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van Velzen M, Boru A, Sarton E, de Beaufort AJ. Design thinking in medical education to tackle real world healthcare problems: The MasterMinds Challenge. Med Teach 2024; 46:611-613. [PMID: 38285020 DOI: 10.1080/0142159x.2024.2305713] [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] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
EDUCATIONAL CHALLENGE Medical education must equip future professionals with the necessary skills to navigate the complex healthcare landscape. Clinical knowledge is essential, and critical and creative thinking skills are vital to meet the challenges of the system. Design thinking offers a structured approach that integrates creativity and innovation, yet its application in medical education is absent. SOLUTION AND IMPLEMENTATION The compulsory MasterMinds Challenge course at Leiden University Medical Center utilizes design thinking principles to address real world healthcare challenges. Final-year medical students participated in a two-day program. The course encompassed empathizing with stakeholders, problem definition, ideation, prototyping, and refining solutions. Presentation skills were emphasized, culminating in a symposium where teams showcase their outcomes. Implementation of the MasterMinds Challenge course was successful with 33 sessions delivered to 1217 medical students. Challenges covered various healthcare topics, yielding creative yet practical outcomes. Students appreciate the real world healthcare challenge, team-based approach, and the applicability of design thinking principles. Challenge owners expressed satisfaction with students' commitment, creativity, and empathizing abilities. LESSONS LEARNED AND NEXT STEPS To further enhance the MasterMinds Challenge course, a more longitudinal format is being designed, enabling greater autonomy and emphasizing the refining and implementation phases. The course can be extended to medical postgraduate professionals and interdisciplinary collaborations, fostering innovative ideas beyond current practices. By developing problem-solving skills, the MasterMinds Challenge course contributes to a future-proof medical education program and prepares students to meet the evolving needs of healthcare.
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Affiliation(s)
- Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Asli Boru
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
- Delft University of Technology, Delft Center for Entrepreneurship, Technology Policy and Management, Delft, The Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnout Jan de Beaufort
- Center for Innovation in Medical Education, Leiden University Medical Center, Leiden University Medical Center, Leiden, The Netherlands
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van Lemmen M, Florian J, Li Z, van Velzen M, van Dorp E, Niesters M, Sarton E, Olofsen E, van der Schrier R, Strauss DG, Dahan A. Naloxone for Opioid Overdose: Reply. Anesthesiology 2024; 140:857-859. [PMID: 38335033 DOI: 10.1097/aln.0000000000004872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Albert Dahan
- Leiden University Medical Center, Leiden, The Netherlands (A.D.).
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Hoek K, Sarton E, van Velzen M. Response to correspondance on patient-embodied virtual reality as a learning tool for therapeutic communication skills among anaesthesiologists: A phenomenological study. Patient Educ Couns 2023; 117:107980. [PMID: 37730465 DOI: 10.1016/j.pec.2023.107980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Krista Hoek
- Leiden University Medical Center, Rijnsburg, the Netherlands.
| | - Elise Sarton
- Leiden University Medical Center, the Netherlands
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van Lemmen M, Florian J, Li Z, van Velzen M, van Dorp E, Niesters M, Sarton E, Olofsen E, van der Schrier R, Strauss DG, Dahan A. Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology 2023; 139:342-353. [PMID: 37402248 DOI: 10.1097/aln.0000000000004622] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Opioids are effective analgesics, but they can have harmful adverse effects, such as addiction and potentially fatal respiratory depression. Naloxone is currently the only available treatment for reversing the negative effects of opioids, including respiratory depression. However, the effectiveness of naloxone, particularly after an opioid overdose, varies depending on the pharmacokinetics and the pharmacodynamics of the opioid that was overdosed. Long-acting opioids, and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics, are particularly resistant to the effects of naloxone. In this review, the authors examine the pharmacology of naloxone and its safety and limitations in reversing opioid-induced respiratory depression under different circumstances, including its ability to prevent cardiac arrest.
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Affiliation(s)
- Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeffrey Florian
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Zhihua Li
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eveline van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - David G Strauss
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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van Lemmen M, van der Schrier R, Dahan A, van Velzen M, Sarton E, Niesters M. Pharmacology of viable mechanism agnostic respiratory stimulants for the reversal of drug-induced respiratory depression in humans. Expert Opin Drug Metab Toxicol 2023; 19:671-679. [PMID: 37795596 DOI: 10.1080/17425255.2023.2262386] [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: 05/15/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Drug-induced respiratory depression is potentially fatal and can be caused by various drugs such as synthetic opioids and tranquilizers. The only class of respiratory depressants that has a specific reversal agent are opioids, such as naloxone. These reversal agents have limited utility in situations of polysubstance ingestion with agents from multiple respiratory depressant classes. Hence, there is an unmet need for drugs that stimulate breathing irrespective of the underlying cause of respiratory depression, i.e. mechanism agnostic respiratory stimulants. AREAS COVERED In this review, we discuss agnostic respiratory stimulants, tested in humans with promising results, i.e. ampakines, drugs that act at the carotid bodies, N-methyl-D-aspartate receptor antagonist ketamine, and orexin receptor-2-agonist danavorexton, and others that demonstrated positive effects in animals but not yet in humans. EXPERT OPINION Rapid, effective rescuing of individuals who overdosed on respiratory depressants saves lives. While naloxone is the preferred drug for reversing opioid-induced respiratory depression, its effectiveness is limited in cases involving non-opioids. While several agnostic respiratory stimulants showed promise in humans, further research is needed to optimize dosing, evaluate safety and efficacy in deeper respiratory depression (apnea). Additionally, future studies should combine agnostic stimulants with naloxone, to improve rapid, effective rescue from drug overdoses.
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Affiliation(s)
- Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
- PainLess Foundation, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
- PainLess Foundation, Leiden, the Netherlands
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Hellinga M, Algera MH, van der Schrier R, Sarton E, van Velzen M, Dahan A, Olofsen E, Niesters M. A biomarker of opioid-induced respiratory toxicity in experimental studies. iScience 2023; 26:106520. [PMID: 37123241 PMCID: PMC10139987 DOI: 10.1016/j.isci.2023.106520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Opioids are commonly used painkillers and drugs of abuse and have serious toxic effects including potentially lethal respiratory depression. It remains unknown which respiratory parameter is the most sensitive biomarker of opioid-induced respiratory depression (OIRD). To evaluate this issue, we studied 24 volunteers and measured resting ventilation, resting end-tidal PCO2 (PETCO2) and the hypercapnic ventilatory response (HCVR) before and at 1-h intervals following intake of the opioid tapentadol. Pharmacokinetic/pharmacodynamic analyses that included CO2 kinetics were applied to model the responses with focus on resting variables obtained without added CO2, HCVR slope and ventilation at an extrapolated PETCO2 of 55 mmHg ( V ˙ E 55). The HCVR, particularly V ˙ E 55 followed by slope, was most sensitive in terms of potency; resting variables were least sensitive and responded slower to the opioid. Using V ˙ E 55 as biomarker in quantitative studies on OIRD allows standardized comparison among opioids in the assessment of their safety.
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Hellinga M, Algera MH, Olofsen E, van der Schrier R, Sarton E, van Velzen M, Dahan A, Niesters M. Oral Oxycodone-Induced Respiratory Depression during Normocapnia and Hypercapnia: A Pharmacokinetic-Pharmacodynamic Modeling Study. Clin Pharmacol Ther 2023; 113:1080-1088. [PMID: 36744649 DOI: 10.1002/cpt.2863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/31/2023] [Indexed: 02/07/2023]
Abstract
The widely prescribed opioid oxycodone may cause lethal respiratory depression. We compared the effects of oxycodone on breathing and antinociception in healthy young volunteers. After pharmacokinetic/pharmacodynamic (PK/PD) modeling, we constructed utility functions to combine the wanted and unwanted end points into a single function. We hypothesized that the function would be predominantly negative over the tested oxycodone concentration range. Twenty-four male and female volunteers received 20 (n = 12) or 40 (n = 12) mg oral oxycodone immediate-release tablets. Hypercapnic ventilatory responses (visit 1) or responses to 3 nociceptive assays (pain pressure, electrical, and thermal tests; visit 2) were measured at regular intervals for 7 hours. the PK/PD analyses, that included carbon dioxide kinetics, stood at the basis of the utility function: probability of antinociception minus probability of respiratory depression. Oxycodone had rapid onset/offset times (30-40 minutes) with potency values (effect-site concentration causing 50% of effect) ranging from 0.05 to 0.13 ng/mL for respiratory variables obtained at hypercapnia and antinociceptive responses. Ventilation at an extrapolated end-tidal carbon dioxide partial pressure of 55 mmHg, was used for creation of 3 utility functions, one for each of the nociceptive tests. Contrary to expectation, the utility functions were close to zero or positive over the clinical oxycodone concentration range. The similar or better likelihood for antinociception relative to respiratory depression may be related to oxycodone's receptor activation profile or to is high likeability that possibly alters the modulation of nociceptive input. Oxycodone differs from other μ-opioids, such as fentanyl, that have a consistent negative utility.
