1
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Payne T, Loadsman JA. Inside the black box: Random effects meta-analysis with zero heterogeneity. J Crit Care 2024; 81:154529. [PMID: 38335863 DOI: 10.1016/j.jcrc.2024.154529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Thomas Payne
- University of Sydney, Faculty of Medicine and Health, Camperdown, Sydney 2006, Australia; The Royal Melbourne Hospital, Parkville, Melbourne 3052, Australia.
| | - John A Loadsman
- University of Sydney, Faculty of Medicine and Health, Camperdown, Sydney 2006, Australia; Royal Prince Alfred Hospital, Department of Anaesthetics, Camperdown, Sydney, 2050, Australia
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2
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Long B, Gottlieb M. Ketamine versus etomidate for induction of intubation in critically ill patients. Acad Emerg Med 2024. [PMID: 38783635 DOI: 10.1111/acem.14941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
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3
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Garnacho-Montero J, Gordillo-Escobar E, Trenado J, Gordo F, Fisac L, García-Prieto E, López-Martin C, Abella A, Jiménez JR, García-Garmendia JL. A Nationwide, Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, Associated Complications, and Outcomes. Crit Care Med 2024; 52:786-797. [PMID: 38259143 DOI: 10.1097/ccm.0000000000006198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVES Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. DESIGN Prospective, observational, and cohort study. SETTING Forty-three Spanish ICU. PATIENTS A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. CONCLUSIONS A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.
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Affiliation(s)
- José Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Elena Gordillo-Escobar
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Josep Trenado
- Servicio Medicina Intensiva UCI-Semicritics, Hospital Universitari MutuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | - Federico Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada-Madrid, Grupo de Investigación en Patología Crítica, Facultad de Medicina, Universidad Francisco de Vitoria (Pozuelo de Alarcón-Madrid), Madrid, Spain
| | - Lourdes Fisac
- Servicio Medicina Intensiva, Hospital Universitario de Burgos, Burgos, Spain
| | - Emilio García-Prieto
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Cristina López-Martin
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Ana Abella
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada-Madrid, Grupo de Investigación en Patología Crítica, Facultad de Medicina, Universidad Francisco de Vitoria (Pozuelo de Alarcón-Madrid), Madrid, Spain
| | - Juan Ramón Jiménez
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - José Luis García-Garmendia
- Servicio de Cuidados Críticos y Urgencias, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain
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4
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Mansvelder FJ, Bossers SM, Loer SA, Bloemers FW, Van Lieshout EMM, Den Hartog D, Hoogerwerf N, van der Naalt J, Absalom AR, Peerdeman SM, Bulte CSE, Schwarte LA, Schober P. Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury. Anesthesiology 2024; 140:742-751. [PMID: 38190220 DOI: 10.1097/aln.0000000000004894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands. METHODS This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis. RESULTS In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data. CONCLUSIONS The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Floor J Mansvelder
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sebastiaan M Bossers
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nico Hoogerwerf
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 3, Volkel, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Saskia M Peerdeman
- Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, The Netherlands
| | - Carolien S E Bulte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands; and Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, The Netherlands
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5
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Hohenstein C, Merz S, Eppler F, Arslan V, Ayvaci BM, Ünlü L. Emergency airway management: an EUSEM statement with regard to the guidelines of the Society of Critical Care Medicine. Eur J Emerg Med 2024; 31:83-85. [PMID: 38100641 PMCID: PMC10901228 DOI: 10.1097/mej.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Christian Hohenstein
- Department of Emergency Medicine, Zentralklinik Bad Berka, University of Marburg, Faculty of Medicine, Bad Berka
| | - Sabine Merz
- Red Cross Villingen-Schwenningen, Villingen-Schwenningen
| | - Fabian Eppler
- Faculty of Medicine, University of Mainz, Mainz, Germany
| | - Volkan Arslan
- Department of Emergency Medicine, Hacettepe University Medicine Faculty, Ankara
| | - Bariş Murat Ayvaci
- Department of Emergency Medicine, University of Health Sciences Prof. Dr. Cemil Taşcioğlu City Hospital, Istanbul, Turkey
| | - Luca Ünlü
- Faculty of Medicine, Karl-Landsteiner University of Health Sciences, Krems a.d. Donau, Austria
