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El-Kasaby A, Boytsov D, Kasture A, Krumpl G, Hummel T, Freissmuth M, Sandtner W. Allosteric Inhibition and Pharmacochaperoning of the Serotonin Transporter by the Antidepressant Drugs Trazodone and Nefazodone. Mol Pharmacol 2024; 106:56-70. [PMID: 38769018 DOI: 10.1124/molpharm.124.000881] [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: 01/23/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
The antidepressants trazodone and nefazodone were approved some 4 and 3 decades ago, respectively. Their action is thought to be mediated, at least in part, by inhibition of the serotonin transporter [SERT/solute carrier (SLC)-6A4]. Surprisingly, their mode of action on SERT has not been characterized. Here, we show that, similar to the chemically related drug vilazodone, trazodone and nefazodone are allosteric ligands: trazodone and nefazodone inhibit uptake by and transport-associated currents through SERT in a mixed-competitive and noncompetitive manner, respectively. Contrary to noribogaine and its congeners, all three compounds preferentially interact with the Na+-bound outward-facing state of SERT. Nevertheless, they act as pharmacochaperones and rescue the folding-deficient variant SERT-P601A/G602A. The vast majority of disease-associated point mutations of SLC6 family members impair folding of the encoded transporter proteins. Our findings indicate that their folding defect can be remedied by targeting allosteric sites on SLC6 transporters. SIGNIFICANCE STATEMENT: The serotonin transporter is a member of the solute carrier-6 family and is the target of numerous antidepressants. Trazodone and nefazodone have long been used as antidepressants. Here, this study shows that their inhibition of the serotonin transporter digressed from the competitive mode seen with other antidepressants. Trazodone and nefazodone rescued a folding-deficient variant of the serotonin transporter. This finding demonstrates that folding defects of mutated solute carrier-6 family members can also be corrected by allosteric ligands.
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Affiliation(s)
- Ali El-Kasaby
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
| | - Danila Boytsov
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
| | - Ameya Kasture
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
| | - Günther Krumpl
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
| | - Thomas Hummel
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
| | - Michael Freissmuth
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
| | - Walter Sandtner
- Institute of Pharmacology and the Gaston H. Glock Research Laboratories for Exploratory Drug Development, Centre of Physiology and Pharmacology (A.E.-K., D.B., M.F., W.S.), Medical University of Vienna, Vienna, Austria; Department of Neurobiology, University of Vienna, Vienna, Austria (A.K., T.H.); and MRN Medical Research Network GmbH, Vienna, Austria (G.K.)
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Gheat HS, Fayed MM, Elgazzar FM, Draz EI, El-Kelany RS. The possible therapeutic role of intravenous lipid emulsion in acute aluminium phosphide poisoning: a randomized controlled clinical trial. Toxicol Res (Camb) 2024; 13:tfae090. [PMID: 38883412 PMCID: PMC11170490 DOI: 10.1093/toxres/tfae090] [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: 01/08/2024] [Revised: 05/21/2024] [Accepted: 06/02/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Aluminum phosphide (ALP) is a highly toxic rodenticide and the mortality rates caused by it have been demonstrated up to 70-100% in various studies. Unfortunately, there is no specific antidote to manage its toxic effects. This study aimed to assess the biochemical and clinical efficacy and safety of intravenous lipid emulsion as an adjuvant therapy in acute aluminum phosphide poisoning. Patients and methods Sixty-four cases with acute ALP poisoning were stratified according to severity by the Poison Severity Score into severe and moderate groups (32 patients each). Patients were then randomly allocated into either receiving intravenous lipid emulsion in addition to the conventional treatment or receiving the conventional treatment only by using block randomization. Results Treatment by ILE resulted in a significant improvement in the survival time, the mean arterial blood pressure, arterial blood gases, and a significant reduction in serum lactate levels. The need for intubation and mechanical ventilation was insignificantly lower in the intervention groups compared to control groups. However, the reduction in mortality rate in the patients of intervention groups compared with control groups was found to be non-significant. Intravenous lipid emulsion use in acute ALP poisoning significantly prolonged the survival time, improved the metabolic acidosis, decreased the serum lactate levels and increased the mean arterial blood pressure and hospital stay in the intervention groups. And insignificantly decreased the mortality rate, need of intubation and mechanical ventilation, and the total dose of vasopressors.
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Affiliation(s)
- Hafsa Salah Gheat
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
| | - Manar M Fayed
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
| | - Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
| | - Eman I Draz
- Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta, Gharbia 31527 Egypt
| | - Rabab S El-Kelany
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
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Kazemi-Darabadi S, Tavakoli S, Panahi Y, Akbari H. Evaluating the effects of rifampin in the prevention of neurogenic symptoms and cardiac arrhythmias caused by the systemic toxicity of lidocaine in rats. VETERINARY RESEARCH FORUM : AN INTERNATIONAL QUARTERLY JOURNAL 2023; 14:559-566. [PMID: 37901354 PMCID: PMC10612392 DOI: 10.30466/vrf.2022.1985909.3724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/19/2023] [Indexed: 10/31/2023]
Abstract
Lidocaine toxicity is caused by unintended intravascular injection or overdose. Lidocaine is metabolized in the liver by the CYP3A4 isoenzyme. The objective was to investigate if the administration of rifampin could accelerate animal recovery and reduce the symptoms of lidocaine toxicity by induction of the CYP3A4. Thirty-six male rats were divided into control and treatment groups, each containing three subgroups. The treatment group received oral rifampin suspension daily for 1 week. In all rats, 2.00% lidocaine was injected intravenously. The first subgroup was monitored for neurological symptoms. In the second subgroup, data were recorded after the electrode was placed in the right hippocampus. Electrocardiograms were taken from the third subgroup. CYP3A4 was measured using an ELISA kit. Neurological recovery was seen after 22 and 15 min in the control and treatment groups, respectively. Rifampin also caused a significant reduction in amplitude and number of field action potentials compared to the control group. Numerous cardiac arrhythmias were observed in the control group. The mean level of CYP3A4 in the treatment group was significantly higher than in the control group. In conclusion, oral rifampin could increase the synthesis of CYP3A4, therefore, the animal recovery from lidocaine toxicity was accelerated.
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Affiliation(s)
- Siamak Kazemi-Darabadi
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran;
| | - Soodeh Tavakoli
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran;
| | - Yousef Panahi
- Department of Basic Sciences, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran.
| | - Hamid Akbari
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran;
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Ma H, Pan Z, Lai B, Zan C, Liu H. Recent Research Advances in Nano-Based Drug Delivery Systems for Local Anesthetics. Drug Des Devel Ther 2023; 17:2639-2655. [PMID: 37667787 PMCID: PMC10475288 DOI: 10.2147/dddt.s417051] [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: 04/13/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023] Open
Abstract
From a clinical perspective, local anesthetics have rather widespread application in regional blockade for surgery, postoperative analgesia, acute/chronic pain control, and even cancer treatments. However, a number of disadvantages are associated with traditional local anesthetic agents as well as routine drug delivery administration ways, such as neurotoxicity, short half-time, and non-sustained release, thereby limiting their application in clinical practice. Successful characterization of drug delivery systems (DDSs) for individual local anesthetic agents can support to achieve more efficient drug release and prolonged duration of action with reduced systemic toxicity. Different types of DDSs involving various carriers have been examined, including micromaterials, nanomaterials, and cyclodextrin. Among them, nanotechnology-based delivery approaches have significantly developed in the last decade due to the low systemic toxicity and the greater efficacy of non-conventional local anesthetics. Multiple nanosized materials, including polymeric, lipid (solid lipid nanoparticles, nanostructured lipid carriers, and nanoemulsions), metallic, inorganic non-metallic, and hybrid nanoparticles, offer a safe, localized, and long-acting solution for pain management and tumor therapy. This review provides a brief synopsis of different nano-based DDSs for local anesthetics with variable sizes and structural morphology, such as nanocapsules and nanospheres. Recent original research utilizing nanotechnology-based delivery systems is particularly discussed, and the progress and strengths of these DDSs are highlighted. A specific focus of this review is the comparison of various nano-based DDSs for local anesthetics, which can offer additional indications for their further improvement. All in all, nano-based DDSs with unique advantages provide a novel direction for the development of safer and more effective local anesthetic formulations.