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Affiliation(s)
- Marieke Hellinga
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marijke Hyke Algera
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.,PainLess Foundation, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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van der Schrier R, van Velzen M, Roozekrans M, Sarton E, Olofsen E, Niesters M, Smulders C, Dahan A. Carbon dioxide tolerability and toxicity in rat and man: A translational study. Front Toxicol 2022; 4:1001709. [PMID: 36310693 PMCID: PMC9606673 DOI: 10.3389/ftox.2022.1001709] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/12/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Due the increasing need for storage of carbon dioxide (CO2) more individuals are prone to be exposed to high concentrations of CO2 accidentally released into atmosphere, with deleterious consequences. Methods: We tested the effect of increasing CO2 concentrations in humans (6–12%) and rats (10–50%) at varying inhalation times (10–60 min). In humans, a continuous positive airway pressure helmet was used to deliver the gas mixture to the participants. Unrestrained rats were exposed to CO2 in a transparent chamber. In both species regular arterial blood gas samples were obtained. After the studies, the lungs of the animals were examined for macroscopic and microscopic abnormalities. Results: In humans, CO2 concentrations of 9% inhaled for >10 min, and higher concentrations inhaled for <10 min were poorly or not tolerated due to exhaustion, anxiety, dissociation or acidosis (pH < 7.2), despite intact oxygenation. In rats, concentrations of 30% and higher were associated with CO2 narcosis, epilepsy, poor oxygenation and, at 50% CO2, spontaneous death. Lung hemorrhage and edema were observed in the rats at inhaled concentrations of 30% and higher. Conclusion: This study provides essential insight into the occurrence of physiological changes in humans and fatalities in rats after acute exposure to high levels of CO2. Humans tolerate 9% CO2 and retain their ability to function coherently for up to 10 min. These data support reconsideration of the current CO2 levels (<7.5%) that pose a risk to exposed individuals (<7.5%) as determined by governmental agencies to ≤9%.
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Affiliation(s)
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Margot Roozekrans
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands,Department of Anesthesiology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands,*Correspondence: Albert Dahan,
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9
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Algera H, van der Schrier R, Cavalla D, van Velzen M, Roozekrans M, McMorn A, Snape M, Horrigan JP, Evans S, Kiernan B, Sarton E, Olofsen E, Niesters M, Dahan A. Respiratory effects of the atypical tricyclic antidepressant tianeptine in human models of opioid-induced respiratory depression. Anesthesiology 2022; 137:446-458. [PMID: 35867853 DOI: 10.1097/aln.0000000000004324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Animal data suggest that the antidepressant and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor modulator tianeptine is able to prevent opioid-induced respiratory depression. We hypothesize that oral or intravenous tianeptine can effectively prevent or counteract opioid-induced respiratory depression in humans. METHODS Healthy male and female volunteers participated in two studies that had a randomized, double blind, placebo-controlled, crossover design. We first tested oral tianeptine (37.5, 50 and 100 mg, 8 subjects/group) pretreatment followed by induction of alfentanil-induced respiratory depression (alfentanil target concentration 100 ng/mL). Primary endpoint was ventilation at an extrapolated end-tidal carbon dioxide concentration of 55 mmHg (V̇E55). We next determined the ability of four subsequent and increasing infusions of intravenous tianeptine (target tianeptine plasma concentrations 400, 1,000, 1,500 and 2,000 ng/mL, each given over 15 min), to counteract remifentanil-induced respiratory depression in 15 volunteers. Ventilation was measured at isohypercpania (baseline ventilation 20 ± 2 L/min). Primary endpoint was minute ventilation during the 60 min of tianeptine versus placebo infusion. RESULTS Alfentanil reduced V̇E55 to 13.7 (95% CI 8.6-18.8) L/min following placebo pretreatment and to 17.9 (10.2-25.7) L/min following 50 mg tianeptine pretreatment (mean difference between treatments 4.2 (-11.5-3.0) L/min, p = 0.070). Intravenous tianeptine in the measured concentration range of 500 to 2,000 ng/ml did not stimulate ventilation but instead worsened remifentanil-induced respiratory depression: tianeptine 9.6 ± 0.8 L/min versus placebo 15.0 ± 0.9 L/min, mean difference 5.3 L/min, 95% CI 2.5-8.2 L/min; p = 0.001, after 1 hour of treatment. CONCLUSIONS Neither oral nor intravenous tianeptine were respiratory stimulants. Intravenous tianeptine over the concentration range of 500-2000 ng/mL worsened respiratory depression induced by remifentanil.
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Affiliation(s)
- Hyke Algera
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Margot Roozekrans
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Anesthesiology, Noordwest Ziekenhuisgroep, location Alkmaar, Alkmaar, the Netherlands
| | | | | | | | | | | | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.,PainLess Foundation, Leiden, the Netherlands
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van Heijster S, Janssen J, Sarton E, Niesters M, Dahan A. [Postoperative opioid overdose due to patient-controlled analgesia by proxy]. Ned Tijdschr Geneeskd 2020; 164:D5084. [PMID: 33332033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Patient-controlled analgesia (PCA) is a popular and efficacious form of postoperative pain relief that, however, is not without complications. Here we describe a 73-year-old Somalian male patient that underwent abdominal surgery and received intravenous morphine PCA for postoperative pain relief. Due to his inability to speak the native language, his son served as interpreter. On the day after surgery, the patient was found unresponsive by the nursing staff with an oxygen saturation of 91%. He was treated with naloxone and transferred to a medium care facility. The son indicated that he had operated the PCA system at regular intervals over the last 12 hours. The dangers of PCA and PCA by proxy in particular are discussed. In this case, the language barrier, and possibly cultural differences and health illiteracy may have contributed to the PCA by proxy.
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Affiliation(s)
| | | | - E Sarton
- LUMC, afd. Anesthesiologie, Leiden
| | | | - A Dahan
- LUMC, afd. Anesthesiologie, Leiden
- Contact: A. Dahan
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van Dam CJ, Algera MH, Olofsen E, Aarts L, Smith T, Velzen MV, Sarton E, Niesters M, Dahan A. Opioid utility function: methods and implications. Ann Palliat Med 2020; 9:528-536. [DOI: 10.21037/apm.2019.10.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 10/26/2019] [Indexed: 11/06/2022]
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Pietersen LC, Sarton E, Alwayn I, Lam HD, Putter H, van Hoek B, Braat AE. Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation. Liver Transpl 2019; 25:1690-1699. [PMID: 31276282 DOI: 10.1002/lt.25592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/06/2019] [Indexed: 01/13/2023]
Abstract
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
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Affiliation(s)
- Lars Cornelis Pietersen
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian Alwayn
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hwai-Ding Lam
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andries Erik Braat
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Jonkman K, van Rijnsoever E, Olofsen E, Aarts L, Sarton E, van Velzen M, Niesters M, Dahan A. Esketamine counters opioid-induced respiratory depression. Br J Anaesth 2018; 120:1117-1127. [DOI: 10.1016/j.bja.2018.02.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 01/09/2023] Open
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Jonkman K, van der Schrier R, van Velzen M, Aarts L, Olofsen E, Sarton E, Niesters M, Dahan A. Differential role of nitric oxide in the psychedelic symptoms induced by racemic ketamine and esketamine in human volunteers. Br J Anaesth 2018; 120:1009-1018. [DOI: 10.1016/j.bja.2018.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/08/2018] [Accepted: 01/29/2018] [Indexed: 12/21/2022] Open
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Dahan A, Dunne A, Swartjes M, Proto PL, Heij L, Vogels O, van Velzen M, Sarton E, Niesters M, Tannemaat MR, Cerami A, Brines M. Erratum to: ARA 290 Improves Symptoms in Patients with Sarcoidosis-Associated Small Nerve Fiber Loss and Increases Corneal Nerve Fiber Density. Mol Med 2016; 22:674. [DOI: 10.2119/molmed.2013.00122.erratum] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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16
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Dahan A, Dunne A, Swartjes M, Proto PL, Heij L, Vogels O, van Velzen M, Sarton E, Niesters M, Tannemaat MR, Cerami A, Brines M. ARA 290 improves symptoms in patients with sarcoidosis-associated small nerve fiber loss and increases corneal nerve fiber density. Mol Med 2013; 19:334-45. [PMID: 24136731 DOI: 10.2119/molmed.2013.00122] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/08/2013] [Indexed: 01/09/2023] Open
Abstract
Small nerve fiber loss and damage (SNFLD) is a frequent complication of sarcoidosis that is associated with autonomic dysfunction and sensory abnormalities, including pain syndromes that severely degrade the quality of life. SNFLD is hypothesized to arise from the effects of immune dysregulation, an essential feature of sarcoidosis, on the peripheral and central nervous systems. Current therapy of sarcoidosis-associated SNFLD consists primarily of immune suppression and symptomatic treatment; however, this treatment is typically unsatisfactory. ARA 290 is a small peptide engineered to activate the innate repair receptor that antagonizes inflammatory processes and stimulates tissue repair. Here we show in a blinded, placebo-controlled trial that 28 d of daily subcutaneous administration of ARA 290 in a group of patients with documented SNFLD significantly improves neuropathic symptoms. In addition to improved patient-reported symptom-based outcomes, ARA 290 administration was also associated with a significant increase in corneal small nerve fiber density, changes in cutaneous temperature sensitivity, and an increased exercise capacity as assessed by the 6-minute walk test. On the basis of these results and of prior studies, ARA 290 is a potential disease-modifying agent for treatment of sarcoidosis-associated SNFLD.