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Levin JH, Wallace MW, Hess TN, Beavers JR, Chang T, Beyene RT. The Effect of Propofol on Peri-Induction Hemodynamics and Resuscitation in Operative Penetrating Trauma. Am Surg 2024; 90:731-738. [PMID: 37209120 DOI: 10.1177/00031348231177932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND Hemorrhaging trauma patients may be disproportionately affected by choice of induction agent during rapid sequence intubation (RSI). Etomidate, ketamine, and propofol are safe in the trauma population-at-large but have not been assessed in patients with ongoing hemorrhage. We hypothesize that in hemorrhaging patients with penetrating injury, propofol deleteriously affects peri-induction hypotension compared to etomidate and ketamine. METHODS Retrospective cohort study. Primary outcome was the effect of induction agent on peri-induction systolic blood pressure. Secondary outcomes were the incidence of peri-induction vasopressor use and quantity of peri-induction blood transfusion requirements. Linear multivariate regression modeling assessed the effect of induction agent on the variables of interest. RESULTS 169 patients were included, 146 received propofol and 23 received etomidate or ketamine. Univariate analysis revealed no difference in peri-induction systolic blood pressure (P = .53), peri-induction vasopressor administration (P = .62), or transfusion requirements within the first hour after induction (PRBC P = .24, FFP P = .19, PLT P = .29). Choice of RSI agent did not independently predict peri-induction systolic blood pressure or blood product administration. Rather, only presenting shock index independently predicted peri-induction hypotension. CONCLUSIONS This is the first study to directly assess the peri-induction effects of anesthetic induction agent choice in penetrating trauma patients undergoing emergent hemorrhage control surgery. Propofol does not appear to worsen peri-induction hypotension regardless of dose. Patient physiology is most predictive of peri-induction hypotension.
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Affiliation(s)
- Jeremy H Levin
- Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | | | - T Noel Hess
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer R Beavers
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tony Chang
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robel T Beyene
- Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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7
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Koroki T, Kotani Y, Yaguchi T, Shibata T, Fujii M, Fresilli S, Tonai M, Karumai T, Lee TC, Landoni G, Hayashi Y. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care 2024; 28:48. [PMID: 38368326 PMCID: PMC10874027 DOI: 10.1186/s13054-024-04831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/10/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Tracheal intubation is a high-risk intervention commonly performed in critically ill patients. Due to its favorable cardiovascular profile, ketamine is considered less likely to compromise clinical outcomes. This meta-analysis aimed to assess whether ketamine, compared with other agents, reduces mortality in critically ill patients undergoing intubation. METHODS We searched MEDLINE, Embase, and the Cochrane Library from inception until April 27, 2023, for randomized controlled trials and matched observational studies comparing ketamine with any control in critically ill patients as an induction agent. The primary outcome was mortality at the longest follow-up available, and the secondary outcomes included Sequential Organ Failure Assessment score, ventilator-free days at day 28, vasopressor-free days at day 28, post-induction mean arterial pressure, and successful intubation on the first attempt. For the primary outcome, we used a Bayesian random-effects meta-analysis on the risk ratio (RR) scale with a weakly informative neutral prior corresponding to a mean estimate of no difference with 95% probability; the estimated effect size will fall between a relative risk of 0.25 and 4. The RR and 95% credible interval (CrI) were used to estimate the probability of mortality reduction (RR < 1). The secondary outcomes were assessed with a frequentist random-effects model. We registered this study in Open Science Framework ( https://osf.io/2vf79/ ). RESULTS We included seven randomized trials and one propensity-matched study totaling 2978 patients. Etomidate was the comparator in all the identified studies. The probability that ketamine reduced mortality was 83.2% (376/1475 [25%] vs. 411/1503 [27%]; RR, 0.93; 95% CrI, 0.79-1.08), which was confirmed by a subgroup analysis excluding studies with a high risk of bias. No significant difference was observed in any secondary outcomes. CONCLUSIONS All of the included studies evaluated ketamine versus etomidate among critically ill adults requiring tracheal intubation. This meta-analysis showed a moderate probability that induction with ketamine is associated with a reduced risk of mortality.
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Affiliation(s)
- Takatoshi Koroki
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan.