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Affiliation(s)
- He Ma
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Zhenxiang Pan
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Bingjie Lai
- Department of Intensive Care Unit, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Chunfang Zan
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, People’s Republic of China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, People’s Republic of China
| | - He Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, People’s Republic of China
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Levine M, Brent J, Wiegand T, Maguire B, Cohen N, Vaerrier D, Beuhler M, Leikin JB, Ganetsky M, Stellpflug S, Ruha AM, Carey J, Geib AJ, Cao DJ, Kleinschmidt K, Vohra R, Riley BD, Moore P, Schwarz E, Neavyn M, Rusyniak DE, Greene S, Nogar J, Manini A, Wermuth M, Pizon A, Hendrickson RG, Griswold M, Aldy K, Wax P, Spyres MB, Campleman S, Macdonald E, Finkelstein Y. Lipid emulsion therapy during management of the critically-ill poisoned patient: a prospective cohort study. Clin Toxicol (Phila) 2023; 61:584-590. [PMID: 37655788 DOI: 10.1080/15563650.2023.2248372] [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: 10/12/2022] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Despite conflicting data, intravenous lipid emulsion has emerged as a potential antidote. The "lipid sink" theory suggests that following intravenous administration of lipid, lipophilic drugs are sequestered in the vascular compartment, thereby reducing their tissue concentrations. This study sought to determine if survival is associated with the intoxicant's degree of lipophilicity. METHODS We reviewed all cases in the Toxicology Investigators Consortium's lipid sub-registry between May 2012 through December 2018. Information collected included demographics, exposure circumstances, clinical course, management, disposition, and outcome. The primary outcome was survival after lipid emulsion therapy. Survival was stratified by the log of the intoxicant's octanol-water partition coefficient. We also assessed the association between intoxicant lipophilicity and an increase in systolic blood pressure after lipid emulsion administration. RESULTS We identified 134 patients, including 81 (60.4%) females. The median age was 40 years (interquartile range 21-75). One hundred and eight (80.6%) patients survived, including 45 (33.6%) with cardiac arrest during their intoxication. Eighty-two (61.2%) were hypotensive, and 98 (73.1%) received mechanical ventilation. There was no relationship between survival and the log of the partition coefficient of the intoxicant on linear analysis (P = 0.89) or polynomial model (P = 0.10). Systolic blood pressure increased in both groups. The median (interquartile range) systolic blood pressure before lipid administration was 68 (60-78) mmHg for those intoxicants with a log partition coefficient < 3.6 compared with 89 (76-104) mmHg after lipid administration. Among those drugs with a log partition coefficient > 3.6, the median (interquartile range) was 69 (60-84) mmHg before lipid and 89 (80-96) mmHg after lipid administration. CONCLUSION Most patients in this cohort survived. Lipophilicity was not correlated with survival or the observed changes in blood pressure. The study did not address the efficacy of lipid emulsion.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, University of California, Los Angeles, CA, USA
| | | | - Timothy Wiegand
- Department of Emergency Medicine, Division of Medical Toxicology, University of Rochester, Rochester, NY, USA
| | - Bryan Maguire
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Neta Cohen
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - David Vaerrier
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Jerrold B Leikin
- Division of Environmental and Occupational Health Science and the Occupational and Environmental Medicine Service of UI Health, University of Illinois Chicago, Chicago, IL, USA
| | - Michael Ganetsky
- Department of Emergency Medicine, Division of Medical Toxicology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Samuel Stellpflug
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Anne-Michelle Ruha
- Department of Medical Toxicology, Banner University Medical Center, Phoenix, AZ, USA
| | - Jennifer Carey
- Department of Emergency Medicine, University of Massachusetts, Worchester, MA, USA
| | | | - Dazhe James Cao
- Department of Emergency Medicine, Division of Medical Toxicology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kurt Kleinschmidt
- Department of Emergency Medicine, Division of Medical Toxicology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rais Vohra
- Department of Emergency Medicine, Division of Medical Toxicology, University of California San Francisco-Fresno Medical Center, Fresno, CA, USA
| | - Brad D Riley
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Phillip Moore
- Department of Emergency Medicine, Penn State University College of Medicine, Hershey, PA, USA
| | - Evan Schwarz
- Department of Emergency Medicine, University of California, Los Angeles, CA, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University, St. Louis, MO, USA
| | - Mark Neavyn
- Department of Emergency Medicine, Hartford Hospital, Hartford, CT, USA
| | - Daniel E Rusyniak
- Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Spencer Greene
- Department of Emergency Medicine, HCA Houston Healthcare - Kingwood, University of Houston College of Medicine, Houston, TX, USA
| | - Joshua Nogar
- Department of Emergency Medicine, North Shore University, Manhasset, NY, USA
| | - Alex Manini
- Department of Emergency Medicine, Division of Medical Toxicology, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA
| | - Mary Wermuth
- Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anthony Pizon
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert G Hendrickson
- Department of Emergency Medicine, Division of Medical Toxicology, Oregon Health Science University, Portland, OR, USA
| | - Matthew Griswold
- Department of Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Kim Aldy
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Meghan Beth Spyres
- Department of Medical Toxicology, Banner University Medical Center, Phoenix, AZ, USA
| | | | - Erin Macdonald
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yaron Finkelstein
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Burch CS, Stevens CG. A Hematoma Block in the Wrist for a Displaced Distal Radius Fracture Induces Systemic Neurological Symptoms: A Case Report. Cureus 2023; 15:e42921. [PMID: 37664356 PMCID: PMC10474967 DOI: 10.7759/cureus.42921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Hematoma blocks are considered a relatively simple, safe, and effective technique in the acute setting to provide sufficient anesthesia and allow for closed reduction of displaced distal radius fractures. Complications associated with the utilization of local anesthetics in this setting are rare. We present the case of a patient who had a hematoma block in the wrist and developed short-term systemic neurologic complications likely secondary to systemic absorption of 20 mL of 1% lidocaine without epinephrine via the cancellous bone channels.
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Fettiplace MR, Weinberg G. Lipid emulsion for xenobiotic overdose: PRO. Br J Clin Pharmacol 2023; 89:1708-1718. [PMID: 36454165 PMCID: PMC10175108 DOI: 10.1111/bcp.15620] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 12/03/2022] Open
Abstract
Infusion of lipid emulsion for drug overdose arose as a treatment for local anaesthetic systemic toxicity (LAST) initially based on laboratory results in animal models with the subsequent support of favourable case reports. Following successful translation to the clinic, practitioners also incorporated lipid emulsion as a treatment for non-local anaesthetic toxicities but without formal clinical trials. Recent clinical trials demonstrate a benefit of lipid emulsion in antipsychotic, pesticide, metoprolol and tramadol overdoses. Formal trials of lipid emulsion in LAST may never occur, but alternative analytic tools indicate strong support for its efficacy in this indication; for example, lipid emulsion has obviated the need for cardiopulmonary bypass in most cases of LAST. Herein, we describe the pre-clinical support for lipid emulsion, evaluate the most recent clinical studies of lipid emulsion for toxicity, identify a possible dose-based requirement for efficacy and discuss the limitations to uncontrolled studies in the field.
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Affiliation(s)
- Michael R. Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, 02114
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL 60622 USA
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8
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Fabbri A, Voza A, Riccardi A, Serra S, Iaco FD. The Pain Management of Trauma Patients in the Emergency Department. J Clin Med 2023; 12:jcm12093289. [PMID: 37176729 PMCID: PMC10179230 DOI: 10.3390/jcm12093289] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/20/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
The vast majority of injured patients suffer from pain. Systematic assessment of pain on admission to the emergency department (ED) is a cornerstone of translating the best treatment strategies for patient care into practice. Pain must be measured with severity scales that are validated in clinical practice, including for specific populations (such as children and older adults). Although primary care ED of trauma patients focuses on resuscitation, diagnosis and treatment, pain assessment and management remains a critical element as professionals are not prepared to provide effective and early therapy. To date, most EDs have pain assessment and management protocols that take into account the patient's hemodynamic status and clinical condition and give preference to non-pharmacological approaches where possible. When selecting medications, the focus is on those that are least disruptive to hemodynamic status. Pain relief may still be necessary in hemodynamically unstable patients, but caution should be exercised, especially when using opioids, as absorption may be impaired or shock may be exacerbated. The analgesic dose of ketamine is certainly an attractive option. Fentanyl is clearly superior to other opioids in initial resuscitation and treatment as it has minimal effects on hemodynamic status and does not cause central nervous system depression. Inhaled analgesia techniques and ultrasound-guided nerve blocks are also increasingly effective solutions. A multimodal pain approach, which involves the use of two or more drugs with different mechanisms of action, plays an important role in the relief of trauma pain. All EDs must have policies and promote the adoption of procedures that use multimodal strategies for effective pain management in all injured patients.
