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O'Gara B, Boncyk C, Meiser A, Jerath A, Bellgardt M, Jabaudon M, Beitler JR, Hughes CG. Volatile Anesthetic Sedation for Critically Ill Patients. Anesthesiology 2024; 141:163-174. [PMID: 38860793 DOI: 10.1097/aln.0000000000004994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Volatile anesthetics have multiple properties that make them useful for sedation in the intensive care unit. The team-based approach to volatile anesthetic sedation leverages these properties to provide a safe and effective alternative to intravenous sedatives.
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Affiliation(s)
- Brian O'Gara
- Beth Israel Deaconess Medical Center, Department of Anaesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, Massachusetts
| | - Christina Boncyk
- Vanderbilt University Medical Center, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andreas Meiser
- Saarland University Hospital, Privatdozent Medical Faculty of Saarland University, Homburg, Germany
| | - Angela Jerath
- Sunnybrook Research Institute, Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Martin Bellgardt
- St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum, Germany
| | - Matthieu Jabaudon
- University Hospital Center Clermont-Ferrand, Department of Perioperative Medicine, Clermont Auvergne University, Institute of Genetics, Reproduction, and Development, National Center for Scientific Research, National Institute of Health and Medical Research, Clermont-Ferrand, France
| | - Jeremy R Beitler
- New York Presbyterian/Columbia University Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Christopher G Hughes
- Vanderbilt University Medical Center, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
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Fuchs VF, Simon HV, Soldinger N, Volk T, Meiser A. Neuropsychological follow-up of isoflurane sedated intensive care patients: a substudy of a randomized trial. Minerva Anestesiol 2024; 90:377-385. [PMID: 38482637 DOI: 10.23736/s0375-9393.24.17834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Inhaled sedation of intensive care unit (ICU) patients ventilated >24 hours may have long term effects. We hypothesized that isoflurane has a better neuropsychological outcome in a one-year follow-up compared to propofol sedation. METHODS All 66 patients included by the coordinating center of the ISOCONDA study (EudraCT#: 2016-004551-67) took part in this substudy (DRKS00020240). A delirium test (CAM-ICU) was performed 24 hours after end of sedation. Sedation-, ventilator-, ICU- and delirium-free days within 30 days were calculated. Patients were sent five questionnaires one, three and twelve months after ICU discharge: ICU-Memory-tool (ICU-MT), Short-Form-36-Health-survey (SF-36), Posttraumatic-Stress-Scale-14 (PTSS-14), WHO-Five-Well-Being-Index (WHO-5) and Hospital-Anxiety-Depression-Scale (HADS). RESULTS CAM-ICU was positive in 17% of patients, however 68% showed signs of delirium during the ICU stay (no group differences). Mortality was lower after isoflurane (30-days: 1/33 versus 7/33, P=0.024; One-year: 9/33 versus 14/33, P=0.156). Isoflurane led to significantly more sedation- (median [IQR]: 28[25-29] versus 24[21-29], P=0.016), ventilator- (28[24-29] versus 22[4-28], P=0.011), ICU- (23[13-26] versus 11[0-25], P=0.044) and delirium-free days (25[21-29] versus 20[12-28], P=0.031). Return rate of questionnaires was high (87/128). In the ICU-MT, isoflurane patients recalled significantly more factual memories after one year. Generally, the psychological tests suggested a poor quality of life (SF-36), high rates of post-traumatic-stress-disorder (PTSS-14: 38%) and depression (WHO-5: 54%, HADS: 43%), without significant group differences. CONCLUSIONS Isoflurane sedation leads to more delirium free days during the ICU treatment and more factual memories of the ICU stay one year after the ICU stay. However long-term outcome of ventilated ICU patients is poor, and there were no differences between isoflurane and propofol sedation.