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Affiliation(s)
- Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ann Dunne
- Araim Pharmaceuticals, Ossining, New York, United States of America
| | - Maarten Swartjes
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paolo L Proto
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lara Heij
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Oscar Vogels
- Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anthony Cerami
- Araim Pharmaceuticals, Ossining, New York, United States of America Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Michael Brines
- Araim Pharmaceuticals, Ossining, New York, United States of America
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Niesters M, Aarts L, Sarton E, Dahan A. Influence of ketamine and morphine on descending pain modulation in chronic pain patients: a randomized placebo-controlled cross-over proof-of-concept study. Br J Anaesth 2013; 110:1010-6. [PMID: 23384733 DOI: 10.1093/bja/aes578] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Descending inhibition of pain, part of the endogenous pain modulation system, is important for normal pain processing. Dysfunction is associated with various chronic pain states. Here, the effect of ketamine and morphine on descending inhibition is examined using the conditioned pain modulation (CPM) paradigm in chronic neuropathic pain patients. METHODS CPM responses were obtained in 10 adult neuropathic pain subjects (two men/eight women). All subjects had peripheral neuropathy as defined by abnormal quantitative sensory testing. The effects of S(+)-ketamine (0.57 mg kg(-1) h(-1) for 1 h) and morphine (0.065 mg kg(-1) h(-1) for 1 h) were tested in a randomized, placebo-controlled double-blind study. CPM was measured at baseline and 100 min after the start of treatment and was induced by immersion of the leg into a cold-water bath. The test stimulus was a 30 s static thermal stimulus to the skin of the forearm. RESULTS Without treatment, no CPM was detectable. Treatment with ketamine, morphine, and placebo produced CPM responses of 40.2 (10.9)%, 28.5 (7.0)%, and 22.1 (12.0)%, respectively (for all treatments, CPM effect P<0.05), with no statistical difference in the magnitude of CPM among treatments. The magnitude of CPM correlated positively with the magnitude and duration of spontaneous pain relief. CONCLUSIONS The observed treatment effects in chronic pain patients suggest a role for CPM engagement in analgesic efficacy of ketamine, morphine, and placebo treatment.
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Affiliation(s)
- M Niesters
- Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Boom M, Niesters M, Sarton E, Aarts L, W. Smith T, Dahan A. Non-Analgesic Effects of Opioids: Opioid-induced Respiratory Depression. Curr Pharm Des 2012; 18:5994-6004. [DOI: 10.2174/138161212803582469] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 05/24/2012] [Indexed: 11/22/2022]
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Olofsen E, Noppers I, Niesters M, Kharasch E, Aarts L, Sarton E, Dahan A. Estimation of the contribution of norketamine to ketamine-induced acute pain relief and neurocognitive impairment in healthy volunteers. Anesthesiology 2012; 117:353-64. [PMID: 22692377 DOI: 10.1097/aln.0b013e31825b6c91] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The N-methyl-D-aspartate receptor antagonist ketamine is metabolized in the liver into its active metabolite norketamine. No human data are available on the relative contribution of norketamine to ketamine-induced analgesia and side effects. One approach to assess the ketamine and norketamine contributions is by measuring the ketamine effect at varying ketamine and norketamine plasma concentrations using the CYP450 inducer rifampicin. METHODS In 12 healthy male volunteers the effect of rifampicin versus placebo pretreatment on S-ketamine-induced analgesia and cognition was quantified; the S-ketamine dosage was 20 mg/h for 2 h. The relative ketamine and norketamine contribution to effect was estimated using a linear additive population pharmacokinetic-pharmacodynamic model. RESULTS S-ketamine produced significant analgesia, psychotropic effects (drug high), and cognitive impairment (including memory impairment and reduced psychomotor speed, reaction time, and cognitive flexibility). Modeling revealed a negative contribution of S-norketamine to S-ketamine- induced analgesia and absence of contribution to cognitive impairment. At ketamine and norketamine effect concentrations of 100 ng/ml and 50 ng/ml, respectively, the ketamine contribution to analgesia is -3.8 cm (visual analog pain score) versus a contribution of norketamine of +1.5 cm, causing an overall effect of -2.3 cm. The blood-effect site equilibration half-life ranged from 0 (cognitive flexibility) to 11.8 (pain intensity) min and was 6.1 min averaged across all endpoints. CONCLUSIONS This first observation that norketamine produces effects in the opposite direction of ketamine requires additional proof. It can explain the observation of ketamine-related excitatory phenomena (such as hyperalgesia and allodynia) upon the termination of ketamine infusions.
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Affiliation(s)
- Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Olofsen E, Sigtermans M, Noppers I, Niesters M, Mooren R, Bauer M, Aarts L, Sarton E, Dahan A. The dose-dependent effect of S(+)-ketamine on cardiac output in healthy volunteers and complex regional pain syndrome type 1 chronic pain patients. Anesth Analg 2012; 115:536-46. [PMID: 22575567 DOI: 10.1213/ane.0b013e31825496f6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ketamine is used as an analgesic for treatment of acute and chronic pain. While ketamine has a stimulatory effect on the cardiovascular system, little is known about the concentration-effect relationship. We examined the effect of S(+)-ketamine on cardiac output in healthy volunteers and chronic pain patients using a pharmacokinetic-pharmacodynamic modeling approach. METHODS In 10 chronic pain patients (diagnosed with complex regional pain syndrome type 1 [CRPS1] with a mean age 43.2 ± 13 years, disease duration 8.4 years, range 1.1 to 21.7 years) and 12 healthy volunteers (21.3 ± 1.6 years), 7 increasing IV doses of S(+)-ketamine were given over 5 minutes at 20-minute intervals starting with 1.5 mg with 1.5-mg increments. Cardiac output (CO) was calculated from the arterial pressure curve obtained from an arterial catheter in the radial artery. Ketamine and norketamine plasma concentrations were measured. A novel pharmacokinetic-pharmacodynamic model was constructed to quantify the direct stimulatory effect of ketamine on CO and the following adaptation/inhibition. RESULTS Significant differences in pharmacokinetic estimates were observed between study groups with 15% and 40% larger S(+)-ketamine S(+)-norketamine concentrations in healthy volunteers compared to CRPS1 patients. S(+)-ketamine had a dose-dependent stimulatory effect on CO in patients and volunteers. After infusion an inhibitory effect on CO was observed. Pharmacodynamic model parameters did not differ between CRPS1 patients and healthy volunteers. The concentration of S(+)-ketamine causing a 1 L/min increase in CO was 243 ± 54 ng/mL with an onset/offset half-life of 1.3 ± 0.21 minutes. The inhibitory component was slow (time constant of 67.2 ± 17.0 minutes). CONCLUSIONS S(+)-ketamine pharmacokinetics but not pharmacodynamics differed between study populations, related to differences in disease state (CRPS1 or not) or age. The dose-dependent effect of S(+)-ketamine on CO was well described by the biphasic dynamic model. The effect of S(+)-ketamine on CO was similar between study groups with respect to its stimulatory and inhibitory components, despite group differences in age and health.
