK, Oh JS, Kim WY, Moon HJ, Abella BS, Elmer J, Callaway CW, Rittenberger JC. Variability of Post-Cardiac Arrest Care Practices Among Cardiac Arrest Centers: United States and South Korean Dual Network Survey of Emergency Physician Research Principal Investigators. Ther Hypothermia Temp Manag 2016; 7:30-35. [PMID: 27419613 DOI: 10.1089/ther.2016.0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is little consensus regarding many post-cardiac arrest care parameters. Variability in such practices could confound the results and generalizability of post-arrest care research. We sought to characterize the variability in post-cardiac arrest care practice in Korea and the United States. A 54-question survey was sent to investigators participating in one of two research groups in South Korea (Korean Hypothermia Network [KORHN]) and the United States (National Post-Arrest Research Consortium [NPARC]). Single investigators from each site were surveyed (N = 40). Participants answered questions based on local institutional protocols and practice. We calculated descriptive statistics for all variables. Forty surveys were completed during the study period with 30 having greater than 50% of questions completed (75% response rate; 24 KORHN and 6 NPARC). Most centers target either 33°C (N = 16) or vary the target based on patient characteristics (N = 13). Both bolus and continuous infusion dosing of sedation are employed. No single indication was unanimous for cardiac catheterization. Only six investigators reported having an institutional protocol for withdrawal of life-sustaining therapy (WLST). US patients with poor neurological prognosis tended to have WLST with subsequent expiration (N = 5), whereas Korean patients are transferred to a secondary care facility (N = 19). Both electroencephalography modality and duration vary between institutions. Serum biomarkers are commonly employed by Korean, but not US centers. We found significant variability in post-cardiac arrest care practices among US and Korean medical centers. These practice variations must be taken into account in future studies of post-arrest care.
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Affiliation(s)
- Patrick J Coppler
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Physician Assistant Studies, University of the Sciences , Philadelphia, Pennsylvania
| | - Kelly N Sawyer
- 3 Department of Emergency Medicine, William Beaumont Hospital , Royal Oak, Michigan
| | - Chun Song Youn
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Seung Pill Choi
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Kyu Nam Park
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Young-Min Kim
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Joshua C Reynolds
- 5 Department of Emergency Medicine, Michigan State University College of Human Medicine , Grand Rapids, Michigan
| | - David F Gaieski
- 6 Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University Hospital , Philadelphia, Pennsylvania
| | - Byung Kook Lee
- 7 Chonnam National University Hospital , Gwangju, South Korea
| | - Joo Suk Oh
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Won Young Kim
- 8 Ulsan University College of Medicine , Asan Medical Center, Seoul, South Korea
| | - Hyung Jun Moon
- 9 Soonchunhyang University Cheonan Hospital , Cheonan, South Korea
| | - Benjamin S Abella
- 10 Department of Emergency Medicine, Pereleman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Jonathan Elmer
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,11 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Clifton W Callaway
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Jon C Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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Al Balushi A, Guilbault MP, Wintermark P. Secondary Increase of Lactate Levels in Asphyxiated Newborns during Hypothermia Treatment: Reflect of Suboptimal Hemodynamics (A Case Series and Review of the Literature). AJP Rep 2016; 6:e48-58. [PMID: 26929870 PMCID: PMC4737629 DOI: 10.1055/s-0035-1565921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 09/02/2015] [Indexed: 12/02/2022] Open
Abstract
Objective To evaluate whether a secondary increase of serum lactate levels in asphyxiated newborns during hypothermia treatment may reflect suboptimal dynamics. Methods-Retrospective case series and review of the literature. We present the clinical course of four asphyxiated newborns treated with hypothermia who presented with hypotension requiring inotropic support, and who displayed a secondary increase of serum lactate levels during hypothermia treatment. Serial serum lactate levels are correlated with blood pressure and inotropic support within the first 96 hours of life. Results Lactate levels initially decreased in the four patients. However, each of them started to present lower blood pressure, and lactate levels started to increase again. Inotropic support was started to raise blood pressure. The introduction of an epinephrine drip consistently worsened the increase of lactate levels in these newborns, whereas dopamine and dobutamine enabled the clearance of lactate in addition to raising the blood pressure. Rewarming was associated with hemodynamics perturbations (a decrease of blood pressure and/or an increase of lactate levels) in the three newborns who survived. Conclusions Lactate levels during the first 4 days of life should be followed as a potential marker for suboptimal hemodynamic status in term asphyxiated newborns treated with hypothermia, for whom the maintenance of homeostasis during hypothermia treatment is of utmost importance to alleviate brain injury.
