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1.
Medicine (Baltimore) ; 98(35): e17012, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31464960

RESUMO

BACKGROUND: Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients. METHODS: The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 µg·kg for 10 minutes, then adjusted to 0.2-0.7 µg·kg·hour), group D2 (n = 68, DEX infusion at 1 µg·kg for 10 minutes, then adjusted to 0.2-0.7 µg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 µg·kg for 10 minutes, then adjusted to 0.2-0.4 µg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded. RESULTS: Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ±â€Š3.23 vs 12.42 ±â€Š2.12 vs 13.88 ±â€Š3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05). CONCLUSIONS: During percutaneous tracheostomy, compared with sufentanil, DEX (1 µg·kg for 10 minutes, then adjusted to 0.2-0.7 µg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Sufentanil/administração & dosagem , Traqueostomia/métodos , Adulto , Tosse/prevenção & controle , Dexmedetomidina/efeitos adversos , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Hipnóticos e Sedativos/efeitos adversos , Laringismo/prevenção & controle , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sufentanil/efeitos adversos
2.
J Zoo Wildl Med ; 50(2): 457-460, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31260214

RESUMO

Two anesthetic protocols in adult giraffe were compared by retrospective study. Thirteen anesthesia records for medetomidine-ketamine (MK) and seven for medetomidine-ketamine with a potent opioid (MKO) were evaluated for differences in demographic, behavioral, drug, and respiratory parameters. Giraffe stood significantly more quickly with MKO vs MK though MK animals were physically restrained to preclude premature standing as part of normal recovery practices (5.5 min vs 21.4 min, P = 0.01). Regurgitation was recorded in 5/13 and resedation in 4/13 MK animals. The range of values for blood lactate was higher in MKO (5.18-11.25 mM/L) than in MK giraffe (0.78-6.08 mM/L). Despite limitations of a retrospective study, both MK and MKO giraffe anesthesia protocols exhibit benefits and side effects. Awareness and management of these factors will improve outcomes until standardized, prospective studies of giraffe immobilization offer more comprehensive guidance on protocol selection.


Assuntos
Analgésicos Opioides/farmacologia , Anestesia/veterinária , Girafas , Ketamina/farmacologia , Medetomidina/farmacologia , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestésicos Dissociativos/administração & dosagem , Anestésicos Dissociativos/efeitos adversos , Anestésicos Dissociativos/farmacologia , Animais , Feminino , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/farmacologia , Injeções Intramusculares , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Masculino , Medetomidina/administração & dosagem , Medetomidina/efeitos adversos , Estudos Retrospectivos
3.
Br J Anaesth ; 123(3): 298-308, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277837

RESUMO

BACKGROUND: Emergence from sedation entails rapid increase in the levels of both awareness and wakefulness, the two axes of consciousness. Functional MRI (fMRI) studies of emergence from sedation often focus on the recovery period, with no description of the moment of emergence. We hypothesised that by focusing on the moment of emergence, novel insights, primarily about subcortical activity and increased wakefulness, will be gained. METHODS: We conducted a resting state fMRI analysis of 17 male subjects (20-40 yr old) gradually entering into and emerging from deep sedation (average computed propofol concentrations of 2.41 and 1.11 µg ml-1, respectively), using target-controlled infusion of propofol. RESULTS: Functional connectivity analysis revealed a robust spatiotemporal signature of return of consciousness, in which subcortical seeds showed transient positive correlations that rapidly turned negative shortly after emergence. Elements of this signature included four components of the ascending reticular activating system: the ventral tegmentum area, the locus coeruleus, median raphe, and the mammillary body. The involvement of the rostral dorsolateral pontine tegmentum, which is specifically impaired in comatose patients with pontine lesions, in emergence was previously unknown. CONCLUSIONS: Emergence from propofol sedation is characterised, and possibly driven, by a transient activation of brainstem loci. Some of these loci are known components of the ascending reticular activating system, whereas an additional locus was found that is also impaired in comatose patients.