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Takahiko Yaguchi
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
| | - Taisuke Shibata
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
| | - Motoki Fujii
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mayuko Tonai
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
| | - Toshiyuki Karumai
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296-8602, Japan
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8
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Catoire P, Roussel M, Teissandier D. Sequence of administration of anesthetic agents during rapid sequence induction for emergency intubation: a French survey on current practices. Eur J Emerg Med 2024; 31:71-73. [PMID: 37792524 DOI: 10.1097/mej.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Affiliation(s)
- Pierre Catoire
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris
| | - Mélanie Roussel
- Emergency Department, University Rouen Normandie, CHU Rouen, Rouen, France
| | - Dorian Teissandier
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris
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9
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Abdildin Y, Tapinova K, Nemerenova A, Viderman D. The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials. Acute Crit Care 2024; 39:34-46. [PMID: 38476062 PMCID: PMC11002615 DOI: 10.4266/acc.2023.00829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/25/2023] [Accepted: 01/03/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients. METHODS We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay. RESULTS Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome. CONCLUSIONS Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.
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Affiliation(s)
- Yerkin Abdildin
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Karina Tapinova
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Assel Nemerenova
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Dmitriy Viderman
- Department of Surgery, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- Department of Anesthesiology, Intensive Care, and Pain Medicine, National Research Oncology Center, Astana, Kazakhstan
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10
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A R, Han Z, Wang T, Zhu M, Zhou M, Sun X. Pulmonary delivery of nano-particles for lung cancer diagnosis and therapy: Recent advances and future prospects. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2024; 16:e1933. [PMID: 37857568 DOI: 10.1002/wnan.1933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/21/2023]
Abstract
Although our understanding of lung cancer has significantly improved in the past decade, it is still a disease with a high incidence and mortality rate. The key reason is that the efficacy of the therapeutic drugs is limited, mainly due to insufficient doses of drugs delivered to the lungs. To achieve precise lung cancer diagnosis and treatment, nano-particles (NPs) pulmonary delivery techniques have attracted much attention and facilitate the exploration of the potential of those in inhalable NPs targeting tumor lesions. Since the therapeutic research focusing on pulmonary delivery NPs has rapidly developed and evolved substantially, this review will mainly discuss the current developments of pulmonary delivery NPs for precision lung cancer diagnosis and therapy. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Respiratory Disease Therapeutic Approaches and Drug Discovery > Emerging Technologies Diagnostic Tools > In Vivo Nanodiagnostics and Imaging.
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Affiliation(s)
- Rong A
- Department of Nuclear Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
- NHC Key Laboratory of Molecular Probe and Targeted Diagnosis and Therapy, Molecular Imaging Research Center (MIRC) of Harbin Medical University, Harbin, China
| | - Zhaoguo Han
- Department of Nuclear Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
- NHC Key Laboratory of Molecular Probe and Targeted Diagnosis and Therapy, Molecular Imaging Research Center (MIRC) of Harbin Medical University, Harbin, China
| | - Tianyi Wang
- Department of Nuclear Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
- NHC Key Laboratory of Molecular Probe and Targeted Diagnosis and Therapy, Molecular Imaging Research Center (MIRC) of Harbin Medical University, Harbin, China
| | - Mengyuan Zhu
- Department of Nuclear Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
- NHC Key Laboratory of Molecular Probe and Targeted Diagnosis and Therapy, Molecular Imaging Research Center (MIRC) of Harbin Medical University, Harbin, China
| | - Meifang Zhou
- Department of Nuclear Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
- NHC Key Laboratory of Molecular Probe and Targeted Diagnosis and Therapy, Molecular Imaging Research Center (MIRC) of Harbin Medical University, Harbin, China
| | - Xilin Sun
- Department of Nuclear Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
- NHC Key Laboratory of Molecular Probe and Targeted Diagnosis and Therapy, Molecular Imaging Research Center (MIRC) of Harbin Medical University, Harbin, China
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11
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Condliffe R, Newton R, Bauchmuller K, Bonnett T, Kerry R, Mannings A, Nair A, Selby K, Skinner PP, Wilson VJ, Kiely DG. Surgery and Anesthesia in Patients with Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:797-809. [PMID: 37729924 DOI: 10.1055/s-0043-1772753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.