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Affiliation(s)
- Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Dahan A, Noppers I, Niesters M, Aarts L, Sarton E, Drewes AM. S(+)-Ketamine analgesic drug dose. Pain 2012. [DOI: 10.1016/j.pain.2011.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Sigtermans M, Noppers I, Sarton E, Bauer M, Mooren R, Olofsen E, Dahan A. An observational study on the effect of S(+)-ketamine on chronic pain versus
experimental acute pain in Complex Regional Pain Syndrome type 1 patients. Eur J Pain 2012; 14:302-7. [DOI: 10.1016/j.ejpain.2009.05.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 05/16/2009] [Accepted: 05/23/2009] [Indexed: 01/17/2023]
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Abstract
IMPORTANCE OF THE FIELD Worldwide the number of patients affected by chronic pain is growing and conventional treatment is often insufficient. Recently the importance of the N-methyl-d-aspartate receptor (NMDAR) in the mechanisms and maintenance of chronic pain was established. Ketamine (introduced in the 1960s as an anesthetic) is the most studied NMDAR antagonist in the treatment of various chronic pain syndromes. AREAS COVERED IN THIS REVIEW The pharmacology, safety and toxicology of ketamine are discussed. Further, electronic databases were scanned for prospective, randomized controlled trials that assessed ketamine's analgesic effect in patients with chronic pain. The focus of this review is on trials published after 2008 that applied long-term intravenous infusions. WHAT THE READER WILL GAIN While most studies on intravenous ketamine show acute analgesic effects, three recent trials on long-term ketamine treatment (days to weeks) demonstrate the effectiveness of ketamine in causing long-term (months) relief of chronic pain. Despite these positive results, further studies are needed on safety/toxicity issues. Other administration modes are less effective in causing long-term pain relief. TAKE HOME MESSAGE There is now evidence form a limited number of studies that pain relief lasting for months is observed after long-term intravenous ketamine infusion, suggesting a modulatory effect of ketamine in the process of chronic pain, possibly via blockade of upregulated NMDAR.
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Affiliation(s)
- Ingeborg Noppers
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Boom M, Grefkens J, van Dorp E, Olofsen E, Lourenssen G, Aarts L, Dahan A, Sarton E. Opioid chronopharmacology: influence of timing of infusion on fentanyl's analgesic efficacy in healthy human volunteers. J Pain Res 2010; 3:183-90. [PMID: 21197322 PMCID: PMC3004635 DOI: 10.2147/jpr.s13616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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: 09/22/2010] [Indexed: 11/28/2022] Open
Abstract
Chronopharmacology studies the effect of the timing of drug administration on drug effect. Here, we measured the influence of 4 timing moments on fentanyl-induced antinociception in healthy volunteers. Eight subjects received 2.1 μg/kg intravenous fentanyl at 2 pm and 2 am, with at least 2 weeks between occasions, and 8 others at 8 am and 8 pm. Heat pain measurements using a thermode placed on the skin were taken at regular intervals for 3 hours, and verbal analog scores (VAS) were then obtained. The data were modeled with a sinusoid function using the statistical package NONMEM. The study was registered at trialregister.nl under number NTR1254. A significant circadian sinusoidal rhythm in the antinociceptive effect of fentanyl was observed. Variations were observed for peak analgesic effect, duration of effect, and the occurrence of hyperalgesia. A peak in pain relief occurred late in the afternoon (5:30 pm) and a trough in the early morning hours (5:30 am). The difference between the peak and trough in pain relief corresponds to a difference in VAS of 1.3–2 cm. Only when given at 2 am, did fentanyl cause a small but significant period of hyperalgesia following analgesia. No significant changes were observed for baseline pain, sedation, or the increase in end-tidal CO2. The variations in fentanyl’s antinociceptive behavior are well explained by a chronopharmacodynamic effect originating at the circadian clock in the hypothalamus. This may be a direct effect through shared pathways of the circadian and opioid systems or an indirect effect via diurnal variations in hormones or endogenous opioid peptides that rhythmically change the pain response and/or analgesic response to fentanyl.
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Affiliation(s)
- Merel Boom
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Niesters M, Dahan A, Kest B, Zacny J, Stijnen T, Aarts L, Sarton E. Do sex differences exist in opioid analgesia? A systematic review and meta-analysis of human experimental and clinical studies. Pain 2010; 151:61-68. [PMID: 20692097 DOI: 10.1016/j.pain.2010.06.012] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 05/17/2010] [Accepted: 06/11/2010] [Indexed: 12/21/2022]
Abstract
Although a contribution of sex in opioid efficacy has garnered much attention, the confirmation and direction of any such difference remain elusive. We performed a systematic review of the available literature on sex differences in μ and mixed μ/κ opioid effect on acute and experimental pain. Fifty unique studies (including three unpublished studies) were included in the analyses. Across the 25 clinical studies on μ-opioids there was no significant sex-analgesia association. Restricting the analysis to patient-controlled analgesia (PCA) studies (irrespective of the opioid) yielded greater analgesia in women (n=15, effect size 0.22, 95% c.i. 0.02-0.42, P=0.028). Further restricting the analysis to PCA morphine studies yielded an even greater effect in women (n=11, effect size=0.36, 95% c.i. 0.17-0.56, P=0.003). Meta-regression indicated that the longer the duration of PCA, the difference in effect between the sexes further increased. Across experimental pain studies on μ-opioids women had greater antinociception from opioids (n=11, effect size=0.35; 95% c.i. 0.01-0.69, P=0.047), which was predominantly due to 6 morphine studies. Female patients had greater μ/κ opioid analgesia (n=7, effect size 0.84; 95% c.i. 0.25-1.43, P=0.005), but no sex-analgesia association was present in experimental studies (n=7). Sex differences exist in morphine-induced analgesia in both experimental pain studies and clinical PCA studies, with greater morphine efficacy in women. The data on non-morphine μ and mixed μ/κ-opioids are less convincing and require further study.
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Affiliation(s)
- Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands Department of Psychology and Center for Developmental Neurosciences, The College of Staten Island, City University New York, NY 10314, USA Doctoral Program in Neuropsychology, Queens College, City University New York, Flushing, NY 11367, USA Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA Department of Medical Statistics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Abstract
It is widely reported that analgesic drugs acting at mu, kappa, and delta opioid-receptors display quantitative and qualitative differences in effect in males and females. These sex-related differences are not restricted to the analgesic/antinociceptive properties of opioids, but are also present in opioid-induced side effects, such as changes in respiration, locomotor activity, learning/memory, addiction, and changes in the cardiovascular system. An increasing number of well-controlled animal and human studies directly examining the issue of sex in the potency of opioids show that, although sex may affect opioid analgesia, the direction and magnitude of sex differences depend on many interacting variables. These include those specific to the drug itself, such as dose, pharmacology, and route and time of administration, and those particular to the subject, such as species, type of pain, genetics, age, and gonadal/hormonal status. In the current review, we systematically present these animal and human studies and discuss the data in relation to the depending variables. Although the observed sex differences in opioid effect may be clinically relevant, lack of knowledge on other factors involved in the large variability in patient opioid analgesic sensitivity should compel practitioners to customize their dosing regimens based on individual requirements.
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Affiliation(s)
- Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, P5-Q, 2300 RC Leiden, The Netherlands.
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Yassen A, Olofsen E, van Dorp E, Sarton E, Teppema L, Danhof M, Dahan A. Mechanism-based pharmacokinetic-pharmacodynamic modelling of the reversal of buprenorphine-induced respiratory depression by naloxone : a study in healthy volunteers. Clin Pharmacokinet 2008; 46:965-80. [PMID: 17922561 DOI: 10.2165/00003088-200746110-00004] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Respiratory depression is a potentially life-threatening adverse effect of opioid therapy. It has been postulated that the difficulty of reversing buprenorphine-induced respiratory depression is caused by slow receptor association-dissociation kinetics at the opioid mu receptor. The aim of this study was to characterise the pharmacodynamic interaction between buprenorphine and naloxone in healthy volunteers. METHODS A competitive pharmacodynamic interaction model was proposed to describe and predict the time course of naloxone-induced reversal of respiratory depression. The model was identified using data from an adaptive naloxone dose-selection trial following intravenous administration of buprenorphine 0.2mg/70kg or 0.4mg/70kg. RESULTS The pharmacokinetics of naloxone and buprenorphine were best described by a two-compartment model and a three-compartment model, respectively. A combined biophase equilibration-receptor association-dissociation pharmacodynamic model described the competitive interaction between buprenorphine and naloxone at the opioid mu receptor. For buprenorphine, the values of the rate constants of receptor association (k(on)) and dissociation (k(off)) were 0.203 mL/ng/min and 0.0172 min(-)(1), respectively. The value of the equilibrium dissociation constant (K(D)) was 0.18 nmol/L. The half-life (t((1/2))) of biophase equilibration was 173 minutes. These estimates of the pharmacodynamic parameters are similar to values obtained in the absence of naloxone co-administration. For naloxone, the half-life of biophase distribution was 6.5 minutes. CONCLUSIONS Because of the slow receptor association-dissociation kinetics of buprenorphine in combination with the fast elimination kinetics of naloxone, naloxone is best administered as a continuous infusion for reversal of buprenorphine-induced respiratory depression.