Assuntos
Córtex Cerebral/efeitos dos fármacos , Sedação Profunda/métodos , Hipnóticos e Sedativos/farmacologia , Propofol/farmacologia , Adulto , Período de Recuperação da Anestesia , Mapeamento Encefálico/métodos , Tronco Encefálico/diagnóstico por imagem , Tronco Encefálico/efeitos dos fármacos , Tronco Encefálico/fisiologia , Córtex Cerebral/diagnóstico por imagem , Córtex Cerebral/fisiologia , Estado de Consciência/efeitos dos fármacos , Esquema de Medicação , Humanos , Hipnóticos e Sedativos/administração & dosagem , Imagem por Ressonância Magnética , Masculino , Rede Nervosa/efeitos dos fármacos , Propofol/administração & dosagem , Adulto Jovem
5.
Eur J Pharm Sci ; 135: 77-82, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31102650

RESUMO

Cytochrome P450 3A (CYP3A) isozymes metabolize about 50% of all marketed drugs. Their activity can be modulated up to 400-fold, which has great impact on individual dose requirements for CYP3A substrates. The activity of CYP3A can be monitored using the CYP3A substrate midazolam. To avoid pharmacological midazolam effects during phenotyping, a microdosing approach is preferred. However, the preparation of microdosed dosage forms remains a challenge. Fast dissolving buccal films are therefore proposed to facilitate this task. It was the aim of the present study to clinically evaluate a novel buccal film containing microdoses of midazolam for assessment of CYP3A activity. In a randomized, open-label crossover design, the pharmacokinetics of midazolam and its active hydroxy-metabolite, 1'­OH­midazolam, was assessed in 12 healthy volunteers after administration of single microdoses of midazolam (30 µg) as buccal film or buccal solution. The buccal film did rapidly disintegrate, was well tolerated, and no adverse events occurred. The film and the solution showed very similar midazolam plasma concentration-time profiles but were not bioequivalent according to EMA and FDA guidelines. For Cmax, AUC0-12h, and AUC0-∞ the geometric mean ratios of film to solution, with their 90% confidence intervals in parentheses, were 1.15 (1.00-1.32), 1.16 (1.04-1.28), and 1.19 (1.08-1.31), respectively. As a proxy for CYP3A activity, molar metabolic ratios of midazolam and 1'­OH­midazolam were analyzed over time, which revealed good correlations already 1 h or 2 h after application of the film or the solution, respectively. The tested midazolam buccal film is a convenient dosage form that facilitates administration of a phenotyping probe considerably and may potentially be used in special patient populations such as pediatric patients. Clinical Trials.gov Identifier: NCT03204578.


Assuntos
Ansiolíticos/farmacocinética , Citocromo P-450 CYP3A/metabolismo , Hipnóticos e Sedativos/farmacocinética , Midazolam/farmacocinética , Administração Bucal , Ansiolíticos/administração & dosagem , Ansiolíticos/efeitos adversos , Área Sob a Curva , Estudos Cross-Over , Composição de Medicamentos , Interações de Medicamentos , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Masculino , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Absorção pela Mucosa Oral
6.
J Zoo Wildl Med ; 50(1): 167-175, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-31120675

RESUMO

The intracoelomic implantation of satellite transmitters is associated with lower survival in surf scoters (Melanitta perspicillata) compared with other species of diving ducks, potentially due to physiologic alterations following physical exertion and stress caused by handling and confinement. The effect of intranasal administration of midazolam hydrochloride on survival of surf scoters surgically implanted with intracelomic transmitters was evaluated. Shortly after their capture in Forestville (QC, Canada) in the fall of 2013, 26 randomly selected adult female surf scoters were administered midazolam hydrochloride (4.6-5.9 mg/kg) intranasally. The same volume of saline (1 mL) was given to another 26 adult female surf scoters as a control group. All birds were surgically implanted with an intracoelomic transmitter equipped with a percutaneous antenna. Transmitters were programmed to transmit 2 hr each day for 30 days after implantation, and mortality was estimated for each group using the telemetry data. The association between the administration of midazolam and survival was assessed while controlling for other factors such as body mass, transmitter-mass-to-body-mass ratio, hematocrit, total solids, and duration of surgery, anesthesia, and confinement. The odds of presumed death in the saline group were 5.3 times higher than in the midazolam group (95% confidence interval: 1.7, 19.0; P = 0.004). The presumed mortality at 30 days for the midazolam group (23%) was lower than for the saline group (61%). No other variable was significantly associated with survival. These results suggest that sedation with midazolam shortly after capture increased the postsurgical survival of female surf scoters surgically implanted with intracoelomic transmitters.