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Affiliation(s)
- Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Antonio Voza
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, 20089 Milano, Italy
| | | | - Sossio Serra
- Emergency Department, AUSL Romagna, Ospedale M. Bufalini, 47521 Cesena, Italy
| | - Fabio De Iaco
- Struttura Complessa di Medicina di Emergenza Urgenza, Ospedale Maria Vittoria, ASL Città di Torino, 10144 Torino, Italy
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Kiristioglu MO, Gunduz GU, Doganay S. Acute reversible bilateral hearing loss after retrobulbar anesthesia. Oman J Ophthalmol 2023; 16:366-369. [PMID: 37602167 PMCID: PMC10433043 DOI: 10.4103/ojo.ojo_129_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 08/22/2023] Open
Abstract
This is the first reported case who had bilateral reversible hearing loss after regional anesthesia (RA) without a procedural sedoanalgesia. Furthermore, 20% lipid emulsion infusion (LEI) was first used in the treatment of a patient with hearing loss as an indicator of impending brainstem anesthesia. The ophthalmologist had performed a retrobulbar block without any difficulties to a 55-year-old the patient who undergone pars plana vitrectomy. A combination of lidocaine and bupivacaine was injected slowly through a 23G, 1.5-inch needle. Few minutes later, the patient experienced sudden bilateral hearing loss and, subsequently, mental confusion and mild respiratory distress. Local anesthetic toxicity to the predominantly brainstem was the diagnosis. Consequently, 20% LEI was administered, and his hearing loss gradually improved within a few hours. Prompt intervention is crucial in case of severe systemic complications of RA. LEI might be beneficial to halt the deepening of brainstem toxicity.
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Affiliation(s)
| | - Gamze Ucan Gunduz
- Department of Ophthalmology, Medical Faculty, Bursa Uludag University, Bursa, Turkey
| | - Selim Doganay
- Department of Ophthalmology, Medical Faculty, Bursa Uludag University, Bursa, Turkey
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10
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Sohn JT. Lipid Emulsion-Mediated Improvement of Hemodynamic Depression Caused by Amlodipine Toxicity. Pediatr Emerg Care 2023; 39:205-206. [PMID: 36083186 DOI: 10.1097/pec.0000000000002842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea; and Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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Possible Brainstem Anaesthesia in a Cat after Ultrasound-Guided Retrobulbar Block. Animals (Basel) 2023; 13:ani13050781. [PMID: 36899638 PMCID: PMC10000029 DOI: 10.3390/ani13050781] [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: 01/17/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
A 13-year-old neutered, blue-eyed female Siamese cat with a bodyweight of 4.8 kg was admitted for enucleation of the right eye. An ultrasound guided retrobulbar block with 1 mL of ropivacaine was performed under general anaesthesia. When the tip of the needle was visualised inside the intraconal space, negative aspiration of the syringe before injection and no obvious resistance during injection were confirmed. Instantly, after ropivacaine was administered, the cat became apnoeic, and its heart rate and the blood pressure increased significantly for a short period of time. During surgery, the cat needed cardiovascular support to maintain blood pressure and was under continuous mechanical ventilation. Spontaneous breathing returned 20 min after the end of anaesthesia. Brainstem anaesthesia was suspected, and after recovery, the contralateral eye was examined. A reduced menace response, horizontal nystagmus, mydriasis, and absence of the pupillary light reflex were present. The following day, mydriasis was still present, but the cat was visual and was discharged. The inadvertent intra-arterial injection of ropivacaine was suspected to be the cause of the spread into the brainstem. To the current authors' knowledge, possible brainstem anaesthesia has only been reported in a cat 5 min after a retrobulbar block but never instantly.
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12
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Park M, Yu HK, Lee SH, Ok SH, Yoon S, Sohn JT. Lipid emulsion-induced recovery from unconsciousness caused by lidocaine toxicity: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231153776. [PMID: 36776207 PMCID: PMC9909049 DOI: 10.1177/2050313x231153776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/11/2023] [Indexed: 02/09/2023] Open
Abstract
Lipid emulsion is used to treat systemic toxicity caused by local anesthetics. In addition, lipid emulsion was reported to be effective in ameliorating cardiovascular depression evoked by non-local anesthetic drug toxicity with high lipid solubility. A 47-year-old woman underwent local anesthetic infiltration with 40 mL of 2% lidocaine (20 and 20 mL) to remove a mass in the upper back. After operation, she experienced convulsions and loss of consciousness due to lidocaine toxicity. Midazolam followed by lipid emulsion was administered to treat central nervous system symptoms including unconsciousness and decreased Glasgow Coma Scale. The patient recovered from unconsciousness and presented improved Glasgow Coma Scale after lipid emulsion administration, and then fully recovered from local anesthetic systemic toxicity. This case suggests that early lipid emulsion treatment, before further progression of local anesthetic systemic toxicity, provides an enhanced recovery from unconsciousness and decreased Glasgow Coma Scale due to lidocaine toxicity.
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Affiliation(s)
- Miyeong Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea
| | - Ho Kyung Yu
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea
| | - Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea,Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea,Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
| | - Sangcheol Yoon
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea,Ju-Tae Sohn, Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, 79 Gangnam-ro, Jinju-si 52727, Republic of Korea.
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13
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Sohn JT. Half-Life of Lipid Emulsions Used in Lipid Emulsion Treatment for Drug Toxicity. J Emerg Med 2023; 64:253-254. [PMID: 36906377 DOI: 10.1016/j.jemermed.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, and Institute of Health Sciences, Gyeonsang National University, Republic of Korea
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14
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Lee SH, Kim S, Sohn JT. Lipid Emulsion Treatment for Drug Toxicity Caused by Nonlocal Anesthetic Drugs in Pediatric Patients: A Narrative Review. Pediatr Emerg Care 2023; 39:53-59. [PMID: 35981328 DOI: 10.1097/pec.0000000000002828] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Lipid emulsion (LE) has been used to treat children with cardiovascular collapse induced by toxic doses of nonlocal anesthetics with high lipid solubility. We aimed to analyze case reports on LE administration for resuscitation of toxicity induced by these drugs in pediatric patients. METHODS Case reports involving pediatric patients undergoing LE treatment for toxicity caused by nonlocal anesthetic drugs until December 31, 2021, were searched through PubMed and Scopus using the following terms: "toxicity, or intoxication, or poisoning, or overdose" and "LE or intralipid." RESULTS Twenty-eight cases on LE treatment for toxicity induced by nonlocal anesthetic drugs in pediatric patients (younger than 19 years) were retrieved. The total number of patients was 31. Lipid emulsion treatment was carried out during toxicity caused by amitriptyline, flecainide, bupropion, propranolol, and lamotrigine, which was unresponsive to supportive treatment. These drugs are highly lipid-soluble and inhibit cardiac sodium channels, which is similar to pharmacological properties of the local anesthetic bupivacaine. The most frequent method of delivery involved bolus administration followed by continuous infusion; 1.5 mL/kg LE administration followed by 0.25 mL/kg/min LE was most frequently used. Lipid emulsion improved various symptoms of drug toxicity in 29 patients (29/31, 93.54%), and symptoms were improved in 14 patients (14/31, 45.16%) within an h after LE administration. The trend in frequency of improved symptoms after LE treatment was as follows: the cardiovascular symptom alone > symptoms of the central nervous system alone > symptoms of the cardiovascular and central nervous systems. The adverse effects of LE treatment in the reported cases were hypertriglyceridemia, mild pancreatitis, and elevated levels of aspartate and alanine aminotransaminases. CONCLUSIONS Lipid emulsion treatment may be effective in ameliorating intractable cardiovascular depression when systemic toxicity caused by drugs, including cardiac sodium channel blockers, is unresponsive to supportive treatments.
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Affiliation(s)
| | - Sunmin Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital
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15
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Pigolkin YI, Shigeev SV, Denisova AV, Natarova KV, Krupin KN. [Forensic medical assessment of lidocaine and bupivacaine systemic toxicity]. Sud Med Ekspert 2023; 66:62-66. [PMID: 37496485 DOI: 10.17116/sudmed20236604162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
THE AIM OF THE STUDY Was to assess the lidocaine and bupivacaine systemic toxicity in forensic medical practice. The number of patients' clinical observations equal three with local anesthetic systemic toxicity (LAST) from the practice of forensic medical experts were studied, and a search of scientific publications for the last 5 years in PubMed database was conducted. The amount of publications, describing cases with LAST, equal four were selected. Differential diagnostic features between LAST and anaphylaxis were considered. The literature data about relationship between lidocaine's concentration in the blood serum and clinical features are shown. The forensic medical assessment of LAST is proposed.
