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Khan I. Postoperative Epistaxis Following Dental Treatment With Nitrous Oxide/Oxygen Sedation. Anesth Prog 2023; 70:75-79. [PMID: 37379092 PMCID: PMC10328194 DOI: 10.2344/anpr-70-01-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/16/2023] [Indexed: 06/29/2023] Open
Abstract
A 12-year-old Caucasian male undergoing a dental extraction for a grossly carious mandibular molar under inhalational sedation with nitrous oxide/oxygen experienced an episode of anterior epistaxis postoperatively that was controlled well with local measures. Epistaxis following inhalational sedation with nitrous oxide/oxygen in the dental setting is a very rare complication but has been previously reported in the literature. This case report provides a review of the existing literature regarding cases of epistaxis associated with inhalational sedation using nitrous oxide/oxygen and discusses the potential etiology of epistaxis associated with inhalational sedation. Patients at higher risk of epistaxis should be properly informed of the risks prior to inhalational sedation with nitrous oxide/oxygen, and dentists should also be familiar with epistaxis management in the dental setting.
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Affiliation(s)
- Ishfaq Khan
- Honorary Clinical Lecturer, School of Dentistry, College of Medical and Dental Sciences, University of Birmingham, UK
- Senior Dental Surgeon, Midlands Partnership University NHS Foundation Trust, University of Portsmouth, UK
- Postgraduate Student, Dental Academy, University of Portsmouth, UK
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Georgevici AI, Kyprianou T, Herzog-Niescery J, Procopiuc L, Loganathan S, Weber TP, Bellgardt M. Negative drift of sedation depth in critically ill patients receiving constant minimum alveolar concentration of isoflurane, sevoflurane, or desflurane: a randomized controlled trial. Crit Care 2021; 25:141. [PMID: 33849618 DOI: 10.1186/s13054-021-03556-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/30/2021] [Indexed: 11/21/2022]
Abstract
Background Intensive care unit (ICU) physicians have extended the minimum alveolar concentration (MAC) to deliver and monitor long-term volatile sedation in critically ill patients. There is limited evidence of MAC’s reliability in controlling sedation depth in this setting. We hypothesized that sedation depth, measured by the electroencephalography (EEG)-derived Narcotrend-Index (burst-suppression N_Index 0—awake N_Index 100), might drift downward over time despite constant MAC values. Methods This prospective single-centre randomized clinical study was conducted at a University Hospital Surgical Intensive Care Unit and included consecutive, postoperative ICU patients fulfilling the inclusion criteria. Patients were randomly assigned to receive uninterrupted inhalational sedation with isoflurane, sevoflurane, or desflurane. The end-expiratory concentration of the anaesthetics and the EEG-derived index were measured continuously in time-stamped pairs. Sedation depth was also monitored using Richmond-Agitation-Sedation-Scale (RASS). The paired t-test and linear models (bootstrapped or multilevel) have been employed to analyze MAC,
N_Index and RASS across the three groups. Results Thirty patients were recruited (female/male: 10/20, age 64 ± 11, Simplified Acute Physiology Score II 30 ± 10). In the first 24 h, 21.208 pairs of data points (N_Index and MAC) were recorded. The median MAC of 0.58 ± 0.06 remained stable over the sedation time in all three groups. The t-test indicated in the isoflurane and sevoflurane groups a significant drop in RASS and EEG-derived N_Index in the first versus last two sedation hours. We applied a multilevel linear model on the entire longitudinal data, nested per patient, which produced the formula N_Index = 43 − 0.7·h (R2 = 0.76), showing a strong negative correlation between sedation’s duration and the N_Index. Bootstrapped linear models applied for each sedation group produced: N_Index of 43–0.9, 45–0.8, and 43–0.4·h for isoflurane, sevoflurane, and desflurane, respectively. The regression coefficient for desflurane was almost half of those for isoflurane and sevoflurane, indicating a less pronounced time-effect in this group. Conclusions Maintaining constant MAC does not guarantee stable sedation depth. Thus, the patients necessitate frequent clinical assessments or, when unfeasible, continuous EEG monitoring. The differences across different volatile anaesthetics regarding their time-dependent negative drift requires further exploration. Trial registration: NCT03860129. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03556-y.