Assuntos
Ansiolíticos/administração & dosagem , Patos/fisiologia , Hipnóticos e Sedativos/administração & dosagem , Longevidade/efeitos dos fármacos , Midazolam/administração & dosagem , Procedimentos Cirúrgicos Operatórios/veterinária , Telemetria/veterinária , Administração Intranasal/veterinária , Animais , Animais Selvagens/fisiologia , Feminino , Próteses e Implantes/veterinária , Telemetria/instrumentação
8.
Medicine (Baltimore) ; 98(21): e15615, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31124940

RESUMO

RATIONALE: The palliative sedation therapy is defined as the intentional reduction of the alert state, using pharmacological tools. Propofol is a short-acting general anesthetic agent, widely used for induction and maintenance of general anesthesia and rarely employed in palliative care. PATIENT CONCERNS AND DIAGNOSES: This case series describes 5 pediatric oncology inpatients affected by relapsed/refractory solid tumors received palliative sedation using propofol alone or in combination with opioids and benzodiazepines. INTERVENTIONS AND OUTCOMES: Five terminally ill children affected by solid tumors received propofol-based palliative sedation. All patients were previously treated with opioids and some of them reduced the consumption of these drugs after propofol starting. In all cases the progressive increase of the level of sedation until the death has been the only effective measure of control of refractory symptoms related todisease progression and psychological suffering. LESSONS: We evaluated the quality of propofol-based palliative sedation in a series of pediatric oncology patients with solid tumors at the end of their life. We concluded that propofol represents an effective and tolerable adjuvant drug for the management of intractable suffering and a practicable strategy for palliative sedation in pediatric oncology patients at the end of their life.


Assuntos
Hipnóticos e Sedativos/administração & dosagem , Neoplasias/terapia , Cuidados Paliativos/métodos , Propofol/administração & dosagem , Assistência Terminal/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Neoplasias/complicações , Dor/tratamento farmacológico , Dor/etiologia , Estudos Retrospectivos , Estresse Psicológico/tratamento farmacológico , Estresse Psicológico/etiologia
9.
Medicine (Baltimore) ; 98(21): e15709, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31124948

RESUMO

BACKGROUND: It is uncertain if dexmedetomidine has more favorable pharmacokinetic profile than the traditional sedative drug propofol in patients who undergo endovascular therapy for acute stroke. We conducted a prospective randomized control trial to compare the safety and efficacy of dexmedetomidine with propofol for patients undergoing endovascular therapy for acute stroke. METHODS: A total of 80 patients who met study inclusion criteria were received either propofol (n = 45) or dexmedetomidine (n = 35) between January 2016 and August 2018. We recorded the favorable neurologic outcome (modified Rankin score <3) both at discharge and 3 months after stroke, National Institute of Health Stroke scale (NIHSS) at 48 hours post intervention, modified thrombolysis in myocardial infarction score on digital subtraction angiography, intraprocedural hemodynamics, recovery time, relevant time intervals, satisfaction score of the surgeon, mortality, and complications. RESULTS: There were no significant differences between the 2 groups (P > .05) with respect to heart rate, respiratory rate, and SPO2 during the procedure. The mean arterial pressure (MAP) was significantly low in the propofol group until 15 minutes after anesthesia was induced. No difference was recorded between the groups at the incidence of fall in MAP >20%, MAP >40% and time spent with MAP fall >20% from baseline MAP. In the propofol group, the time spent with MAP fall >40% from baseline MAP was significantly long (P < .05). Midazolam and fentanyl were similar between the 2 groups (P > .05) that used vasoactive drugs. The time interval from stroke onset to CT room, from stroke onset to groin puncture, and from stroke onset to recanalization/end of the procedure, was not significantly different between the 2 groups (P > .05). The recovery time was longer in the dexmedetomidine group (P < .05). There was no difference between the groups with respect to complications, favorable neurological outcome, and mortality both at hospital discharge and 3 months later, successful recanalization and NIHSS score after 48 hours (P > .05). However, the satisfaction score of the surgeon was higher in the dexmedetomidine group (P < .05). CONCLUSIONS: Dexmedetomidine was undesirable than propofol as a sedative agent during endovascular therapy in patients with acute stroke for a long-term functional outcome, though the satisfaction score of the surgeon was higher in the dexmedetomidine group.