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Affiliation(s)
- Yu I Pigolkin
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - S V Shigeev
- Bureau of Forensic Medicine of the Moscow Department of Health, Moscow, Russia
| | - A V Denisova
- Bureau of Forensic Medicine of the Moscow Department of Health, Moscow, Russia
| | - K V Natarova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - K N Krupin
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Research-and-development Laboratory of Human Morphology, Samara, Russia
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16
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Ausmus J. Pain Management and Analgesia Procedures and Strategies in the Emergency Department. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Wang YL, Lan GR, Zou X, Wang EQ, Dai RP, Chen YX. Apnea caused by retrobulbar anesthesia: A case report. World J Clin Cases 2022; 10:11646-11651. [PMID: 36387800 PMCID: PMC9649527 DOI: 10.12998/wjcc.v10.i31.11646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/05/2022] [Accepted: 09/29/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Apnea caused by retrobulbar anesthesia is a very rare but severe complication during ophthalmic surgery.
CASE SUMMARY We report a rare case of apnea caused by retrobulbar anesthesia, and emergency resuscitation was used. A 74-year-old female patient was diagnosed with rhegmatogenous retinal detachment in the right eye and planned to undergo vitrectomy under retrobulbar anesthesia. After the retrobulbar anesthesia in her right eye, she became unconscious and apneic. It was suggested that she had developed brainstem anesthesia. Assisted ventilation was initiated. Atropine 0.5 mg, epinephrine 1 mg, ephedrine 30 mg, and lipid emulsion were given. Five minutes later, her consciousness and breathing gradually returned, but with uncertain light perception in her right eye. Alprostadil 20 µg was given, and after 2 h her visual acuity resumed to the preoperative level.
CONCLUSION Brainstem anesthesia is a serious complication secondary to retrobulbar anesthesia. Medical staff should pay attention to the identification of brainstem anesthesia and be familiar with the emergency treatment for this complication.
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Affiliation(s)
- Yue-Lin Wang
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Guo-Ru Lan
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xuan Zou
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Er-Qian Wang
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Rong-Ping Dai
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing 100730, China
| | - You-Xin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing 100730, China
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18
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Tikhomirov M, Jajor P, Śniegocki T, Poźniak B. Predicting the efficacy of opioid sequestration by intravenous lipid emulsion using biologically relevant in vitro models of drug distribution. Sci Rep 2022; 12:18683. [PMID: 36333363 PMCID: PMC9636243 DOI: 10.1038/s41598-022-21790-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Intravenous lipid emulsions (ILE), among other uses, are utilized in the treatment of poisonings caused by lipophilic substances. The body of evidence regarding the benefits of this treatment is growing but information about opioids-ILE interaction is still very scarce. In this work, the impact of ILE on the distribution of buprenorphine, fentanyl and butorphanol used in various concentrations (100-500 ng/ml) was investigated. Two different in vitro models were used: disposition of the drugs in plasma after ultracentrifugation and distribution into the simulated biophase (cell monolayer of 3T3 fibroblasts or J774.E macrophages). We confirmed the ability of ILE to sequester the three drugs of interest which results in their decrease in the aqueous part of the plasma by 34.2-38.2%, 11.7-28.5% and 6.0-15.5% for buprenorphine, fentanyl and butorphanol, respectively. Moreover, ILE affected the drug distribution to the biophase in vitro, however, in this case the drug concentration in cells decreased by 97.3 ± 3.1%, 28.6 ± 5.4% and 13.0 ± 7.5% for buprenorphine, fentanyl and butorphanol, respectively. The two models revealed notable differences in ILE's potential for drug sequestration, especially for buprenorphine. Similar, but not as pronounced tendencies were observed for the two other drugs. These discrepancies may result from the difference in protein abundance and resulting drug-protein binding in both systems. Nevertheless, the results obtained with both in vitro models correlated well with the partition coefficient (logP) values for these drugs.
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Affiliation(s)
- Marta Tikhomirov
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Pharmacology and Toxicology, Wroclaw University of Environmental and Life Sciences, 50-375 Wrocław, Poland
| | - Paweł Jajor
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Pharmacology and Toxicology, Wroclaw University of Environmental and Life Sciences, 50-375 Wrocław, Poland
| | - Tomasz Śniegocki
- grid.419811.4Department of Pharmacology and Toxicology, National Veterinary Research Institute, 24-100 Puławy, Poland
| | - Błażej Poźniak
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Pharmacology and Toxicology, Wroclaw University of Environmental and Life Sciences, 50-375 Wrocław, Poland
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19
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Sohn JT. Commentary: Case report: Successful intravenous lipid emulsion therapy for canine amphetamine toxicosis. Front Vet Sci 2022; 9:1011210. [PMID: 36187822 PMCID: PMC9525104 DOI: 10.3389/fvets.2022.1011210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, South Korea
- *Correspondence: Ju-Tae Sohn
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20
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Alshaya OA, Alhamed A, Althewaibi S, Fetyani L, Alshehri S, Alnashmi F, Alharbi S, Alrashed M, Alqifari SF, Alshaya AI. Calcium Channel Blocker Toxicity: A Practical Approach. J Multidiscip Healthc 2022; 15:1851-1862. [PMID: 36065348 PMCID: PMC9440664 DOI: 10.2147/jmdh.s374887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
Calcium channel blockers (CCBs) are widely prescribed medications for various clinical indications in adults and children. They are available in both immediate and long-acting formulations and are generally classified into dihydropyridines and nondihydropyridines, with nondihydropyridines having more cardioselectivity. CCB toxicity is common given the widespread use which leads to serious adverse clinical outcomes, especially in children. Severe CCB toxicities may present with life-threatening bradycardia, hypotension, hyperglycemia, and renal insufficiency. Dihydropyridine toxicity, however, may present with reflex tachycardia instead of bradycardia. Initial patient evaluation and assessment are crucial to identify the severity of CCB toxicity and design the best management strategy. There are different strategies to overcome CCB toxicity that requires precise dosing and close monitoring in various patient populations. These strategies may include large volumes of IV fluids, calcium salts, high insulin euglycemia therapy (HIET), and vasopressors. We hereby summarize the evidence behind the management of CCB toxicity and present a practical guide for clinicians to overcome this common drug toxicity.
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Affiliation(s)
- Omar A Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Correspondence: Omar A Alshaya, Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Saudi Arabia, Email
| | - Arwa Alhamed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Nursing, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sara Althewaibi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Lolwa Fetyani
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fai Alnashmi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shmeylan Alharbi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed Alrashed
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmacy Department, Northwest Medical Center, Tucson, AZ, USA
| | - Saleh F Alqifari
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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21
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Sohn JT. Lipid emulsion dosage used for resuscitation after drug toxicity. Am J Emerg Med 2022; 59:168-169. [PMID: 35868991 DOI: 10.1016/j.ajem.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do 52727, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju-si 52727, Republic of Korea.
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22
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Lipid emulsion treatment of local anesthetic systemic toxicity in pediatric patients. Am J Emerg Med 2022; 57:195-196. [PMID: 34991908 DOI: 10.1016/j.ajem.2021.12.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/23/2021] [Indexed: 11/22/2022] Open
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23
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Zaballos M, Fernández I, Rodríguez L, García S, Varela O, Quintela O, Anadón MJ, Almendral J. Effects of intravenous lipid emulsions on the reversal of pacing-induced ventricular arrhythmias and electrophysiological alterations in an animal model of ropivacaine toxicity. Clin Toxicol (Phila) 2022; 60:902-911. [PMID: 35658706 DOI: 10.1080/15563650.2022.2080075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Ropivacaine is considered to have a wider margin of cardiovascular safety. However, several reports of ventricular arrhythmias (VA) due to ropivacaine toxicity have been documented. Intravenous lipid emulsions (ILEs) have recently been used successfully in the treatment of local anesthetic intoxication. The main objective of the present study was to evaluate the efficacy of the ILEs in the prevention of pacing-induced-VA and electrophysiological alterations in an animal model of ropivacaine toxicity. METHODS Nineteen pigs were anesthetized and instrumentalized. A baseline programmed electrical ventricular stimulation protocol (PEVSP) to induce VA was performed. Ropivacaine (5 mg·kg-1 + 100 μg·kg-1·min-1) followed by normal saline infusion (control group n = 8) or intralipid 20% (1.5 mL·kg-1 + 0.25 mL·kg-1·min-1) for the ILE group (n = 8), were administered three minutes after the ropivacaine bolus. PEVSP was repeated 25 min after the onset of ropivacaine infusion. Pacing-induced VA and electrophysiological abnormalities were assessed in both groups. A sham-control group (n = 3) without ropivacaine infusion was included. RESULTS Most of the electrophysiological parameters evaluated were affected by ropivacaine: PR interval by 28% (p = 0.001), AV interval by 40% (p = 0.001), sinus QRS by 101% (p = 0.001), paced QRS at a rate of 150 bpm by 258% (p = 0.001), and at 120 bpm by 241% (p = 0.001). Seven animals (87.5%) in the control group and eight animals (100%) in the ILE group developed sustained-VA (p = 0.30). Successful resuscitation occurred in 100% of animals in the ILE group vs. 57% of animals in the control group, p = 0.038. Pacing-induced-VA terminated at the first defibrillation attempt in 75% of the animals in the ILE group vs. 0% in the control group, p = 0.01. CONCLUSION Ropivacaine strongly altered the parameters of ventricular conduction, thus facilitating the induction of VA. ILEs did not prevent pacing-induced VA. However, facilitated resuscitation and termination of VA were delivered at the first defibrillation attempt compared to the control group.