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Bellgardt M, Georgevici AI, Klutzny M, Drees D, Meiser A, Gude P, Vogelsang H, Weber TP, Herzog-Niescery J. Use of MIRUS™ for MAC-driven application of isoflurane, sevoflurane, and desflurane in postoperative ICU patients: a randomized controlled trial. Ann Intensive Care 2019; 9:118. [PMID: 31620921 PMCID: PMC6795651 DOI: 10.1186/s13613-019-0594-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/05/2019] [Indexed: 12/22/2022] Open
Abstract
Background The MIRUS™ (TIM, Koblenz, Germany) is an electronical gas delivery system, which offers an automated MAC (minimal alveolar concentration)-driven application of isoflurane, sevoflurane, or desflurane, and can be used for sedation in the intensive care unit. We investigated its consumption of volatile anesthetics at 0.5 MAC (primary endpoint) and the corresponding costs. Secondary endpoints were the technical feasibility to reach and control the MAC automatically, the depth of sedation at 0.5 MAC, and awakening times. Mechanically ventilated and sedated patients after major surgery were enrolled. Upon arrival in the intensive care unit, patients obtained intravenous propofol sedation for at least 1 h to collect ventilation and blood gas parameters, before they were switched to inhalational sedation using MIRUS™ with isoflurane, sevoflurane, or desflurane. After a minimum of 2 h, inhalational sedation was stopped, and awakening times were recorded. A multivariate electroencephalogram and the Richmond Agitation Sedation Scale (RASS) were used to assess the depth of sedation. Vital signs, ventilation parameters, gas consumption, MAC, and expiratory gas concentrations were continuously recorded. Results Thirty patients obtained inhalational sedation for 18:08 [14:46–21:34] [median 1st–3rd quartiles] hours. The MAC was 0.58 [0.50–0.64], resulting in a Narcotrend Index of 37.1 [30.9–42.4] and a RASS of − 3.0 [− 4.0 to (− 3.0)]. The median gas consumption was significantly lowest for isoflurane ([ml h−1]: isoflurane: 3.97 [3.61–5.70]; sevoflurane: 8.91 [6.32–13.76]; and desflurane: 25.88 [20.38–30.82]; p < 0.001). This corresponds to average costs of 0.39 € h−1 for isoflurane, 2.14 € h−1 for sevoflurane, and 7.54 € h−1 for desflurane. Awakening times (eye opening [min]: isoflurane: 9:48 [4:15–20:18]; sevoflurane: 3:45 [0:30–6:30]; desflurane: 2:00 [1:00–6:30]; p = 0.043) and time to extubation ([min]: isoflurane: 10:10 [8:00–20:30]; sevoflurane: 7:30 [4:37–14:22]; desflurane: 3:00 [3:00–6:00]; p = 0.007) were significantly shortest for desflurane. Conclusions A target-controlled, MAC-driven automated application of volatile anesthetics is technically feasible and enables an adequate depth of sedation. Gas consumption was highest for desflurane, which is also the most expensive volatile anesthetic. Although awakening times were shortest, the actual time saving of a few minutes might be negligible for most patients in the intensive care unit. Thus, using desflurane seems not rational from an economic perspective. Trial registration Clinical Trials Registry (ref.: NCT03860129). Registered 24 September 2018—Retrospectively registered.
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Affiliation(s)
- Martin Bellgardt
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.
| | - Adrian Iustin Georgevici
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Mitja Klutzny
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Dominik Drees
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Meiser
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Philipp Gude
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Heike Vogelsang
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Thomas Peter Weber
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Jennifer Herzog-Niescery
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
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Herzog-Niescery J, Seipp HM, Weber TP, Bellgardt M. Inhaled anesthetic agent sedation in the ICU and trace gas concentrations: a review. J Clin Monit Comput 2017; 32:667-675. [PMID: 28861655 DOI: 10.1007/s10877-017-0055-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/15/2017] [Indexed: 12/12/2022]
Abstract
There is a growing interest in the use of volatile anesthetics for inhalational sedation of adult critically ill patients in the ICU. Its safety and efficacy has been demonstrated in various studies and technical equipment such as the anaesthetic conserving device (AnaConDa™; Sedana Medical, Uppsala, Sweden) or the MIRUS™ system (Pall Medical, Dreieich, Germany) have significantly simplified the application of volatile anesthetics in the ICU. However, the personnel's exposure to waste anesthetic gas during daily work is possibly disadvantageous, because there is still uncertainty about potential health risks. The fact that average threshold limit concentrations for isoflurane, sevoflurane and desflurane either differ significantly between countries or are not even defined at all, leads to raising concerns among ICU staff. In this review, benefits, risks, and technical aspects of inhalational sedation in the ICU are discussed. Further, the potential health effects of occupational long-term low-concentration agent exposure, the staffs' exposure levels in clinical practice, and strategies to minimize the individual gas exposure are reviewed.