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Affiliation(s)
- Verena F Fuchs
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
- Department of General Pediatrics and Neonatology, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Henrik V Simon
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany -
| | - Nina Soldinger
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
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Truicu FN, Damian RO, Butoi MA, Belghiru VI, Rotaru LT, Puticiu M, Văruț RM. How to Personalize General Anesthesia-A Prospective Theoretical Approach to Conformational Changes of Halogenated Anesthetics in Fire Smoke Poisoning. Int J Mol Sci 2024; 25:4701. [PMID: 38731919 PMCID: PMC11083261 DOI: 10.3390/ijms25094701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Smoke intoxication is a central event in mass burn incidents, and toxic smoke acts at different levels of the body, blocking breathing and oxygenation. The majority of these patients require early induction of anesthesia to preserve vital functions. We studied the influence of hemoglobin (HMG) and myoglobin (MGB) blockade by hydrochloric acid (HCl) in an interaction model with gaseous anesthetics using molecular docking techniques. In the next part of the study, molecular dynamics (MD) simulations were performed on the top-scoring ligand-receptor complexes to investigate the stability of the ligand-receptor complexes and the interactions between ligands and receptors in more detail. Through docking analysis, we observed that hemoglobin creates more stable complexes with anesthetic gases than myoglobin. Intoxication with gaseous hydrochloric acid produces conformational and binding energy changes of anesthetic gases to the substrate (both the pathway and the binding site), the most significant being recorded in the case of desflurane and sevoflurane, while for halothane and isoflurane, they remain unchanged. According to our theoretical model, the selection of anesthetic agents for patients affected by fire smoke containing hydrochloric acid is critical to ensure optimal anesthetic effects. In this regard, our model suggests that halothane and isoflurane are the most suitable choices for predicting the anesthetic effects in such patients when compared to sevoflurane and desflurane.
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Affiliation(s)
- Flavius Nicușor Truicu
- Emergency Medicine and First Aid Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (F.N.T.); (R.O.D.); (M.A.B.); (V.I.B.)
| | - Roni Octavian Damian
- Emergency Medicine and First Aid Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (F.N.T.); (R.O.D.); (M.A.B.); (V.I.B.)
| | - Mihai Alexandru Butoi
- Emergency Medicine and First Aid Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (F.N.T.); (R.O.D.); (M.A.B.); (V.I.B.)
| | - Vlad Ionuț Belghiru
- Emergency Medicine and First Aid Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (F.N.T.); (R.O.D.); (M.A.B.); (V.I.B.)
| | - Luciana Teodora Rotaru
- Emergency Medicine and First Aid Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (F.N.T.); (R.O.D.); (M.A.B.); (V.I.B.)
| | - Monica Puticiu
- Emergency Medicine and First Aid Department, Faculty of Medicine, University of Medicine and Pharmacy “Vasile Goldiș” Arad, 310025 Arad, Romania
| | - Renata Maria Văruț
- Research Methodology Department, Faculty of Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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Mickle AR, Peñaloza-Aponte JD, Coffey R, Hall NA, Baekey D, Dale EA. Closed-loop cervical epidural stimulation partially restores ipsilesional diaphragm EMG after acute C 2 hemisection. Respir Physiol Neurobiol 2024; 320:104182. [PMID: 37923238 PMCID: PMC11135909 DOI: 10.1016/j.resp.2023.104182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/22/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023]
Abstract
Cervical spinal cord injury creates lasting respiratory deficits which can require mechanical ventilation long-term. We have shown that closed-loop epidural stimulation (CL-ES) elicits respiratory plasticity in the form of increased phrenic network excitability (Malone et. al., E Neuro, Vol 9, 0426-21.2021, 2022); however, the ability of this treatment to create functional benefits for breathing function per se after injury has not been demonstrated. Here, we demonstrate in C2 hemisected anesthetized rats, a 20-minute bout of CL-ES administered at current amplitudes below the motor threshold restores paralyzed hemidiaphragm activity in-phase with breathing while potentiating contralesional activity. While this acute bout of stimulation did not elicit the increased network excitability seen in our chronic model, a subset of stimulated animals continued spontaneous ipsilesional diaphragm activity for several seconds after stopping stimulation. These results support the use of CL-ES as a therapeutic to rescue breathing after high cervical spinal cord injury, with the potential to lead to lasting recovery and device independence.