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Affiliation(s)
- Asim Al Balushi
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Marie-Pier Guilbault
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
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Morbitzer KA, Jordan JD, Rhoney DH. Vancomycin pharmacokinetic parameters in patients with acute brain injury undergoing controlled normothermia, therapeutic hypothermia, or pentobarbital infusion. Neurocrit Care 2016; 22:258-64. [PMID: 25330755 DOI: 10.1007/s12028-014-0079-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Therapeutic strategies that cause an alteration in patient temperature, such as controlled normothermia (CN), therapeutic hypothermia (TH), and pentobarbital infusion (PI), are often used to manage complications caused by acute brain injury. The purpose of this study was to evaluate pharmacokinetic (PK) parameters of vancomycin in patients with acute brain injury undergoing temperature modulation. METHODS This was a retrospective cohort study of adult patients with acute brain injury admitted between May 2010 and March 2014 who underwent CN, TH, or PI and received vancomycin. Predicted PK parameters based on population data were compared with calculated PK parameters based on serum concentrations. RESULTS Seventeen CN patients and 10 TH/PI patients met inclusion criteria. Traumatic brain injury and aneurysmal subarachnoid hemorrhage accounted for the majority of admitting diagnoses. In the CN group, the median dose was 16.7 (15.5-18.4) mg/kg. The median calculated elimination rate constant [0.155 (0.108-0.17) vs. 0.103 (0.08-0.142) hr(-1); p = 0.04] was significantly higher than the predicted value. The median measured trough concentration [8.9 (7.7-11.1) vs. 17.1 (10.8-22.3) υg/mL; p = 0.004] was significantly lower than predicted. In the TH/PI group, the median dose was 15.4 (14.7-17.2) mg/kg. No significant differences were found between the median calculated and predicted elimination rate constant [0.107 (0.097-0.109) vs. 0.112 (0.102-0.127) hr(-1); p = 0.41] and median measured and predicted trough concentration [14.2 (12.7-17.1) vs. 13.1 (11-17.8) υg/mL; p = 0.71]. CONCLUSION Patients who underwent TH/PI did not exhibit PK alterations when compared to predicted PK parameters based on population data, while patients who underwent CN experienced PK alterations favoring an increased elimination of vancomycin.
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Affiliation(s)
- Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115 Beard Hall, Campus Box 7574, Chapel Hill, NC, 27599, USA
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Huang C, Ng OTW, Ho YS, Irwin MG, Chang RCC, Wong GTC. Effect of Continuous Propofol Infusion in Rat on Tau Phosphorylation with or without Temperature Control. J Alzheimers Dis 2016; 51:213-26. [PMID: 26836157 DOI: 10.3233/jad-150645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Several studies suggest a relationship between anesthesia-induced tau hyperphosphorylation and the development of postoperative cognitive dysfunction. This study further characterized the effects of continuous propofol infusion on tau protein phosphorylation in rats, with or without temperature control. Propofol was administered intravenously to 8-10-week-old male Sprague-Dawley rats and infused to the loss of the righting reflex for 2 h continuously. Proteins from cortex and hippocampus were examined by western blot and immunohistochemistry. Rectal temperature was significantly decreased during propofol infusion. Propofol with hypothermia significantly increased phosphorylation of tau at AT8, AT180, Thr205, and Ser199 in cortex and hippocampus except Ser396. With temperature maintenance, propofol still induced significant elevation of AT8, Thr205, and Ser199 in cortex and hippocampus; however, increase of AT180 and Ser396 was only found in hippocampus and cortex, respectively. Differential effects of propofol with or without hypothermia on multiple tau related kinases, such as Akt/GSK3β, MAPK pathways, or phosphatase (PP2A), were demonstrated in region-specific manner. These findings indicated that propofol increased tau phosphorylation under both normothermic and hypothermic conditions, and temperature control could partially attenuate the hyperphosphorylation of tau. Further studies are warranted to determine the long-term impact of propofol on the tau pathology and cognitive functions.