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Affiliation(s)
- Jennifer Herzog-Niescery
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.
| | - Hans-Martin Seipp
- Department of Life Science Engineering, University of Applied Sciences, Wiesenstr. 14, 35390, Giessen, Germany
| | - Thomas Peter Weber
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Martin Bellgardt
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
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Karnjuš I, Mekiš D, Križmarić M. Uncontrolled delivery of liquid volatile anaesthetic when using the anaesthetic conserving device. J Clin Monit Comput 2017; 32:629-638. [PMID: 28567612 DOI: 10.1007/s10877-017-0022-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 04/24/2017] [Indexed: 11/30/2022]
Abstract
During patient sedation with liquid volatile anaesthetic, some problems may occur through a process called auto-pumping, defined as an expansion of bubbles inside the syringe, which can lead to uncontrolled anaesthetic delivery. The study examined how the temperature of liquid volatile anaesthetics (sevoflurane and isoflurane) and the presence of gas bubbles in the syringe affect the occurrence of auto-pumping when using the anaesthetic conserving device (ACD, AnaConDa™, Sedana Medical, Uppsala, Sweden). Four different circumstances for each volatile anaesthetic were tested with a bench study: volatile anaesthetic at room temperature or precooled with and without the presence of gas bubbles in the syringe. Liquid volatile anaesthetic was infused into the ACD via a syringe pump at a fixed rate and heated gradually until the temperature of the syringe surface reached 50 °C. A main-stream gas monitor was used to measure the expired fraction of volatile anaesthetic (FE vol%). The occurrence of auto-pumping was observed only in the subgroups containing gas bubbles, with both anaesthetics. In these subgroups, the values of the expired anaesthetic gas fraction increased dramatically with the expansion of gas bubbles in the syringe (ΔFE ranged from +1.6 to 2.4 vol% for sevoflurane and +2.3 to 3.4 vol% for isoflurane). Furthermore, when the heat source was removed, a substantial decline in anaesthetic agent values below the baseline was observed with both anaesthetics. The presence of gas bubbles in the syringe, especially when exposed to a heat source, may provoke auto-pumping with uncontrolled excessive anaesthetic delivery. If auto-pumping is suspected, the syringe pump must be stopped and the ACD removed from the breathing circuit at once.
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Affiliation(s)
- Igor Karnjuš
- Department of Nursing, Faculty of Health Sciences, University of Primorska, Polje 42, 6310, Izola, Slovenia.
| | - Dušan Mekiš
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia.,Department of Anaesthesiology and Reanimation, Faculty of Medicine, University of Maribor, Taborska 8, 2000, Maribor, Slovenia
| | - Miljenko Križmarić
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, University of Maribor, Taborska 8, 2000, Maribor, Slovenia.,Department of Bioinformatics, Faculty of Health Sciences, University of Maribor, Žitna ulica 15, 2000, Maribor, Slovenia
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Gallego L, Soro M, Alvariño A, Noguera I, Belda FJ. Renal and hepatic integrity in long-term sevoflurane sedation using the anesthetic conserving device: a comparison with intravenous propofol sedation in an animal model. Rev Esp Anestesiol Reanim 2015; 62:191-203. [PMID: 25146774 DOI: 10.1016/j.redar.2014.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 05/21/2014] [Accepted: 05/22/2014] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Critically ill patients are sedated with intravenous agents because the use of inhaled agents is limited by their potential risk of toxicity. Increasing levels of inorganic fluorides after the metabolism of these agents have been considered potentially nephrotoxic. However, hepatic involvement after prolonged administration of sevoflurane has not yet been studied. The present study evaluated the potential renal and hepatic toxicity caused by prolonged administration (72h) of sevoflurane. METHODS For this experimental, prospective, randomized, controlled trial, 22 Landrace x Large-White female pigs were randomly assigned to two groups: intravenous propofol (P) or inhaled sevoflurane via the AnaConDa™ device (S, end-tidal 2.5 vol%). The P group remained sedated for 108h with propofol. In the S group, sevoflurane was administered for 72h and then changed to propofol for the remaining 36h in order to observe the kinetics of fluoride after discontinuation of sevoflurane. Serum creatinine was the primary outcome variable, but inorganic fluoride concentrations and other renal, hepatic, and cardiorespiratory variables were also measured. RESULTS Both groups of animals were comparable at baseline. No differences were found between the two groups for plasma creatinine and urea or creatinine clearance throughout the study. Fluoride levels were significantly higher in the sevoflurane group. No correlation was found between inorganic fluoride and serum creatinine values. No significant differences were observed for hepatic function. Hemodynamic, respiratory, and blood gas variables were comparable between the groups. CONCLUSIONS Long-term sedation with sevoflurane using AnaConDa™ or propofol does not negatively affect renal or hepatic function.
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Affiliation(s)
- L Gallego
- Servicio de Anestesiología y Reanimación, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - M Soro
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España
| | - A Alvariño
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España
| | - I Noguera
- Departamnto de Cirugía, Universitat de València, Valencia, España
| | - F J Belda
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España; Departamnto de Cirugía, Universitat de València, Valencia, España
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