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Affiliation(s)
- Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Ruth Newton
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Tessa Bonnett
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Robert Kerry
- Department of Orthopaedics, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Alexa Mannings
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Amanda Nair
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Karen Selby
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Paul P Skinner
- Department of Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Victoria J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - David G Kiely
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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12
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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13
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Schauer SG, April MD, Arana AA, Long BJ, Maddry JK. Ketamine during resuscitation - Is it as hemodynamically perfect as we think? Am J Emerg Med 2023; 73:234.e3-234.e7. [PMID: 37690953 DOI: 10.1016/j.ajem.2023.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION Ketamine administration in patients experiencing or at risk for hypotension is common based upon the presumption of this agent's favorable hemodynamic profile. The Compensatory Reserve Measurement (CRM) is a novel algorithm that accurately tracks systemic adequacy for delivery of oxygen (DO2) to the tissues. We present a case series of trauma patients receiving ketamine with CRM measurements to offer insight into the DO2 during resuscitation. METHODS We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions and vital signs including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) throughout their emergency department stay. RESULTS Our study included 8 patients who received ketamine for intubation or analgesia (20-300 mg) and had adequate data for analysis. Most were male (88%) with a median age of 28. The most common mechanisms of injury were motor vehicle collisions (MVCs) (38%) and gunshot wounds (38%). After ketamine administration SBP, MAP, and HR all increased while the CRM exhibited minimal change. CONCLUSIONS SBP, MAP, and HR generally appeared to increase while the CRM remained unchanged. Our findings suggest that while standard vital sign measurements appear to increase, ketamine may not improve delivery of oxygen to the tissues. This warrants further study to better understand the effects of ketamine on hemodynamics.
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Affiliation(s)
- Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Departments of Anesthesiology and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; 14th Field Hospital, Fort Stewart, GA, USA
| | | | - Brit J Long
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA; 59th Medical Wing, JBSA Lackland, TX, USA
| | - Joseph K Maddry
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA; 59th Medical Wing, JBSA Lackland, TX, USA
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14
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Knack SKS, Prekker ME, Moore JC, Klein LR, Atkins AH, Miner JR, Driver BE. The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial. J Emerg Med 2023; 65:e371-e382. [PMID: 37741737 DOI: 10.1016/j.jemermed.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.
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Affiliation(s)
- Sarah K S Knack
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Alexandra H Atkins
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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15
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Kotani Y, Piersanti G, Maiucci G, Fresilli S, Turi S, Montanaro G, Zangrillo A, Lee TC, Landoni G. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care 2023; 77:154317. [PMID: 37127020 DOI: 10.1016/j.jcrc.2023.154317] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/20/2023] [Accepted: 04/20/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE We performed a meta-analysis of randomized controlled trials to evaluate if etomidate impacted mortality in critically ill adults when compared with other induction agents. MATERIALS AND METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials which compared etomidate with any other induction agent in critically ill adult patients undergoing endotracheal intubation. The primary outcome was mortality at the main timepoint defined by the study. We conducted a fixed-effects meta-analysis for the risk ratio. Using that risk ratio and 95% confidence interval, we then estimated the probability of any harm (RR > 1) and the number needed to harm ≤100 (RR ≥ 1.05). RESULTS We included 11 randomized trials comprising 2704 patients. We found that etomidate increased mortality (319/1359 [23%] vs. 267/1345 [20%]; risk ratio (RR) = 1.16; 95% confidence interval (CI), 1.01-1.33; P = 0.03; I2 = 0%; number needed to harm = 31). The probabilities of any increase and a 1% increase (NNH ≤100) in mortality were 98.1% and 92.1%, respectively. CONCLUSIONS This meta-analysis found a high probability that etomidate increases mortality when used as an induction agent in critically ill patients with a number needed to harm of 31.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan.
| | - Gioia Piersanti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Maiucci
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giada Montanaro
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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16
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Zhou JS, Peng GF, Liang WD, Chen Z, Liu YY, Wang BY, Guo ML, Deng YL, Ye JM, Zhong ML, Wang LF. Recent advances in the study of anesthesia-and analgesia-related mechanisms of S-ketamine. Front Pharmacol 2023; 14:1228895. [PMID: 37781698 PMCID: PMC10539608 DOI: 10.3389/fphar.2023.1228895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
Ketamine is a racemic mixture of equal amounts of R-ketamine and S-ketamine and is well known to anesthesiologists for its unique dissociative anesthetic properties. The pharmacological properties of ketamine, namely, its sympathetic excitation, mild respiratory depression, and potent analgesia, are still highly valued in its use as an anesthetic for some patients. In particular, since its advent, S-ketamine has been widely used as an anesthetic in many countries due to its increased affinity for NMDA receptors and its enhanced anesthetic and analgesic effects. However, the anesthetic and analgesic mechanisms of S-ketamine are not fully understood. In addition to antagonizing NMDA receptors, a variety of other receptors or channels may be involved, but there are no relevant mechanistic summaries in the literature. Therefore, the purpose of this paper is to review the mechanisms of action of S-ketamine on relevant receptors and systems in the body that result in its pharmacological properties, such as anesthesia and analgesia, with the aim of providing a reference for its clinical applications and research.