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Affiliation(s)
- Chunxia Huang
- Department of Anaesthesiology, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Olivia Tsz-Wa Ng
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Yuen-Shan Ho
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Michael Garnet Irwin
- Department of Anaesthesiology, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Research Centre of Heart, Brain, Hormone and Healthy Aging, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Raymond Chuen-Chung Chang
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Research Centre of Heart, Brain, Hormone and Healthy Aging, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Gordon Tin-Chun Wong
- Department of Anaesthesiology, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Research Centre of Heart, Brain, Hormone and Healthy Aging, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
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Seo HY, Oh BJ, Park EJ, Min YG, Choi SC. Dexmedetomidine Use in Patients with 33℃ Targeted Temperature Management: Focus on Bradycardia as an Adverse Effect. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.4.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Pharmacokinetic and Other Considerations for Drug Therapy During Targeted Temperature Management. Crit Care Med 2015; 43:2228-38. [DOI: 10.1097/ccm.0000000000001223] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: Where to go? Exp Neurol 2015; 272:67-77. [PMID: 26057949 DOI: 10.1016/j.expneurol.2015.06.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/16/2015] [Accepted: 06/04/2015] [Indexed: 01/08/2023]
Abstract
Ischemic stroke is a major cause of death and long-term disability worldwide. Thrombolysis with recombinant tissue plasminogen activator is the only proven and effective treatment for acute ischemic stroke; however, therapeutic hypothermia is increasingly recognized as having a tissue-protective function and positively influencing neurological outcome, especially in cases of ischemia caused by cardiac arrest or hypoxic-ischemic encephalopathy in newborns. Yet, many aspects of hypothermia as a treatment for ischemic stroke remain unknown. Large-scale studies examining the effects of hypothermia on stroke are currently underway. This review discusses the mechanisms underlying the effect of hypothermia, as well as trends in hypothermia induction methods, methods for achieving optimal protection, side effects, and therapeutic strategies combining hypothermia with other neuroprotective treatments. Finally, outstanding issues that must be addressed before hypothermia treatment is implemented at a clinical level are also presented.
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Affiliation(s)
- Ziping Han
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China; Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
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Dengler B, Garvin R, Seifi A. Can therapeutic hypothermia trigger propofol-related infusion syndrome? J Crit Care 2015; 30:823-4. [PMID: 25922173 DOI: 10.1016/j.jcrc.2015.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 03/30/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Bradley Dengler
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Rachel Garvin
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ali Seifi
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio, San Antonio, TX.
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Abstract
Therapeutic hypothermia is the only treatment currently recommended for moderate or severe encephalopathy of hypoxic‒ischaemic origin in term neonates. Though the effects of hypothermia on human physiology have been explored for many decades, much of the data comes from animal or adult studies; the latter originally after accidental hypothermia, followed by application of controlled hypothermia after cardiac arrest or trauma, or during cardiopulmonary bypass. Though this work is informative, the effects of hypothermia on neonatal physiology after perinatal asphyxia must be considered in the context of a prolonged hypoxic insult that has already induced a number of significant physiological sequelae. This article reviews the effects of therapeutic hypothermia on respiratory, cardiovascular, and metabolic parameters, including glycaemic control and feeding requirements. The potential pitfalls of blood‒gas analysis and overtreatment of physiological changes in cardiovascular parameters are also discussed. Finally, the effects of hypothermia on drug metabolism are covered, focusing on how the pharmacokinetics, pharmacodynamics, and dosing requirements of drugs frequently used in neonatal intensive care may change during therapeutic hypothermia.
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