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Affiliation(s)
- Matilde Zaballos
- Department of Forensic Medicine, Psychiatry and Pathology, Department of Anaesthesiology, Faculty of Medicine, Complutense University, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Rodríguez
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - María-José Anadón
- Head Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, National Institute of Toxicology and Forensic Science, Complutense University, Madrid, Spain
| | - Jesús Almendral
- Electrophysiology Arrhythmia Unit, Hospital Monteprincipe Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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Chen WC, Chen HY, Weng TI, Chen CK. Sudden quadriparesis after non-overdose local anesthesia. Int J Emerg Med 2022; 15:19. [PMID: 35581544 PMCID: PMC9112499 DOI: 10.1186/s12245-022-00423-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background A well-known anesthetic, lidocaine is the most widely used local anesthetic. Local anesthetic systemic toxicity (LAST) is a life-threatening event with common and prominent presentations of central nervous system (CNS) toxicity and cardiovascular toxicity. The most frequent and prominent early warning signs and symptoms of LAST are central nervous system symptoms. While rare, cases quadriparesis after the administration of lidocaine has been reported. Case presentation In this paper, we report a very rare case of quadriparesis after local anesthesia administration for vocal cord cyst-removal surgery, which dramatically improved after treatment. LAST can occur during various routes of lidocaine administration, such as local spray. A possible mechanism of our case could be the local diffusion of lidocaine to the spinal cord, which caused the symptoms to mimic anterior cord syndrome. Conclusions Our case presented a favorable outcome following the administration of intravenous lipid emulsion (ILE) for non-over dose local anesthetic drug induced spinal cord inhibition symptoms. These findings highlight the need for further research on the use of ILE to reverse LAST and other adverse effects of local anesthetics.
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Affiliation(s)
- Wei-Chen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Hsien-Yi Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Te-I Weng
- Department of Emergency Medicine, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.,Forensic and Clinical Toxicology Center, College of Medicine, National Taiwan University Hospital, National. Taiwan University, Taipei, Taiwan.,Institute of Forensic Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Lazar AE, Gurzu S, Kovecsi A, Perian M, Cordos B, Gherghinescu MC, Enache LS. Cardio Protective Effects of Lipid Emulsion against Ropivacaine-Induced Local Anesthetic Systemic Toxicity—An Experimental Study. J Clin Med 2022; 11:jcm11102784. [PMID: 35628910 PMCID: PMC9142945 DOI: 10.3390/jcm11102784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022] Open
Abstract
Inadvertent intravascular injection of local anesthetics (LA) during regional anesthesia causes Local Anesthetic Systemic Toxicity (LAST). Theories of lipid rescue in the case of LAST proved that the administration of lipids in LAST has beneficial effects. One possible mechanism of action is based on the lipophilic properties of LA which allow plasma-free LA to be bound by the molecules of Lipid Emulsion (LE). The association LA–LE is shuttled towards organs such as liver and the kidneys, and the half-life of LA is shortened. The main objective of this experimental study was to assess the possible cardio-prophylactic effect of LE administration before the induction of LAST by intravenous administration of Ropivacaine. This was an experimental, interventional, prospective, and non-randomized study. The subjects were divided into groups and received, under general anesthesia, LE 20% first 0.3–0.4 mL, followed by 0.1 mL Ropivacaine 2 mg/mL, or Ropivacaine alone. At the end of the experiment, the subjects were sacrificed, and tissue samples of kidney, heart and liver were harvested for histopathological examination. LE, when administered as prophylaxis in Ropivacaine-induced LAST, had protective cardiac effects in rats. The LE known side effects were not produced if the substance was administered in the low doses used for LAST prophylaxis.
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Affiliation(s)
- Alexandra Elena Lazar
- Department of Anesthesiology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Simona Gurzu
- Department of Morphopathology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
- Correspondence:
| | - Attila Kovecsi
- Department of Morphopathology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Marcel Perian
- Department of Physiology, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Bogdan Cordos
- Veterinary Experimental Base, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Mircea Constantin Gherghinescu
- Department of Surgery, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Liviu Sorin Enache
- Emergency Clinical County Hospital Tirgu Mures, University “Dimitrie Cantemir”, 540136 Tirgu Mures, Romania;
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Wang C, Sun S, Jiao J, Yu X, Huang S. Effects of nalbuphine on the cardiotoxicity of ropivacaine in rats. Fundam Clin Pharmacol 2022; 36:811-817. [PMID: 35373856 DOI: 10.1111/fcp.12778] [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: 12/27/2021] [Revised: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
When combined with nalbuphine, local anesthetics show a longer duration of nerve block without increasing complications. However, no evidence is available concerning the effect of nalbuphine on the cardiotoxicity of local anesthetics. The objective of this work is to investigate whether nalbuphine pretreatment can increase the lethal dose threshold of ropivacaine in rats. Anesthetized Sprague Dawley rats were pretreated with different doses of nalbuphine (0.4, 0.8, 1.5, 3.0, 5.0 mg/kg) or NS (normal saline, negative control) or 30% LE (lipid emulsion, positive control) 2 ml/kg/min for 5 min (n = 6). Then 0.5% ropivacaine was infused at a rate of 2.5 mg/kg/min until asystole occurs. Time of arrhythmia, 50% mean arterial pressure- and 50% heart rate-reduction, and asystole were recorded, and ropivacaine doses were calculated. Nalbuphine (0.4-5.0 mg/kg) did not affect ropivacaine-induced arrhythmia, 50% mean arterial pressure-reduction and 50% heart rate-reduction, and asystole in rats compared with NS pre-treatment. The asystole dose threshold (in milligrams per kilogram) of group LE was higher than that of group NS (NS 28.25(6.32) vs. LE, 41.58(10.65); P = 0.04; 95% confidence interval 0.23 to 26.45), while thresholds of arrhythmia, 50% mean arterial pressure-reduction, and 50% heart rate-reduction were not affected by LE. Nalbuphine doses of 0.4-5.0 mg/kg pretreatment did not increase the threshold of ropivacaine cardiotoxicity compared with NS control; 30% LE increases the lethal dose threshold of ropivacaine in rats.
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Affiliation(s)
- Chenran Wang
- Department of Anesthesia, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
| | - Shen Sun
- Department of Anesthesia, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
| | - Jing Jiao
- Department of Anesthesia, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
| | - Xinhua Yu
- Division of Epidemiology, Biostatistics and Environmental Health, Scholl of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Shaoqiang Huang
- Department of Anesthesia, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
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Sohn JT. Comment on "Efficacy of lipid emulsion therapy in treating cardiotoxicity from diphenhydramine ingestion: a review and analysis of case reports". Clin Toxicol (Phila) 2022; 60:992-993. [PMID: 35343867 DOI: 10.1080/15563650.2022.2057324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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Sohn JT. Lipid emulsion treatment of cardiotoxicity caused by calcium channel blocker and beta-blocker. Am J Emerg Med 2022; 58:331-332. [PMID: 35346530 DOI: 10.1016/j.ajem.2022.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/19/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do 52727, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju-si 52727, Republic of Korea.