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Affiliation(s)
- Ashraf Yassen
- Division of Pharmacology, Leiden/Amsterdam Centre for Drug Research, Leiden, The Netherlands
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Sarton E, Teppema L, Dahan A. Naloxone Reversal of Opioid-Induced Respiratory Depression with Special Emphasis on the Partial Agonist/Antagonist Buprenorphine. Integration in Respiratory Control 2008; 605:486-91. [DOI: 10.1007/978-0-387-73693-8_85] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Ringers J, Dubbeld J, Baranski AG, Coenraad M, Sarton E, Schaapherder AFM, van Hoek B. Reuse of auxiliary liver grafts in second recipients with chronic liver disease. Am J Transplant 2007; 7:2615-8. [PMID: 17927609 DOI: 10.1111/j.1600-6143.2007.01959.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We describe the first cases of reuse of auxiliary liver grafts for orthotopic transplantation in chronic liver disease. A reduced liver graft (segments 2, 3, half of 4) was first transplanted auxiliary for acute liver failure using a new technique. After regeneration of both native liver and graft, the auxiliary graft was removed and immunosuppression discontinued in the first recipients. After informed consent of donors and recipients, both auxiliary grafts were then orthotopically transplanted into second recipients. Both grafts function normally. Reuse of auxiliary grafts may help to reduce the shortage or liver grafts available for transplantation.
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Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Van Dorp E, Los M, Dirven P, Sarton E, Valk P, Teppema L, Stienstra R, Dahan A. Inspired carbon dioxide during hypoxia: effects on task performance and cerebral oxygen saturation. Aviat Space Environ Med 2007; 78:666-72. [PMID: 17679563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Exposure to a hypoxic environment has a deleterious effect on physiological and mental functions. We studied the effect of added inspired CO2 during artificially induced hypoxic normobaric hypoxia (oxygen saturation approximately 80%) on complex task performance. METHODS In random order, 22 healthy volunteers were exposed to 3 gas mixtures for 50 min each: sham hypoxia (SH, PetO2 103 mmHg without inspired CO2); isocapnic hypoxia (IH, PetO2 approximately 40 mmHg, PetcO2 clamped to 0.4 mmHg above resting values); and poikilocapnic hypoxia (PH, PetO2 approximately 40 mmHg; no inspired CO2). Brain oxygenation was measured using near infrared spectroscopy. During minutes 25-45 of hypoxia, subjects performed vigilance and task performance tests used in aviation research: the Vigilance and Tracking test and the Multi-Attribute Task battery (MAT-bat). The tests varied in difficulty with the tracking tests considered most difficult. RESULTS PetCO2 levels differed significantly among groups: IH 42.8 +/- 0.7, SH 39.0 +/- 0.7, and PH 36.8 +/- 0.7 mmHg. Brain oxygenation levels were significantly higher during IH than PH (62.2 +/- 1.0 vs. 59.1 +/- 1.3%). The results of the performance tests indicated a negative effect of PH vs. SH on most function tests. For the Tracking test of the MAT-bat, performance was worst during PH, but returned to baseline during IH. DISCUSSION We demonstrate the ability of added inspired CO2 to improve performance during hypoxia by preventing PH-associated hypocapnia-induced vasoconstriction of brain blood vessels. Our results are relevant to aerospace medicine and other circumstances in which complex tasks are performed in a hypoxic environment such as mountain climbing and working in confined spaces.
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Affiliation(s)
- Eveline Van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Yassen A, Olofsen E, Romberg R, Sarton E, Teppema L, Danhof M, Dahan A. Mechanism-based PK/PD Modeling of the Respiratory Depressant Effect of Buprenorphine and Fentanyl in Healthy Volunteers. Clin Pharmacol Ther 2007; 81:50-8. [PMID: 17185999 DOI: 10.1038/sj.clpt.6100025] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The objective of this study was to characterize the pharmacokinetic/pharmacodynamic (PK/PD) relationship of buprenorphine and fentanyl for the respiratory depressant effect in healthy volunteers. Data on the time course of the ventilatory response at a fixed P(ET)CO(2) of 50 mm Hg and P(ET)O(2) of 110 mm Hg following intravenous administration of buprenorphine and fentanyl were obtained from two phase I studies (50 volunteers received buprenorphine: 0.05-0.6 mg/70 kg and 24 volunteers received fentanyl: 0.075-0.5 mg/70 kg). The PK/PD correlations were analyzed using nonlinear mixed effects modeling. A two- and three-compartment pharmacokinetic model characterized the time course of fentanyl and buprenorphine concentration, respectively. Three structurally different PK/PD models were evaluated for their appropriateness to describe the time course of respiratory depression: (1) a biophase distribution model with a fractional sigmoid E(max) pharmacodynamic model, (2) a receptor association/dissociation model with a linear transduction function, and (3) a combined biophase distribution-receptor association/dissociation model with a linear transduction function. The results show that for fentanyl hysteresis is entirely determined by the biophase distribution kinetics, whereas for buprenorphine hysteresis is caused by a combination of biophase distribution kinetics and receptor association/dissociation kinetics. The half-time values of biophase equilibration (t(1/2, k(eo))) were 16.4 and 75.3 min for fentanyl and buprenorphine, respectively. In addition, for buprenorphine, the value of k(on) was 0.246 ml/ng/min and the value of k(off) was 0.0102 min(-1). The concentration-effect relationship of buprenorphine was characterized by a ceiling effect at higher concentrations (intrinsic activity alpha=0.56, 95% confidence interval (CI): 0.50-0.62), whereas fentanyl displayed full respiratory depressant effect (alpha=0.91, 95% CI: 0.19-1.62).
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Affiliation(s)
- A Yassen
- Department of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
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Ringers J, Baranski AG, Dubbeld J, Sarton E, Veenendaal RA, Schaapherder AFM, van der Linden E, Terpstra OT, van Hoek B. A novel technique for auxiliary partial liver transplantation with reno-portal anastomosis and avoidance of the hepatoduodenal ligament. Am J Transplant 2006; 6:2802-8. [PMID: 17049066 DOI: 10.1111/j.1600-6143.2006.01538.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.
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Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden Univ ersity Medical Center, Leiden, The Netherlands
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Abstract
BACKGROUND The objective of this investigation was to examine the ability of the opioid antagonist naloxone to reverse respiratory depression produced by the mu-opioid analgesic, buprenorphine, in healthy volunteers. The studies were designed in light of the claims that buprenorphine is relatively resistant to the effects of naloxone. METHODS In a first attempt, the effect of an intravenous bolus dose of 0.8 mg naloxone was assessed on 0.2 mg buprenorphine-induced respiratory depression. Next, the effect of increasing naloxone doses (0.5-7 mg, given over 30 min) on 0.2 mg buprenorphine-induced respiratory depression was tested. Subsequently, continuous naloxone infusions were applied to reverse respiratory depression from 0.2 and 0.4 mg buprenorphine. All doses are per 70 kg. Respiration was measured against a background of constant increased end-tidal carbon dioxide concentration. RESULTS An intravenous naloxone dose of 0.8 mg had no effect on respiratory depression from buprenorphine. Increasing doses of naloxone given over 30 min produced full reversal of buprenorphine effect in the dose range of 2-4 mg naloxone. Further increasing the naloxone dose (doses of 5 mg or greater) caused a decline in reversal activity. Naloxone bolus doses of 2-3 mg, followed by a continuous infusion of 4 mg/h, caused full reversal within 40-60 min of both 0.2 and 0.4 mg buprenorphine-induced respiratory depression. CONCLUSIONS Reversal of buprenorphine effect is possible but depends on the buprenorphine dose and the correct naloxone dose window. Because respiratory depression from buprenorphine may outlast the effects of naloxone boluses or short infusions, a continuous infusion of naloxone may be required to maintain reversal of respiratory depression.