Assuntos
Dexmedetomidina/uso terapêutico , Procedimentos Endovasculares/métodos , Hipnóticos e Sedativos/uso terapêutico , Propofol/uso terapêutico , Acidente Vascular Cerebral/cirurgia , Idoso , Período de Recuperação da Anestesia , Dexmedetomidina/administração & dosagem , Dexmedetomidina/efeitos adversos , Feminino , Fibrinolíticos/administração & dosagem , Hemodinâmica , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Propofol/administração & dosagem , Propofol/efeitos adversos , Estudos Prospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Vasoconstritores/administração & dosagem
10.
Vet Anaesth Analg ; 46(3): 325-334, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30935776

RESUMO

OBJECTIVE: To determine the required rate of a detomidine infusion (loading dose 5 µg kg-1; initial rate 12.5 µg kg-1 hour-1) added to a constant infusion of methadone (0.2 mg kg-1; 0.05 mg kg-1 hour-1) for sedation in standing horses and ponies undergoing elective surgeries with appropriate local anaesthetic techniques. STUDY DESIGN: Prospective, clinical study. ANIMALS: Adult, healthy, client-owned, non-food-producing horses or ponies sedated for elective standing surgeries longer than 45 minutes. METHODS: At baseline (in the stables before administration of sedative agents), at 10 minutes after sedation and every 5 minutes thereafter, ataxia, sedation and surgical condition were evaluated; each scored 0-3. These scores were used to adjust the detomidine administration rate using the Ghent Sedation Algorithm. A 10 cm visual analogue scale (VAS) was used by the main surgeon at the end of the procedure to evaluate the surgical conditions. Heart rate, systolic arterial pressure and respiratory frequency were also recorded at each time point. For statistical analysis, anova for normal, Kruskal-Wallis H-test for non-normal variables, and Mann-Whitney U test for VAS were used. RESULTS: From the 42 horses/ponies included in this study, 28 underwent dental procedures and 14 other types of procedures. Overall, dental procedures required higher mean detomidine rates compared with other types of surgeries (16.9 ± 4.5 versus 9.0 ± 1.9 µg kg-1 hour-1) (p < 0.001). Dental procedures were assigned similar VAS scores, median (range), of 7.8 (5.8-10) with other procedures, 8.7 (2.8-10). Cardiovascular changes were not clinically significant. No signs or behavioural changes of abdominal pain were observed postoperatively. CONCLUSIONS AND CLINICAL RELEVANCE: Satisfactory surgical conditions were achieved using a combination of detomidine and methadone infusions with locoregional anaesthesia, with no adverse effects. Dental procedures required higher detomidine dose rates compared with other surgeries.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Anestesia/veterinária , Anestésicos Combinados/administração & dosagem , Cavalos/cirurgia , Hipnóticos e Sedativos/administração & dosagem , Imidazóis/administração & dosagem , Metadona/administração & dosagem , Anestesia Dentária/veterinária , Animais , Infusões Intravenosas/veterinária , Estudos Prospectivos
11.
Vet J ; 247: 57-60, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30971352

RESUMO

Intramuscular (IM) injections may be more aversive than subcutaneous (SC) and intra-nasal (IN) routes. Xylazine is commonly used as a sedative for cattle, but little is known about efficacy via these routes. The first aim of this study was to compare efficacy using these different routes of administration. The second aim was to determine whether a simple behavioural assessment was associated with physiological responses. Using a within-subject design, the effects of xylazine (0.2mg/kg) were assessed in 12 Holstein calves (6.2±2.8days old) administered via IM, SC, IN drip tube (IN) and IN spray (INs). Sedation was assessed on a scale based on recumbency and eyeball rotation. Heart rate (HR), respiratory rate (RR) and rectal temperature (RT) were recorded for 2h after treatment. Intramuscular and SC routes produced an equivalent mean±standard deviation (SD) onset of sedation (IM: 4.8±2.0min vs. SC: 6.8±2.2min) and duration of sedation (IM: 60.3±25.5min vs. SC: 61.9±23.3min). IN treatments produced less consistent and longer onset times (IN: 33.0±26.9min, and INs: 31.0±15.1min) and a shorter duration of sedation (IN: 42.0±31.5min, and INs: 26.7±21.8min). Behaviour scores were moderately correlated with changes in HR (r=-0.52; CI -0.60, -0.43) and changes in RR (r=-0.42; CI -0.51, -0.32), but not with changes in RT (r=-0.09, CI -0.20, 0.02). We conclude that SC is a viable alternative to the more aversive IM route, and that a simple clinical scale can be useful for assessing xylazine sedation.