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Ok SH, Kang D, Lee SH, Kim HJ, Ahn SH, Sohn JT. Lipid emulsions attenuate the inhibition of carnitine acylcarnitine translocase induced by toxic doses of local anesthetics in rat cardiomyoblasts. Hum Exp Toxicol 2022; 41:9603271211065978. [PMID: 35135371 DOI: 10.1177/09603271211065978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The aim of this study was to examine the effects of lipid emulsions on carnitine palmitoyltransferase I (CPT-I), carnitine acylcarnitine translocase (CACT), carnitine palmitoyltransferase II (CPT-II), and the mitochondrial dysfunctions induced by toxic doses of local anesthetics in H9c2 rat cardiomyoblasts. The effects of local anesthetics and lipid emulsions on the activities of CPT-I, CACT, and CPT-II, and concentrations of local anesthetics were examined. The effects of lipid emulsions, N-acetyl-L-cysteine (NAC), and mitotempo on the bupivacaine-induced changes in cell viability, reactive oxygen species (ROS) levels, mitochondrial membrane potential (MMP), and intracellular calcium levels were examined. CACT, without significantly altering CPT-I and CPT-II, was inhibited by toxic concentration of local anesthetics. The levobupivacaine- and bupivacaine-induced inhibition of CACT was attenuated by all concentrations of lipid emulsion, whereas the ropivacaine-induced inhibition of CACT was attenuated by medium and high concentrations of lipid emulsion. The concentration of levobupivacaine was slightly attenuated by lipid emulsion. The bupivacaine-induced increase of ROS and calcium and the bupivacaine-induced decrease of MMP were attenuated by ROS scavengers NAC and mitotempo, and the lipid emulsion. Collectively, these results suggested that the lipid emulsion attenuated the levobupivacaine-induced inhibition of CACT, probably through the lipid emulsion-mediated sequestration of levobupivacaine.
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Affiliation(s)
- Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, 26720Gyeongsang National University, Changwon-si, Republic of Korea.,Department of Anesthesiology and Pain Medicine, 65442Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea.,Institute of Health Sciences, 26720Gyeongsang National University, Jinju-si, Republic of Korea
| | - Dawon Kang
- Department of Physiology, 65442Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea
| | - Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, 26720Gyeongsang National University, Changwon-si, Republic of Korea.,Department of Anesthesiology and Pain Medicine, 65442Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea
| | - Hyun-Jin Kim
- Division of Applied Life Sciences (BK21 four), 26720Gyeongsang National University, Gyeongsang, Republic of Korea.,Department of Food Science & Technology, Institute of Agriculture and Life Science, 26720Gyeongsang National University, Gyeongsang, Republic of Korea
| | - Seung Hyun Ahn
- Department of Anesthesiology and Pain Medicine, 90162Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Ju-Tae Sohn
- Institute of Health Sciences, 26720Gyeongsang National University, Jinju-si, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, 90162Gyeongsang National University Hospital, Jinju-si, Republic of Korea
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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Wang C, Sun S, Jiao J, Yu X, Huang S. Effects of delta-opioid receptor agonist pretreatment on the cardiotoxicity of bupivacaine in rats. BMC Anesthesiol 2022; 22:19. [PMID: 35021986 PMCID: PMC8753886 DOI: 10.1186/s12871-022-01568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 01/04/2022] [Indexed: 11/27/2022] Open
Abstract
Background Delta-opioid receptor is widely expressed in human and rodent hearts, and has been proved to protect cardiomyocytes against ischemia/reperfusion and heart failure. The antagonist of delta-opioid receptor could block the rescue effect of lipid emulsion against local anesthetic cardiotoxicity. However, no evidence is available for the direct effect of delta-opioid-receptor agonists on the cardiotoxicity of local anesthetics. Methods Anesthetized Sprague Dawley rats were divided into five groups. Group NS received 2 ml·kg−1·min−1 normal saline, group LE received 2 ml·kg−1·min−1 30% lipid emulsion and group BW received 0.1, 1.0, or 5.0 mg/kg BW373U86, a delta-opioid-receptor agonist, for 5 min. Then 0.5% bupivacaine was infused intravenously at a rate of 3.0 mg·kg−1·min−1 until asystole. The time of arrhythmia, 50% mean arterial pressure-, 50% heart rate-reduction and asystole were recorded, and the dose of bupivacaine at each time point was calculated. Results All three different doses of BW373U86 did not affect the arrhythmia, 50% mean arterial pressure-reduction, 50% heart rate-reduction and asystole dose of bupivacaine compared with group NS. 30% LE significantly increased the bupivacaine threshold of 50% mean arterial pressure-reduction (17.9 [15.4–20.7] versus 7.2 [5.9–8.7], p = 0.018), 50% heart rate-reduction (18.7 ± 4.2 versus 8.8 ± 1.7, p < 0.001) and asystole (26.5 [21.0–29.1] versus 11.3 [10.7–13.4], p = 0.008) compared with group NS. There was no difference between group LE and group NS in the arrhythmia dose of bupivacaine (9.9 [8.9–11.7] versus 5.6 [4.5–7.0], p = 0.060). Conclusions Our data show that BW373U86 does not affect the cardiotoxicity of bupivacaine compared with NS control in rats. 30% LE pretreatment protects the myocardium against bupivacaine-induced cardiotoxicity.
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Ok SH, Ahn SH, Lee SH, Kim HJ, Sim G, Park JK, Sohn JT. Lipid emulsion attenuates propranolol-induced early apoptosis in rat cardiomyoblasts. Hum Exp Toxicol 2022; 41:9603271221110852. [PMID: 35738838 DOI: 10.1177/09603271221110852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Propranolol is used to treat several cardiovascular diseases; however, toxic doses of propranolol cause severe myocardial depression and cardiac arrest. The aim of this study was to examine the effects of lipid emulsion (LE) on cardiotoxicity induced by toxic doses of propranolol in H9C2 rat cardiomyoblast cell line and to elucidate the underlying mechanism. METHODS The experimental groups comprised control, propranolol alone, esmolol alone, or LE followed by propranolol or esmolol treatment, and reactive oxygen species (ROS) inhibitor N-acetyl-L-cysteine (NAC) followed by propranolol treatment. The effects of propranolol, esmolol, NAC, and LE, alone or in combination, on cell viability, apoptosis, and ROS production were examined. Additionally, we investigated the effect of LE on propranolol concentration. RESULTS LE and NAC reversed the inhibition of cell viability induced by propranolol (p < .001). However, LE had no effect on the inhibition of cell viability caused by esmolol. The LE inhibited propranolol-induced expressions of cleaved caspase-3 (p < .001), caspase-9 (p < .001), and Bax (p < .01), but not caspase-8. NAC inhibited the propranolol-induced expression of cleaved caspase-3. LE inhibited propranolol-induced early apoptosis, but had no effect on late apoptosis. Additionally, LE inhibited the number of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells generated by propranolol. It attenuated propranolol-induced ROS production. However, it had no effect on propranolol concentration. CONCLUSION LE inhibits early apoptosis caused by a toxic dose of propranolol by suppressing the intrinsic apoptotic pathway, via direct inhibition of ROS production.
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Affiliation(s)
- Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, 90162Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea.,Department of Anesthesiology and Pain Medicine, 26720Gyeongsang National University College of Medicine, Jinju, Republic of Korea.,Institute of Health Sciences, 26720Gyeongsang National University, Jinju, Republic of Korea
| | - Seung Hyun Ahn
- Department of Anesthesiology and Pain Medicine, 90162Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, 90162Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea.,Department of Anesthesiology and Pain Medicine, 26720Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Hyun-Jin Kim
- Division of Applied Life Sciences (BK21 four), 26720Gyeongsang National University, Jinju, Republic of Korea.,Department of Food Science and Technology, 26720Institute of Agriculture and Life Science, Gyeongsang National University, Jinju, Republic of Korea
| | - Gyujin Sim
- Department of Anesthesiology and Pain Medicine, 90162Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin Kyeong Park
- Department of Anesthesiology and Pain Medicine, 90162Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Ju-Tae Sohn
- Institute of Health Sciences, 26720Gyeongsang National University, Jinju, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, 90162Gyeongsang National University Hospital, Jinju, Republic of Korea
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Karamlou M, Asaria I, Barron J, Boutros P, Fisher V, Grandinetti R, Johnson J, Richard E, Susko D, Urrutia C, Woolsey B, Baumann R, Cottle J, Sweaney R, Wenzel M, Nusstein J, Hall D. Complications After Dental Sedation: A Myotonic Mystery Case Report. Anesth Prog 2022; 69:26-31. [PMID: 36534775 PMCID: PMC9773408 DOI: 10.2344/anpr-69-02-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 03/18/2022] [Indexed: 12/23/2022] Open
Abstract
Myotonic dystrophy (dystrophia myotonica; DM) is an uncommon progressive hereditary muscle disorder that can present with variable severity at birth, in early childhood, or most commonly as an adult. Patients with DM, especially type 1 (DM1), are extremely sensitive to the respiratory depressant effects of sedative-hypnotics, anxiolytics, and opioid agonists. This case report describes a 37-year-old male patient with previously undiagnosed DM1 who received dental care under minimal sedation using intravenous midazolam. During the case, the patient experienced 2 brief episodes of hypoxemia, the second of which required emergency intubation after propofol and succinylcholine and resulted in extended hospital admission. A lipid emulsion (Liposyn II 20%) infusion was given approximately 2 hours after the last local anesthetic injection due to slight ST elevation and suspicion of local anesthetic toxicity (LAST). Months after treatment, the patient suffered a fall resulting in a fatal traumatic brain injury. Complications noted in this case report were primarily attributed to the unknown diagnosis of DM1, although additional precipitating factors were likely present. This report also provides a basic review of the literature and clinical guidelines for managing myotonic dystrophy patients for dental care with local anesthesia, sedation, or general anesthesia.