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Affiliation(s)
- Eveline van Dorp
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands
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Abstract
In searching for an analgesic with fewer side effects than morphine, examination of morphine's active metabolite, morphine-6-glucuronide (M6G), suggests that M6G is possibly such a drug. In contrast to morphine, M6G is not metabolized but excreted via the kidneys and exhibits enterohepatic cycling, as it is a substrate for multidrug resistance transporter proteins in the liver and intestines. M6G exhibits a delay in its analgesic effect (blood-effect site equilibration half-life 4-8 h), which is partly related to slow passage through the blood-brain barrier and distribution within the brain compartment. In humans, M6G's potency is just half of that of morphine. In clinical studies, M6G is well tolerated and produces adequate and long lasting postoperative analgesia. At analgesic doses, M6G causes similar reduction of the ventilatory response to CO2 as an equianalgesic dose of morphine but significantly less depression of the hypoxic ventilatory response. Preliminary data indicate that M6G is associated less than morphine with nausea and vomiting, causing 50% and 75% less nausea in postoperative and experimental settings, respectively. Although the data from the literature are very promising, we believe that more studies are necessary before we may conclude that M6G is superior to morphine for postoperative analgesia.
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Affiliation(s)
- Eveline L A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Yassen A, Olofsen E, Romberg R, Sarton E, Danhof M, Dahan A. Mechanism-based Pharmacokinetic–Pharmacodynamic Modeling of the Antinociceptive Effect of Buprenorphine in Healthy Volunteers. Anesthesiology 2006; 104:1232-42. [PMID: 16732095 DOI: 10.1097/00000542-200606000-00019] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
The objective of this investigation was to characterize the pharmacokinetic-pharmacodynamic relation of buprenorphine's antinociceptive effect in healthy volunteers.
Methods
Data on the time course of the antinociceptive effect after intravenous administration of 0.05-0.6 mg/70 kg buprenorphine in healthy volunteers was analyzed in conjunction with plasma concentrations by nonlinear mixed-effects analysis.
Results
A three-compartment pharmacokinetic model best described the concentration time course. Four structurally different pharmacokinetic-pharmacodynamic models were evaluated for their appropriateness to describe the time course of buprenorphine's antinociceptive effect: (1) E(max) model with an effect compartment model, (2) "power" model with an effect compartment model, (3) receptor association-dissociation model with a linear transduction function, and (4) combined biophase equilibration/receptor association-dissociation model with a linear transduction function. The latter pharmacokinetic-pharmacodynamic model described the time course of effect best and was used to explain time dependencies in buprenorphine's pharmacodynamics. The model converged, yielding precise estimation of the parameters characterizing hysteresis and the relation between relative receptor occupancy and antinociceptive effect. The rate constant describing biophase equilibration (k(eo)) was 0.00447 min(-1) (95% confidence interval, 0.00299-0.00595 min(-1)). The receptor dissociation rate constant (k(off)) was 0.0785 min(-1) (95% confidence interval, 0.0352-0.122 min(-1)), and k(on) was 0.0631 ml . ng(-1) . min(-1) (95% confidence interval, 0.0390-0.0872 ml . ng(-1) . min(-1)).
Conclusion
This is consistent with observations in rats, suggesting that the rate-limiting step in the onset and offset of the antinociceptive effect is biophase distribution rather than slow receptor association-dissociation. In the dose range studied, no saturation of receptor occupancy occurred explaining the lack of a ceiling effect for antinociception.
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Affiliation(s)
- Ashraf Yassen
- Leiden/Amsterdam Center for Drug Research, Division of Pharmacology, Gorlaeus Laboratories, The Netherlands
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Dahan A, Yassen A, Romberg R, Sarton E, Teppema L, Olofsen E, Danhof M. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth 2006; 96:627-32. [PMID: 16547090 DOI: 10.1093/bja/ael051] [Citation(s) in RCA: 233] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We measured the effect of two weight adjusted i.v. doses (0.2 mg per 70 kg and 0.4 mg per 70 kg) of the potent opioid buprenorphine on analgesia and respiratory depression in healthy volunteers. The aim of the study was to compare buprenorphine's behaviour with respect to the occurrence of ceiling (or apparent maximum) in these typical micro-opioid protein-(MOP) receptor effects. METHODS Ten subjects (5 males) received 0.2 mg per 70 kg, 10 others (5 males) 0.4 mg per 70 kg i.v. buprenorphine. Steady-state inspired minute ventilation at a fixed end-tidal Pco(2) of 7 kPa was measured before drug infusion and at regular intervals after drug infusion. Experimental pain was induced using transcutaneous electrical stimulation and a gradually increasing current. Pain tolerance was measured at regular intervals before and after drug infusion. The studies lasted 8 h. RESULTS After infusion of the drug ventilation showed a rapid decline and reached peak depression between 150 and 180 min after drug administration. This effect was dose-independent with respect to timing and magnitude. At peak respiratory depression minute ventilation was 13.1 (sd 1.8) litre min(-1) in the 0.2 mg group vs 12.0 (sd 1.3) litre min(-1) in the 0.4 mg group (n.s.). At buprenorphine 0.2 mg a small short-lived analgesic effect was observed with a maximum increase in pain tolerance current of 6.7 (sd 2.8) mA occurring at 75 min after drug administration. Peak analgesic effect was 29% above baseline current. In contrast, buprenorphine 0.4 mg caused a large and long-lived analgesic effect with a maximum increase in pain tolerance current of 23.8 (sd 7.4) mA occurring at 130 min after drug administration. Peak analgesic effect was 160% above baseline current (0.4 vs 0.2 mg, P<0.01). CONCLUSIONS While buprenorphine's analgesic effect increased significantly, respiratory depression was similar in magnitude and timing for the two doses tested. We conclude that over the dose range tested buprenorphine displays ceiling in respiratory effect but none in analgesic effect.
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Affiliation(s)
- A Dahan
- Department of Anesthesiology, Leiden University Medical Center PO Box 9600, 2300 RC Leiden, The Netherlands.
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Dahan A, Yassen A, Bijl H, Romberg R, Sarton E, Teppema L, Olofsen E, Danhof M. Comparison of the respiratory effects of intravenous buprenorphine and fentanyl in humans and rats. Br J Anaesth 2005; 94:825-34. [PMID: 15833777 DOI: 10.1093/bja/aei145] [Citation(s) in RCA: 197] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is evidence from animal studies suggesting the existence of a ceiling effect for buprenorphine-induced respiratory depression. To study whether an apparent ceiling effect exists for respiratory depression induced by buprenorphine, we compared the respiratory effects of buprenorphine and fentanyl in humans and rats. METHODS In healthy volunteers, the opioids were infused i.v. over 90 s and measurements of minute ventilation at a fixed end-tidal PCO2 of 7 kPa were obtained for 7 h. Buprenorphine doses were 0.7, 1.4, 4.3 and 8.6 microg kg(-1) (n=20 subjects) and fentanyl doses 1.1, 2.1, 2.9, 4.3 and 7.1 microg kg(-1) (n=21). Seven subjects received placebo. In rats, both opioids were infused i.v. over 20 min, and arterial PCO2 was measured 5, 10, 15 and 20 min after the start of fentanyl infusion and 30, 150, 270 and 390 min after the start of buprenorphine infusion. Doses tested were buprenorphine 0, 100, 300, 1000 and 3000 microg kg(-1) and fentanyl 0, 50, 68 and 90 microg kg(-1). RESULTS In humans, fentanyl produced a dose-dependent depression of minute ventilation with apnoea at doses > or = 2.9 microg kg(-1); buprenorphine caused depression of minute ventilation which levelled off at doses > or = 3.0 microg kg(-1) to about 50% of baseline. In rats, the relationship of arterial PCO2 and fentanyl dose was linear, with maximum respiratory depression at 20 min (maximum PaCO2 8.0 kPa). Irrespective of the time at which measurements were obtained, buprenorphine showed a non-linear effect on PaCO2, with a ceiling effect at doses > 1.4 microg kg(-1). The effect on PaCO2 was modest (maximum value measured, 5.5 kPa). CONCLUSIONS Our data confirm a ceiling effect of buprenorphine but not fentanyl with respect to respiratory depression.
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Affiliation(s)
- A Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
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Zelcer N, van de Wetering K, Hillebrand M, Sarton E, Kuil A, Wielinga PR, Tephly T, Dahan A, Beijnen JH, Borst P. Mice lacking multidrug resistance protein 3 show altered morphine pharmacokinetics and morphine-6-glucuronide antinociception. Proc Natl Acad Sci U S A 2005; 102:7274-9. [PMID: 15886284 PMCID: PMC1091780 DOI: 10.1073/pnas.0502530102] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [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] [Indexed: 02/01/2023] Open
Abstract
Glucuronidation is a major detoxification pathway for endogenous and exogenous compounds in mammals that results in the intracellular formation of polar metabolites, requiring specialized transporters to cross biological membranes. By using morphine as a model aglycone, we demonstrate that multidrug resistance protein 3 (MRP3/ABCC3), a protein present in the basolateral membrane of polarized cells, transports morphine-3-glucuronide (M3G) and morphine-6-glucuronide in vitro. Mrp3(-/-) mice are unable to excrete M3G from the liver into the bloodstream, the major hepatic elimination route for this drug. This results in increased levels of M3G in liver and bile, a 50-fold reduction in the plasma levels of M3G, and in a major shift in the main disposition route for morphine and M3G, predominantly via the urine in WT mice but via the feces in Mrp3(-/-) mice. The pharamacokinetics of injected morphine-glucuronides are altered as well in the absence of Mrp3, and this results in a decreased antinociceptive potency of injected morphine-6-glucuronide.