Assuntos
Bovinos , Hipnóticos e Sedativos/farmacologia , Xilazina/farmacologia , Animais , Comportamento Animal , Vias de Administração de Medicamentos , Feminino , Hipnóticos e Sedativos/administração & dosagem , Masculino , Distribuição Aleatória , Xilazina/administração & dosagem
12.
Clin Interv Aging ; 14: 571-575, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30936687

RESUMO

Objective: Postoperative delirium (POD) is a serious complication in elderly patients undergoing cardiac surgery. This study was aimed at investigating the effect of perioperative administration of dexmedetomidine for general anesthesia maintenance on occurrence and duration of POD in elderly patients after cardiac surgery. Methods: One hundred and sixty-four patients were enrolled after cardiac surgery between June 2009 and December 2016. Patients were assigned by a computer-generated randomization sequence in a 1:1 ratio to receive dexmedetomidine general anesthesia maintenance or propofol general anesthesia maintenance. POD was assessed every day with confusion assessment method for intensive care units (ICU) during the first 5 postoperative days. Results: There was no significance in incidence of POD between the dexmedetomidine group and the propofol group (P=0.0758). In patients treated with dexmedetomidine, the median onset time of delirium was delayed (second day vs first day) and the duration of delirium reduced (2 days vs 3 days) when compared with propofol-treated patients. The dexmedetomidine-treated patients also displayed a lower VAS score and less opiate analgesic consumption. No difference was observed in respect to other postoperative outcomes. Conclusion: For elderly patients, perioperative administration of dexmedetomidine reduced incidence, delayed onset and shortened duration of POD after cardiac surgery.


Assuntos
Delírio/prevenção & controle , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Idoso , Analgésicos , Analgésicos Opioides/efeitos adversos , Anestesia Geral/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Masculino , Período Pós-Operatório , Propofol/administração & dosagem , Fatores de Tempo
14.
Agri ; 31(2): 86-92, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30995329

RESUMO

OBJECTIVES: The aim of this prospective, randomized study was to investigate the effect of magnesium added to midazolam on the hemodynamics, transition time to a T-piece, mechanical ventilation duration, additional sedative-analgesic requirement using bispectral index (BIS) monitorization and sedation scales. METHODS: Fifty critically ill patients receiving mechanical ventilation support in the intensive care unit were randomly assigned to 2 groups. Group I received a 0.03-0.3 mg/kg bolus loading dose+0.03-02 mg/kg/hour midazolam infusion; Group II received a 2 g bolus at 30 minutes, 16 mg/24-hour magnesium infusion+0.03-02 mg/kg/hour midazolam infusion. BIS levels and sedation levels were continuously monitored. RESULTS: The duration of mechanical ventilation in Group I was longer than that of Group II (31+-12 hours, 19+-11 hours, respectively; p<0.01). The length of time to start spontaneous breathing trials with a T-piece was greater in Group I than in Group II (27+-11 hours, 16+-11 hours, respectively; p<0.01). The 48-hour insulin requirement of Group I was greater than that of Group II (p<0.05). CONCLUSION: Adding intravenous magnesium to the traditional sedation protocols in the intensive care unit decreased midazolam use as well as the additional analgesic requirement and mechanical ventilatory support duration without any side effects.


Assuntos
Sedação Consciente , Estado Terminal , Hipnóticos e Sedativos/uso terapêutico , Magnésio/uso terapêutico , Midazolam/uso terapêutico , Respiração Artificial , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Unidades de Terapia Intensiva , Magnésio/administração & dosagem , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
15.
Br J Anaesth ; 122(4): 448-459, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30857601