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Affiliation(s)
- Alyssa R Mickle
- Department of Neuroscience, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; Breathing Research and Therapeutics Center, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; McKnight Brain Institute, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States.
| | - Jesús D Peñaloza-Aponte
- Department of Neuroscience, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; Breathing Research and Therapeutics Center, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; McKnight Brain Institute, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States
| | - Richard Coffey
- Department of Physiology and Aging, University of Florida, 1600 SW Archer Rd M552, Gainesville, FL 32603, United States
| | - Natale A Hall
- Department of Physiology and Aging, University of Florida, 1600 SW Archer Rd M552, Gainesville, FL 32603, United States
| | - David Baekey
- Department of Neuroscience, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; Breathing Research and Therapeutics Center, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; McKnight Brain Institute, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States
| | - Erica A Dale
- Department of Neuroscience, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; Breathing Research and Therapeutics Center, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; McKnight Brain Institute, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, United States; Department of Physiology and Aging, University of Florida, 1600 SW Archer Rd M552, Gainesville, FL 32603, United States
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Marcos-Vidal JM, González R, Merino M, Higuera E, García C. Sedation for Patients with Sepsis: Towards a Personalised Approach. J Pers Med 2023; 13:1641. [PMID: 38138868 PMCID: PMC10744994 DOI: 10.3390/jpm13121641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.
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Affiliation(s)
- José Miguel Marcos-Vidal
- Department of Anesthesiology and Critical Care, Universitary Hospital of Leon, 24071 Leon, Spain; (R.G.); (M.M.); (E.H.); (C.G.)
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Frassanito L, Sbaraglia F, Piersanti A, Vassalli F, Lucente M, Filetici N, Zanfini BA, Catarci S, Draisci G. Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review. J Clin Med 2023; 12:3869. [PMID: 37373564 DOI: 10.3390/jcm12123869] [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: 04/29/2023] [Revised: 05/29/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
Malignant hyperthermia is a rare but life-threatening pharmacogenetic disorder triggered by exposure to specific anesthetic agents. Although this occurrence could affect virtually any patient during the perioperative time, the pediatric population is particularly vulnerable, and it has a five-fold higher incidence in children compared to adults. In the last few decades, synergistic efforts among leading anesthesiology, pediatrics, and neurology associations have produced new evidence concerning the diagnostic pathway, avoiding unnecessary testing and limiting false diagnoses. However, a personalized approach and an effective prevention policy focused on clearly recognizing the high-risk population, defining perioperative trigger-free hospitalization, and rapid activation of supportive therapy should be improved. Based on epidemiological data, many national scientific societies have produced consistent guidelines, but many misconceptions are common among physicians and healthcare workers. This review shall consider all these aspects and summarize the most recent updates.
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Affiliation(s)
- Luciano Frassanito
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Fabio Sbaraglia
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Alessandra Piersanti
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Francesco Vassalli
- Department of Critical Care and Perinatal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Monica Lucente
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Nicoletta Filetici
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Bruno Antonio Zanfini
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Stefano Catarci
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Gaetano Draisci
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
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Adi O, Apoo FN, Fong CP, Ahmad AH, Roslan NL, Khan FA, Fathil S. Inhaled volatile anesthetic gas for severe bronchospasm in the emergency department. Am J Emerg Med 2023; 68:213.e5-213.e9. [PMID: 37120400 DOI: 10.1016/j.ajem.2023.04.032] [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: 03/19/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/01/2023] Open
Abstract
Bronchospasm is caused by reversible constriction of the smooth muscles of the bronchial tree. This causes obstruction of the lower airways, which is commonly seen at the emergency department (ED) in patients with acute exacerbation of asthma or chronic obstructive pulmonary disease. Ventilation may be difficult in mechanically intubated patients with severe bronchospasm due to airflow limitation, air trapping, and high airway resistance. The beneficial effects of volatile inhaled anesthetic gas had been reported due to its bronchodilation properties. In this case series, we would like to share our experience delivering inhaled volatile anesthetic gas via a conserving device for three patients with refractory bronchospasm at the ED. Inhaled anesthetic gas is safe, feasible and should be considered as an alternative rescue therapy for ventilated patients with severe lower airway obstruction.
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Affiliation(s)
- Osman Adi
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia.
| | - Farah Nuradhwa Apoo
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Chan Pei Fong
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Azma Haryaty Ahmad
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Nurul Liana Roslan
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Kuala Lumpur, Malaysia
| | | | - Shahridan Fathil
- Department of Anesthesia & Critical Care, Gleneagles Hospital Medini Johor, Johor, Malaysia
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