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Affiliation(s)
- Noam Zelcer
- Division of Molecular Biology and Center of Biomedical Genetics, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Dahan A, Romberg R, Teppema L, Sarton E, Bijl H, Olofsen E. Simultaneous measurement and integrated analysis of analgesia and respiration after an intravenous morphine infusion. Anesthesiology 2004; 101:1201-9. [PMID: 15505457 DOI: 10.1097/00000542-200411000-00021] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To study the influence of morphine on chemical control of breathing relative to the analgesic properties of morphine, the authors quantified morphine-induced analgesia and respiratory depression in a single group of healthy volunteers. Both respiratory and pain measurements were performed over single 24-h time spans. METHODS Eight subjects (four men, four women) received a 90-s intravenous morphine infusion; eight others (four men, four women) received a 90-s placebo infusion. At regular time intervals, respiratory variables (breathing at a fixed end-tidal partial pressure of carbon dioxide of 50 mmHg and the isocapnic acute hypoxic response), pain tolerance (derived from a transcutaneous electrical acute pain model), and arterial blood samples were obtained. Data acquisition continued for 24 h. Population pharmacokinetic (sigmoid Emax)-pharmacodynamic models were applied to the respiratory and pain data. The models are characterized by potency parameters, shape parameters (gamma), and blood-effect site equilibration half-lives. All collected data were analyzed simultaneously using the statistical program NONMEM. RESULTS Placebo had no systematic effect on analgesic or respiratory variables. Morphine potency parameter and blood-effect site equilibration half-life did not differ significantly among the three measured effect parameters (P > 0.01). The integrated NONMEM analysis yielded a potency parameter of 32 +/- 1.4 nm (typical value +/- SE) and a blood-effect site equilibration half-life of 4.4 +/- 0.3 h. Parameter gamma was 1 for hypercapnic and hypoxic breathing but 2.4 +/- 0.7 for analgesia (P < 0.01). CONCLUSIONS Our data indicate that systems involved in morphine-induced analgesia and respiratory depression share important pharmacodynamic characteristics. This suggests similarities in central mu-opioid analgesic and respiratory pathways (e.g., similarities in mu-opioid receptors and G proteins). The clinical implication of this study is that after morphine administration, despite lack of good pain relief, moderate to severe respiratory depression remains possible.
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Affiliation(s)
- Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands.
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Romberg R, Olofsen E, Sarton E, Teppema L, Dahan A. Increased Margin of Safety of Morphine-6-glucuronide Relative to Morphine. Anesthesiology 2004; 100:1622; author reply 1622-3. [PMID: 15166596 DOI: 10.1097/00000542-200406000-00048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Romberg R, Olofsen E, Sarton E, den Hartigh J, Taschner PEM, Dahan A. Pharmacokinetic-pharmacodynamic modeling of morphine-6-glucuronide-induced analgesia in healthy volunteers: absence of sex differences. Anesthesiology 2004; 100:120-33. [PMID: 14695733 DOI: 10.1097/00000542-200401000-00021] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Morphine-6-glucuronide (M6G) is a metabolite of morphine and a micro-opioid agonist. To quantify the potency and speed of onset-offset of M6G and explore putative sex dependency, the authors studied the pharmacokinetics and pharmacodynamics of M6G in volunteers using a placebo-controlled, randomized, double-blind study design. METHODS Ten men and 10 women received 0.3 mg/kg intravenous M6G and placebo (two thirds of the dose as bolus, one third as a continuous infusion over 1 h) on separate occasions. For 7 h, pain tolerance was measured using gradually increasing transcutaneous electrical stimulation, and blood samples were obtained. A population pharmacokinetic (inhibitory sigmoid Emax)-pharmacodynamic analysis was used to analyze M6G-induced changes in tolerated stimulus intensity. The improvement in model fits by inclusion of covariate sex was tested for significance. P values less than 0.01 were considered significant. Taking into account previous morphine data, a predictive pharmacokinetic-pharmacodynamic model was constructed to determine the contribution of M6G to morphine analgesia. RESULTS M6G concentrations did not differ between men and women. M6G caused analgesia significantly greater than that observed with placebo (P < 0.01). The M6G analgesia data were well described by the pharmacokinetic-pharmacodynamic model. The M6G effect site concentration causing a 25% increase in current (C25) was 275 +/- 135 nm (population estimate +/- SE), the blood effect site equilibration half-life was 6.2 +/- 3.3 h, and the steepness parameter was 0.71 +/- 0.18. Intersubject variability was 167% for C25 and 218% for the effect half-life. None of the model parameters showed sex dependency. CONCLUSIONS A cumulative dose of 0.3 mg/kg M6G, given over 1 h, produces long-term analgesia greater than that observed with placebo, with equal dynamics (potency and speed of onset-offset) in men and women. Possible causes for the great intersubject response variability, such as genetic polymorphism of the micro-opioid receptor and placebo-related phenomena, are discussed. The predictive pharmacokinetic-pharmacodynamic model was applied successfully and was used to estimate M6G analgesia after morphine in patients with normal and impaired renal function.
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Affiliation(s)
- Raymonda Romberg
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands
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Dahan A, Romberg R, Sarton E, Teppema L. Antioxidants Prevent Blunting of Hypoxic Ventilatory Response by Low-Dose Halothane. Advances in Experimental Medicine and Biology 2004; 551:217-20. [PMID: 15602967 DOI: 10.1007/0-387-27023-x_33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Romberg R, Sarton E, Teppema L, Matthes HWD, Kieffer BL, Dahan A. Comparison of morphine-6-glucuronide and morphine on respiratory depressant and antinociceptive responses in wild type and μ-opioid receptor deficient mice. Br J Anaesth 2003; 91:862-70. [PMID: 14633759 DOI: 10.1093/bja/aeg279] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Morphine-6-glucuronide (M6G) is a metabolite of morphine with potent analgesic properties. The influence of M6G on respiratory and antinociceptive responses was investigated in mice lacking the micro -opioid receptor (MOR) and compared with morphine. METHODS Experiments were performed in mice lacking exon 2 of the MOR (n=18) and their wild type (WT) littermates (n=20). The influence of M6G and morphine on respiration was measured using whole body plethysmography during three elevations of inspired carbon dioxide. Antinociception was assessed using tail flick and hotplate tests. RESULTS In WT but not null mutant mice, a dose-dependent depression of the slope of the ventilatory carbon dioxide response was observed after M6G and morphine. Similarly, both opioids were devoid of antinociceptive effects in null mutant mice, but showed potent dose-dependent analgesia in WT animals. Potency differences between M6G and morphine in WT mice were of the same order of magnitude for analgesia and respiration. CONCLUSIONS The data indicate that the desired (antinociceptive) and undesired (respiratory depression) effects of M6G and morphine are linked to the same gene product; that is the MOR. Other opioid- and non-opioid-receptor systems may play a minor role in the actions of M6Gs and morphine. The clinical implications of our findings are that any agent acting at the MOR will invariably cause (potent) analgesia in combination with (variable) respiratory depression.
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MESH Headings
- Analgesics, Opioid/pharmacology
- Animals
- Carbon Dioxide
- Dose-Response Relationship, Drug
- Female
- Male
- Mice
- Mice, Knockout
- Morphine/pharmacology
- Morphine Derivatives/pharmacology
- Pain Threshold/drug effects
- Plethysmography, Whole Body
- Reaction Time/drug effects
- Receptors, Opioid, mu/deficiency
- Receptors, Opioid, mu/genetics
- Receptors, Opioid, mu/physiology
- Respiratory Insufficiency/chemically induced
- Respiratory Insufficiency/physiopathology
- Sensation/drug effects
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Affiliation(s)
- R Romberg
- Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Romberg R, Olofsen E, Sarton E, Teppema L, Dahan A. Pharmacodynamic Effect of Morphine-6-glucuronide versus Morphine on Hypoxic and Hypercapnic Breathing in Healthy Volunteers. Anesthesiology 2003; 99:788-98. [PMID: 14508308 DOI: 10.1097/00000542-200310000-00008] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Morphine-6-glucuronide (M6G) is an active metabolite of morphine that is generally associated with less respiratory depression than morphine. Because M6G will be on the market in the near future, the authors assessed the time profile and relative potency of M6G's effect versus morphine's effect on carbon dioxide-driven and hypoxic breathing.