RESUMO

Propofol infusion syndrome is a rare, potentially fatal condition first described in children in the 1990s and later reported in adults. We provide a narrative review of what is currently known about propofol infusion syndrome, including a structured analysis of all published case reports; child and adult cases were analysed separately as propofol is no longer used for long-term sedation in children. The review contains an update on current knowledge of the pathophysiology of this condition along with recommendations for its diagnosis, prevention, and management. We reviewed 108 publications documenting 168 cases of propofol infusion syndrome. We evaluated clinical features and analysed factors influencing mortality in child and adult cases using separate multivariate analysis models. We used separate multiple linear regression models to analyse relationships between cumulative dose of propofol and the number of features seen and organ systems involved. Lipidaemia, fever, and hepatomegaly occurred more frequently in children than in adults, whilst rhabdomyolysis and hyperkalaemia were more frequent in adults. Mortality from propofol infusion syndrome is independently associated with fever and hepatomegaly in children, and electrocardiogram changes, hypotension, hyperkalaemia, traumatic brain injury, and a mean propofol infusion rate >5 mg kg-1 h-1 in adults. The cumulative dose of propofol was associated with an increased number of clinical features and the number of organ systems involved in adult cases only. Clinicians should consider propofol infusion syndrome in cases of unexplained metabolic acidosis, ECG changes, and rhabdomyolysis. We recommend early consideration of continuous haemofiltration in the management of propofol infusion syndrome.


Assuntos
Anestésicos Intravenosos/administração & dosagem , Síndrome da Infusão de Propofol/diagnóstico , Propofol/administração & dosagem , Fatores Etários , Anestésicos Intravenosos/efeitos adversos , Relação Dose-Resposta a Droga , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Propofol/efeitos adversos , Síndrome da Infusão de Propofol/mortalidade , Fatores de Risco
16.
Br J Anaesth ; 122(4): 480-489, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30857604

RESUMO

BACKGROUND: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. METHODS: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. RESULTS: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04]. CONCLUSIONS: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00590707.


Assuntos
Sedação Consciente/métodos , Sedação Profunda/métodos , Delírio do Despertar/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Raquianestesia , Sedação Consciente/efeitos adversos , Relação Dose-Resposta a Droga , Delírio do Despertar/etiologia , Delírio do Despertar/mortalidade , Feminino , Força da Mão , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Estimativa de Kaplan-Meier , Masculino , Maryland/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Propofol/administração & dosagem , Propofol/efeitos adversos , Recuperação de Função Fisiológica
17.
Medicine (Baltimore) ; 98(13): e14990, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30921212

RESUMO

RATIONALE: Complex regional pain syndrome (CRPS) usually occurs after trauma and surgery but can also occur spontaneously. There are various known pathophysiology and treatment protocols for CRPS. However, there is no established treatment guideline. Although physical therapy is known as the first line treatment for CRPS, performing physical therapy is difficult due to severe pain. This case reports the first case with positive effect of physical therapy under sedation that allowed early physical therapy. PATIENT CONCERNS: A 19-year old female had her right elbow area slightly hit by someone else, after which it began to swell and become more painful. Active and passive range of motion (ROM) of the right upper extremity gradually decreased through 3 months, and pain and edema worsened. DIAGNOSES: She had allodynia, nonpitting edema, temperature asymmetry, and trophic change in fingernails in the right upper extremity, which met the diagnostic criteria for CRPS. In the 3-phase bone scan, which is a specific tool to diagnose CRPS, there was trace uptake increase in the right elbow and wrist, indicating possibility of CRPS. INTERVENTIONS: Despite conventional treatments such as pharmacologic and interventional therapies, neither pain nor edema subsided. Pain was so severe that it was impossible to apply physical therapy. Therefore, the patient underwent passive ROM exercise in the right upper extremity under sedation for 30 minutes, which was relatively easier due to decreased pain. After 2 days of passive ROM exercise under sedation, the patient was able to receive passive ROM exercise twice daily without sedation for 18 days. OUTCOMES: After 20 days of passive ROM exercise, including 2 days of passive ROM exercise under sedation, the circumference of her right hand decreased by 5 cm, wrist 2 cm, and elbow 6 cm compared to the initial measurement. Numeric pain rating scale improved from 9 to 3, and her manual muscle test marked fair plus from trace, Jebsen-Taylor hand function test score 43 from 0. LESSONS: This case suggests that passive ROM exercise under sedation may be a successful alternative as a treatment when exercise, currently known as a treatment to CRPS, is impossible.