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Affiliation(s)
- Milad Karamlou
- Former Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Iman Asaria
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Jaime Barron
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Petra Boutros
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Vincent Fisher
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Rachel Grandinetti
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Julian Johnson
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Emily Richard
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - David Susko
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Cristobal Urrutia
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Bryce Woolsey
- Chief Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Ronald Baumann
- Former Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - James Cottle
- Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Richard Sweaney
- Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Mark Wenzel
- Program Director and Hospital Attending, The Ohio State University College of Dentistry General Practice Residency Program and Wexner Medical Center, Columbus, Ohio
| | - John Nusstein
- Professor and Chair Division of Endodontics, The Ohio State University College of Dentistry, Columbus, Ohio
| | - David Hall
- Associate Professor and Hospital Attending, The Ohio State University College of Dentistry General Practice Residency Program and Wexner Medical Center, Columbus, Ohio
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Sohn JT. Putative Mechanisms Associated With Lipid Emulsion Treatment for Cardiac Toxicity Caused by Yew Intoxication. Pediatr Emerg Care 2022; 38:e438. [PMID: 32649486 DOI: 10.1097/pec.0000000000002196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Liu Y, Zhang J, Yu P, Niu J, Yu S. Mechanisms and Efficacy of Intravenous Lipid Emulsion Treatment for Systemic Toxicity From Local Anesthetics. Front Med (Lausanne) 2021; 8:756866. [PMID: 34820396 PMCID: PMC8606423 DOI: 10.3389/fmed.2021.756866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Local anesthetics are widely used clinically for perioperative analgesia to achieve comfort in medical treatment. However, when the concentration of local anesthetics in the blood exceeds the tolerance of the body, local anesthetic systemic toxicity (LAST) will occur. With the development and popularization of positioning technology under direct ultrasound, the risks and cases of LAST associated with direct entry of the anesthetic into the blood vessel have been reduced. Clinical occurrence of LAST usually presents as a series of severe toxic reactions such as myocardial depression, which is life-threatening. In addition to basic life support (airway management, advanced cardiac life support, etc.), intravenous lipid emulsion (ILE) has been introduced as a treatment option in recent years and has gradually become the first-line treatment for LAST. This review introduces the mechanisms of LAST and identifies the clinical symptoms displayed by the central nervous system and cardiovascular system. The paper features the multimodal mechanism of LAST reversal by ILE, describes research progress in the field, and identifies other anesthetics involved in the resuscitation process of LAST. Finally, the review presents key issues in lipid therapy. Although ILE has achieved notable success in the treatment of LAST, adverse reactions and contraindications also exist; therefore, ILE requires a high degree of attention during use. More in-depth research on the treatment mechanism of ILE, the resuscitation dosage and method of ILE, and the combined use with other resuscitation measures is needed to improve the efficacy and safety of clinical resuscitation after LAST in the future.
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Affiliation(s)
- Yang Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiangfeng Niu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Shuchun Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
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36
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Vingan NR, Teitelbaum S, Moorman R, Kenkel JM. Asystolic Cardiac Arrest Associated With Unstable Bradycardia During Augmentation Mammaplasty: A Case Report. Aesthet Surg J Open Forum 2021; 4:ojab047. [PMID: 35072070 PMCID: PMC8781763 DOI: 10.1093/asjof/ojab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cardiac arrest is a rare but reported complication during breast augmentation surgery. It is even more rare in a reportedly healthy patient without preexisting cardiac disease. The authors present the case of a healthy 34-year-old female who underwent elective bilateral augmentation mammaplasty and experienced unanticipated asystolic cardiac arrest intraoperatively following general anesthesia supplemented by a regional pectoral (pec I) nerve block. The performing plastic surgeon provided cardiopulmonary resuscitation while the anesthesiologist initiated a rescue protocol per Advanced Cardiac Life Support (ACLS) guidelines. Fortunately, the patient was resuscitated in a timely manner and had a successful return of spontaneous circulation within 1 minute. This case report serves to briefly review the literature and recommendations on proper resuscitation of cardiac arrest per ACLS protocols as well as discuss unstable bradycardia in otherwise healthy patients undergoing breast augmentation surgery. Plastic surgeons and anesthesiologists who perform this procedure should be aware of the possible, rare but serious progression to asystole as well as the proper resuscitative measures to take should they be required. LEVEL OF EVIDENCE 5
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Affiliation(s)
- Nicole R Vingan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven Teitelbaum
- associate clinical professor of plastic surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rita Moorman
- American Board of Anesthesiology in private practice in Santa Monica, CA, USA
| | - Jeffrey M Kenkel
- Corresponding Author: Dr Jeffrey M. Kenkel, Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-9132, USA. E-mail:
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38
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Haloperidol Toxicity and Lipid Emulsion Treatment. Am J Ther 2021; 29:489-490. [DOI: 10.1097/mjt.0000000000001456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Sohn JT. Letter to "Intralipid infusion at time of embryo transfer in women with history of recurrent implantation failure: A systematic review and meta-analysis". J Obstet Gynaecol Res 2021; 47:3743. [PMID: 34365678 DOI: 10.1111/jog.14975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/29/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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He KS, Fernando R, Cabrera T, Valenti D, Algharras A, Martínez N, Liu DM, Noel G, Muchantef K, Bessissow A, Boucher LM. Hepatic Hilar Nerve Block for Hepatic Interventions: Anatomy, Technique, and Initial Clinical Experience in Thermal Ablation of Liver Tumors. Radiology 2021; 301:223-228. [PMID: 34254852 DOI: 10.1148/radiol.2021203410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Image-guided procedures for treatment of liver diseases can be painful and require heavy sedation of the patient. Local-regional nerve blocks improve pain control and reduce oversedation risks, but there are no documented liver-specific nerve blocks. Purpose To develop a safe and technically simple liver-specific nerve block. Materials and Methods Between March 2017 and October 2019, three cadavers were dissected to evaluate the hepatic hilar anatomy. The hepatic hilar nerves were targeted with transhepatic placement of a needle adjacent to the main portal vein, under US guidance, and evaluated with use of an injection of methylene blue. A hepatic nerve block, using similar technique and 0.25% bupivacaine, was offered to patients undergoing liver tumoral ablation. In a prospective pilot study, 12 patients who received the nerve block were compared with a control group regarding complications, safety, pain scores, and intraoperative opioid requirement. Student t tests were used to compare the groups' characteristics, and Mann-Whitney U tests were used for the measured outcomes. Results Cadaver results confirmed that the hepatic nerves coursing in the hepatic hilum can be targeted with US for injection of anesthetic agents, with adequate spread of injected methylene blue around the nerves in the hepatic hilar perivascular space. The 12 participants (mean age ± standard deviation, 66 years ± 13; eight men) who received a hepatic hilar block before liver thermal ablations demonstrated reduced pain compared with a control group of 12 participants (mean age, 63 years ± 15; eight men) who received only intravenous sedation. Participants who received the nerve block had a lower mean visual analog scale score for pain than the control group (3.9 ± 2.4 vs 7.0 ± 2.8, respectively; P = .01) and decreased need for intraprocedural fentanyl (mean dose, 152 μg ± 78.0 vs 235.4 μg ± 58.2, respectively; P = .01). No major complications occurred in the hepatic hilar nerve block group. Conclusion A dedicated hepatic hilar nerve block with 0.25% bupivacaine can be safely performed to provide anesthesia during liver tumoral ablation. © RSNA, 2021.