Methods
In nine healthy female volunteers, the effects of 0.2 mg/kg intravenous M6G, 0.13 mg/kg intravenous morphine, and intravenous placebo were tested on ventilation at a fixed end-tidal pressure of carbon dioxide (Petco2) of 45 mmHg (Vi45) and on the acute hypoxic ventilatory response (AHR). All subjects participated in all three arms of the study. Respiratory studies were performed at 1-h intervals for 7 h after drug infusion. The data were analyzed using a population dose-driven approach, which uses a dose rate in function of time as input function driving the pharmacodynamics, and a population pharmacokinetic-pharmacodynamic (PK/PD) approach in which fixed pharmacokinetic parameter values from the literature were used as input function to the respiratory model. From the latter analysis, the authors obtained the blood effect-site equilibration half-life (t1/2ke0) and the effect-site concentration producing 25% depression of Vi45 and AHR (C25). Values reported are mean +/- SE.
Results
Placebo had no effect on Vi45 or AHR over time. Both analysis approaches yielded good descriptions of the data with comparable model parameters. M6G PK/PD model parameters for Vi45 were t1/2ke0 2.1 +/- 0.2 h and C25 528 +/- 88 nm and for AHR were t1/2ke0 1.0 +/- 0.1 h and C25 873 +/- 81 nm. Morphine PK/PD model parameters for Vi45 were t1/2ke0 3.8 +/- 0.9 h and C25 28 +/- 6 nm and for AHR were t1/2ke0 4.3 +/- 0.6 h and C25 16 +/- 2 nm.
Conclusions
Morphine is more potent in affecting hypoxic ventilatory control than M6G, with a potency ratio ranging from 1:19 for Vi45 to 1:50 for AHR. At drug concentrations causing 25% depression of Vi45, M6G caused only 15% depression of AHR, whereas morphine caused greater than 50% depression of AHR. Furthermore, the speed of onset/offset of M6G is faster than morphine by a factor of approximately 2. The authors discuss some of the possible mechanisms for the observed differences in opioid behavior.
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Affiliation(s)
- Raymonda Romberg
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands
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Nieuwenhuijs DJF, Olofsen E, Romberg RR, Sarton E, Ward D, Engbers F, Vuyk J, Mooren R, Teppema LJ, Dahan A. Response surface modeling of remifentanil-propofol interaction on cardiorespiratory control and bispectral index. Anesthesiology 2003; 98:312-22. [PMID: 12552187 DOI: 10.1097/00000542-200302000-00008] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Since propofol and remifentanil are frequently combined for monitored anesthesia care, we examined the influence of the separate and combined administration of these agents on cardiorespiratory control and bispectral index in humans. METHODS The effect of steady-state concentrations of remifentanil and propofol was assessed in 22 healthy male volunteer subjects. For each subject, measurements were obtained from experiments using remifentanil alone, propofol alone, and remifentanil plus propofol (measured arterial blood concentration range: propofol studies, 0-2.6 microg/ml; remifentanil studies, 0-2.0 ng/ml). Respiratory experiments consisted of ventilatory responses to three to eight increases in end-tidal Pco2 (Petco2). Invasive blood pressure, heart rate, and bispectral index were monitored concurrently. The nature of interaction was assessed by response surface modeling using a population approach with NONMEM. Values are population estimate plus or minus standard error. RESULTS A total of 94 responses were obtained at various drug combinations. When given separately, remifentanil and propofol depressed cardiorespiratory variables in a dose-dependent fashion (resting V(i) : 12.6 +/- 3.3% and 27.7 +/- 3.5% depression at 1 microg/ml propofol and 1 ng/ml remifentanil, respectively; V(i) at fixed Petco of 55 mmHg: 44.3 +/- 3.9% and 57.7 +/- 3.5% depression at 1 microg/ml propofol and 1 ng/ml remifentanil, respectively; blood pressure: 9.9 +/- 1.8% and 3.7 +/- 1.1% depression at 1 microg/ml propofol and 1 ng/ml remifentanil, respectively). When given in combination, their effect on respiration was synergistic (greatest synergy observed for resting V(i)). The effects of both drugs on heart rate and blood pressure were modest, with additive interactions when combined. Over the dose range studied, remifentanil had no effect on bispectral index even when combined with propofol (inert interaction). CONCLUSIONS These data show dose-dependent effects on respiration at relatively low concentrations of propofol and remifentanil. When combined, their effect on respiration is strikingly synergistic, resulting in severe respiratory depression.
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Affiliation(s)
- Elise Sarton
- Department of Anaesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Teppema LJ, Nieuwenhuijs D, Sarton E, Romberg R, Olievier CN, Ward DS, Dahan A. Antioxidants prevent depression of the acute hypoxic ventilatory response by subanaesthetic halothane in men. J Physiol 2002; 544:931-8. [PMID: 12411535 PMCID: PMC2290639 DOI: 10.1113/jphysiol.2002.025999] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We studied the effect of the antioxidants (AOX) ascorbic acid (2 g, I.V.) and alpha-tocopherol (200 mg, P.O.) on the depressant effect of subanaesthetic doses of halothane (0.11 % end-tidal concentration) on the acute isocapnic hypoxic ventilatory response (AHR), i.e. the ventilatory response upon inhalation of a hypoxic gas mixture for 3 min (leading to a haemoglobin saturation of 82 +/- 1.8 %) in healthy male volunteers. In the first set of protocols, two groups of eight subjects each underwent a control hypoxic study, a halothane hypoxic study and finally a halothane hypoxic study after pretreatment with AOX (study 1) or placebo (study 2). Halothane reduced the AHR by more than 50 %, from 0.79 +/- 0.31 to 0.36 +/- 0.14 l min(-1) %(-1) in study 1 and from 0.79 +/- 0.40 to 0.36 +/- 0.19 l min(-1) %(-1) in study 2, P < 0.01 for both. Pretreatment with AOX prevented this depressant effect of halothane in the subjects of study 1 (AHR returning to 0.77 +/- 0.32 l min(-1) %(-1), n.s. from control), whereas placebo (study 2) had no effect (AHR remaining depressed at 0.36 +/- 0.27 l min(-1) %(-1), P < 0.01 from control). In a second set of protocols, two separate groups of eight subjects each underwent a control hypoxic study, a sham halothane hypoxic study and finally a sham halothane hypoxic study after pretreatment with AOX (study 3) or placebo (study 4). In studies 3 and 4, sham halothane did not modify the control hypoxic response, nor did AOX (study 3) or placebo (study 4). The 95 % confidence intervals for the ratio of hypoxic sensitivities, (AOX + halothane) : halothane in study 1 and (AOX - sham halothane) : sham halothane in study 3, were [1.7, 2.6] and [1.0, 1.2], respectively. Because the antioxidants prevented the reduction of the acute hypoxic response by halothane, we suggest that this depressant effect may be caused by reactive species produced by a reductive metabolism of halothane during hypoxia or that a change in redox state of carotid body cells by the antioxidants prevented or changed the binding of halothane to its effect site. Our findings may also suggest that reactive species have an inhibiting effect on the acute hypoxic ventilatory response.
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Affiliation(s)
- Luc J Teppema
- Department of Physiology, Leiden University Medical Centre, The Netherlands.
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Sarton E, Teppema L, Nieuwenhuijs D, Matthes HW, Kieffer B, Dahan A. Opioid effect on breathing frequency and thermogenesis in mice lacking exon 2 of the mu-opioid receptor gene. Adv Exp Med Biol 2002; 499:399-404. [PMID: 11729915 DOI: 10.1007/978-1-4615-1375-9_64] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- E Sarton
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands
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Abstract
Ventilatory control in humans depends on complex mechanisms which aim to maintain a cellular CO2-, O2- and H(+)-homeostasis under physiological conditions. This regulation is based on chemical control which predominantly acts via peripheral chemoreceptors in the carotid bodies and central chemoreceptors in the ventral medulla of the brainstem on the one hand, and behavioural control on the other, by which it is possible to adapt respiration to conditions of daily living. The influence of anaesthesia and related conditions may depress respiration and have a sustained effect on ventilatory control. Perioperative respiratory depression remains a serious clinical problem in perioperative medicine. This review will give an overview of ventilatory control and discuss the most relevant responses, describe the effects of pain, anaesthetics and opioids on ventilatory control and their interaction. The current body of knowledge is put into perspective to identify patients at risk for perioperative respiratory depression.
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Affiliation(s)
- E Sarton
- Abteilung für Anästhesiologie, Universitätsklinik Leiden, Leiden, Niederlande
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