Assuntos
Síndromes da Dor Regional Complexa/reabilitação , Hipnóticos e Sedativos/uso terapêutico , Modalidades de Fisioterapia , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Amplitude de Movimento Articular , Adulto Jovem
18.
Expert Opin Drug Metab Toxicol ; 15(5): 349-351, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30913933

RESUMO

Analgosedation on ECMO is more than the choice of any drug, it has to be context specific. Ketamine may be considered as an adjunctive therapy in patients requiring high-dose opioids and sedatives during ECMO support with difficulty to achieve a target RASS. Considering ketamine provides analgesia while maintaining airway reflexes, it could be useful for early ECMO weaning and use of ECMO in awake, non-intubated, spontaneously breathing patients with respiratory failure ('awake' ECMO), especially for patients having considerable waiting periods while being bridged to transplant. The hemodynamic effects of ketamine may provide the benefit of decreasing vasopressor requirements, thereby potentially improving microcirculation. In this context, the effects on end-organ function and the need for renal replacement therapy should be investigated. Pharmacokinetic and pharmacodynamic studies on ketamine ex- and in vivo are of utmost importance to delineate its pharmacological profile and effectiveness during ECMO therapy and to create admissible future study hypothesis.


Assuntos
Analgésicos/administração & dosagem , Oxigenação por Membrana Extracorpórea/métodos , Ketamina/administração & dosagem , Analgésicos/farmacocinética , Analgésicos/farmacologia , Analgésicos Opioides/administração & dosagem , Animais , Humanos , Hipnóticos e Sedativos/administração & dosagem , Ketamina/farmacocinética , Ketamina/farmacologia
19.
Int J Artif Organs ; 42(5): 233-240, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30819020

RESUMO

OBJECTIVE: Patients on extracorporeal membrane oxygenation are frequently in need for sedation. Use of propofol has been associated with impaired oxygenator function due to adsorption to the membrane as well as lipid load. The aim of our retrospective analysis was to compare two different sedation regimens containing either propofol or midazolam with respect to oxygenator running time. METHODS: Midazolam was used in 73 patients whereas propofol was used in 49 patients, respectively. In the propofol group, veno-arterial-extracorporeal membrane oxygenation was used predominantly (84%), while veno-venous-extracorporeal membrane oxygenation was used more often in the midazolam group (64%). RESULTS: Oxygenator running time until first exchange was 7 days in both groups ( p = 0.759). No statistically significant differences could be observed between the subgroup of patients receiving lipid-free (n = 24) and lipid-containing (n = 31) parenteral nutrition, respectively. Laboratory parameters like triglycerides, free hemoglobin, fibrinogen, platelets, and activated partial thromboplastin time were not significantly different between both sedation regimens ( p = 0.462, p = 0.489, p = 0.960, p = 0.134, and p = 0.843) and were not associated with oxygenator running time. CONCLUSION: The use of propofol as sedative seems suitable in patients undergoing extracorporeal membrane oxygenation therapy.


Assuntos
Sedação Consciente/métodos , Oxigenação por Membrana Extracorpórea , Midazolam , Oxigenadores , Adulto , Idoso , Falha de Equipamento , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Pessoa de Meia-Idade , Propofol/administração & dosagem , Propofol/efeitos adversos , Estudos Retrospectivos
20.
Rev Bras Ter Intensiva ; 31(1): 15-20, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30843950

RESUMO

OBJECTIVE: To describe the incidence of clinical and non-clinical events during intrahospital transport of critically ill patients and to analyze the associated risk factors. METHODS: Cohort study with retrospective data collected from October 2016 to October 2017. All cases of intrahospital transport for diagnostic and therapeutic purposes in a large hospital with six adult intensive care units were analyzed, and the adverse events and related risk factors were evaluated. RESULTS: During the study period, 1,559 intrahospital transports were performed with 1,348 patients, with a mean age of 66 ± 17 years and a mean transport time of 43 ± 34 minutes. During transport, 19.8% of the patients were using vasoactive drugs; 13.7% were under sedation; and 10.6% were under mechanical ventilation. Clinical events occurred in 117 transports (7.5%), and non-clinical events occurred in 125 (8.0%) transports. Communication failures were prevalent; however, the multivariate analysis showed that the use of sedatives, noradrenaline and nitroprusside and a transport time greater than 36.5 minutes were associated with adverse clinical events. The use of dobutamine and a transport time greater than 36.5 minutes were associated with non-clinical events. At the end of transport, 98.1% of the patients presented unchanged clinical conditions compared with baseline. CONCLUSION: Intrahospital transport is related to a high incidence of adverse events, and transport time and the use of sedatives and vasoactive drugs were related to these events.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva , Transporte de Pacientes/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hospitais , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Nitroprussiato/administração & dosagem , Nitroprussiato/efeitos adversos , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Respiração Artificial/efeitos adversos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
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