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Affiliation(s)
- Kevin S He
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Rukshan Fernando
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Tatiana Cabrera
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - David Valenti
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Abdulaziz Algharras
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Nicolás Martínez
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - David M Liu
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Geoffroy Noel
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Karl Muchantef
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Ali Bessissow
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
| | - Louis-Martin Boucher
- From the Departments of Diagnostic Radiology (K.S.H., T.C., D.V., A.A., K.M., A.B., L.M.B.) and Anatomical Sciences (G.N.), McGill University Health Centre, 1001 Blvd Décarie, Montreal, QC, Canada H4A 3J1; Department of Radiology, Auckland City Hospital, Auckland, New Zealand (R.F.); Department of Radiology, University of Chile Clinical Hospital, Independencia, Chile (N.M.); and Department of Radiology, University of British Columbia, Vancouver, Canada (D.M.L.)
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41
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Sohn JT. The Underlying Mechanism of Lipid Emulsion Treatment as a Nonspecific Antidote to Drug Toxicity. J Emerg Med 2021; 60:e137-e138. [PMID: 34016386 DOI: 10.1016/j.jemermed.2020.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/22/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea; Institute of Health Sciences, Gyeonsang National University, Jinju-si, Gyeongsangnam-do, Republic of Korea
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42
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Ok SH, Sohn JT. Effect of lipid emulsion on acute clozapine poisoning-induced QT prolongation. Hum Exp Toxicol 2021; 40:2237-2239. [PMID: 34137281 DOI: 10.1177/09603271211025598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S-H Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Gyeongsangnam-do, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
| | - J-T Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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43
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Hwang Y, Sohn JT. Lipid emulsion treatment of hydroxychloroquine toxicity. Mod Rheumatol 2021; 31:924-925. [PMID: 34060429 DOI: 10.1080/14397595.2020.1836790] [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]
Affiliation(s)
- Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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44
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Pharmacokinetic Disposition of Amiodarone When Given with an Intralipid Rescue Strategy. Pharmaceutics 2021; 13:pharmaceutics13040539. [PMID: 33924314 PMCID: PMC8069539 DOI: 10.3390/pharmaceutics13040539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 11/20/2022] Open
Abstract
While the antiarrhythmic drug amiodarone is commonly used in clinical practice, it has a narrow therapeutic index that can lead to acute overdose. One proposed method to deal with this toxicity is lipid emulsion therapy, which may potentially quench the free amiodarone in blood and prevent its further distribution to target organs and tissues. In this study, we utilize an established swine model to examine the effects of Intralipid™ (IL) administration for acute amiodarone toxicity. A total of 14 pigs received an overdose of intravenous amiodarone. After twenty minutes, half of the pigs (n = 7) received IL while the control group (n = 7) received normal saline. Serum concentrations of amiodarone were then analyzed using a validated high-performance liquid chromatography (HPLC) method. Noncompartmental pharmacokinetic analyses were performed on the observed concentrations. There were no statistical differences in the area under the concentration time curve (6 h) or clearance, but there was a difference in the half-life between the two groups (3.12 vs. 0.85 h, p = 0.01). The administration of IL did not statistically change the overall exposure of amiodarone in the blood in the first 6 h; however, trends toward prolonged blood retention in the IL group were seen.
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45
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Lipid Emulsion Treatment and Long Chain Fatty Acid Supply. Am J Ther 2021; 29:e367-e368. [PMID: 33852472 DOI: 10.1097/mjt.0000000000001362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Lipid Emulsion Enhances Vasoconstriction Induced by Dexmedetomidine in the Isolated Endothelium-Intact Aorta. Int J Mol Sci 2021; 22:ijms22073309. [PMID: 33804982 PMCID: PMC8038020 DOI: 10.3390/ijms22073309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/16/2021] [Accepted: 03/20/2021] [Indexed: 11/16/2022] Open
Abstract
This study aimed to examine the effect of lipid emulsion (LE) on the vasoconstriction induced by dexmedetomidine (DMT) in the isolated rat aorta and elucidate the associated cellular mechanism. The effect of LE, NW-nitro-L-arginine methyl ester (L-NAME), and methyl-β-cyclodextrin (MβCD) on the DMT-induced contraction was examined. We investigated the effect of LE on the DMT-induced cyclic guanosine monophosphate (cGMP) formation and DMT concentration. The effect of DMT, LE, 4-Amino-3-(4-chlorophenyl)-1-(t-butyl)-1H-pyrazolo[3,4-d]pyrimidine,4-Amino-5-(4-chlorophenyl)-7-(t-butyl)pyrazolo[3,4-d]pyrimidine (PP2), and rauwolscine on the phosphorylation of endothelial nitric oxide synthase (eNOS), caveolin-1, and Src kinase was examined in the human umbilical vein endothelial cells. L-NAME, MβCD, and LE (1%, standardized mean difference (SMD): 2.517) increased the DMT-induced contraction in the endothelium-intact rat aorta. LE (1%) decreased the DMT (10−6 M) concentration (SMD: −6.795) and DMT-induced cGMP formation (SMD: −2.132). LE (1%) reversed the DMT-induced eNOS (Ser1177 and Thr496) phosphorylation. PP2 inhibited caveolin-1 and eNOS phosphorylation induced by DMT. DMT increased the Src kinase phosphorylation. Thus, LE (1%) enhanced the DMT-induced contraction by inhibition of NO synthesis, which may be caused by the decreased DMT concentration. DMT-induced NO synthesis may be caused by the increased eNOS (Ser1177) phosphorylation and decreased eNOS (Thr495) phosphorylation potentially mediated by Src kinase-induced caveolin-1 phosphorylation.
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47
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Lipid emulsion treatment as an antidote for chloroquine and hydroxychloroquine toxicity. Am J Emerg Med 2021; 42:258-259. [PMID: 33546954 DOI: 10.1016/j.ajem.2021.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
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48
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Sohn JT. Plasma clearance and lipaemic index of lipid emulsion used for lipid emulsion treatment. Ann Clin Biochem 2021; 58:547-548. [PMID: 33435698 DOI: 10.1177/0004563221990686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Gyeongsangnam-do, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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49
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Fletcher DJ, Boller M. Fluid Therapy During Cardiopulmonary Resuscitation. Front Vet Sci 2021; 7:625361. [PMID: 33585610 PMCID: PMC7876065 DOI: 10.3389/fvets.2020.625361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022] Open
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of blood flow and ventilation, is fatal if left untreated. Cardiopulmonary resuscitation (CPR) is targeted at restoring oxygen delivery to tissues to mitigate ischemic injury and to provide energy substrate to the tissues in order to achieve return of spontaneous circulation (ROSC). In addition to basic life support (BLS), targeted at replacing the mechanical aspects of circulation and ventilation, adjunctive advanced life support (ALS) interventions, such as intravenous fluid therapy, can improve the likelihood of ROSC depending on the specific characteristics of the patient. In hypovolemic patients with CPA, intravenous fluid boluses to improve preload and cardiac output are likely beneficial, and the use of hypertonic saline may confer additional neuroprotective effects. However, in euvolemic patients, isotonic or hypertonic crystalloid boluses may be detrimental due to decreased tissue blood flow caused by compromised tissue perfusion pressures. Synthetic colloids have not been shown to be beneficial in patients in CPA, and given their documented potential for harm, they are not recommended. Patients with documented electrolyte abnormalities such as hypokalemia or hyperkalemia benefit from therapy targeted at those disturbances, and patients with CPA induced by lipid soluble toxins may benefit from intravenous lipid emulsion therapy. Patients with prolonged CPA that have developed significant acidemia may benefit from intravenous buffer therapy, but patients with acute CPA may be harmed by buffers. In general, ALS fluid therapies should be used only if specific indications are present in the individual patient.
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Affiliation(s)
- Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Manuel Boller
- Faculty of Veterinary and Agricultural Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, VIC, Australia
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50
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Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia 2021; 76 Suppl 1:27-39. [PMID: 33426662 DOI: 10.1111/anae.15282] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 12/21/2022]
Abstract
Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.
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Affiliation(s)
- A J R Macfarlane
- Department of Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK.,2University of Glasgow, Glasgow, UK
| | - M Gitman
- Department of Anaesthesia, University of Illinois College of Medicine, Chicago, IL, USA
| | - K J Bornstein
- Department of Medical Education, University of Miami School of Medicine, Miami, FL, USA
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - G Weinberg
- Department of Anaesthesia, University of Illinois College of Medicine, Chicago, IL, USA.,Jesse Brown VA Medical Centre, Chicago, IL, USA
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