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Affiliation(s)
- Jian-shun Zhou
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Guan-fa Peng
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Wei-dong Liang
- Department of Anesthesiology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Ganzhou Key Laboratory of Anesthesiology, Ganzhou, China
| | - Zhen Chen
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Ying-ying Liu
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Bing-yu Wang
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Ming-ling Guo
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Yun-ling Deng
- Department of Anesthesiology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Ganzhou Key Laboratory of Anesthesiology, Ganzhou, China
| | - Jun-ming Ye
- Department of Anesthesiology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Ganzhou Key Laboratory of Anesthesiology, Ganzhou, China
| | - Mao-lin Zhong
- Department of Anesthesiology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Ganzhou Key Laboratory of Anesthesiology, Ganzhou, China
| | - Li-feng Wang
- Department of Anesthesiology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Ganzhou Key Laboratory of Anesthesiology, Ganzhou, China
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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18
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Kim J, Jung K, Moon J, Kwon J, Kang BH, Yoo J, Song S, Bang E, Kim S, Huh Y. Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea. BMC Emerg Med 2023; 23:57. [PMID: 37248552 DOI: 10.1186/s12873-023-00833-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/24/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation. METHODS We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. RESULTS In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis. CONCLUSION In this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.
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Affiliation(s)
- Jinjoo Kim
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jayoung Yoo
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Seoyoung Song
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Eunsook Bang
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Sora Kim
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea.
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19
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Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med 2023; 70:19-29. [PMID: 37196592 DOI: 10.1016/j.ajem.2023.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
PURPOSE Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.
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Affiliation(s)
- Kellyn Engstrom
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Alicia E Mattson
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Neal Lyons
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
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20
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Srivilaithon W, Bumrungphanithaworn A, Daorattanachai K, Limjindaporn C, Amnuaypattanapon K, Imsuwan I, Diskumpon N, Dasanadeba I, Siripakarn Y, Ueamsaranworakul T, Pornpanit C, Pornpachara V. Clinical outcomes after a single induction dose of etomidate versus ketamine for emergency department sepsis intubation: a randomized controlled trial. Sci Rep 2023; 13:6362. [PMID: 37076524 PMCID: PMC10115773 DOI: 10.1038/s41598-023-33679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/17/2023] [Indexed: 04/21/2023] Open
Abstract
Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2-0.3 mg/kg of etomidate or 1-2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], - 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021-Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001 .
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Affiliation(s)
- Winchana Srivilaithon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand.
| | - Atidtaya Bumrungphanithaworn
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Kiattichai Daorattanachai
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Chitlada Limjindaporn
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Kumpol Amnuaypattanapon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Intanon Imsuwan
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Nipon Diskumpon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Ittabud Dasanadeba
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Yaowapha Siripakarn
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Thosapol Ueamsaranworakul
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Chatchanan Pornpanit
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Vanussarin Pornpachara
- Division of Endocrinology, Department of Medicine, Rajavithi Hospital, Bangkok, Thailand
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21
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Choi C, Karamchandani K. CON: The Best Induction Agent for the Physiologically Difficult Airway Is Ketamine-Propofol Admixture ("Ketofol"). J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00196-9. [PMID: 37100637 DOI: 10.1053/j.jvca.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Christopher Choi
- Division of Critical Care Medicine, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kunal Karamchandani
- Division of Critical Care Medicine, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX.
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22
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Etomidate for endotracheal intubation in sepsis. Intensive Care Med 2023; 49:369. [PMID: 36600028 DOI: 10.1007/s00134-022-06962-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/05/2023]
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23
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Matchett G, Moon TS, Stewart JW, Liang L, Fox PE. Etomidate for endotracheal intubation in sepsis. Author's reply. Intensive Care Med 2023; 49:370-371. [PMID: 36820877 DOI: 10.1007/s00134-023-06987-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Gerald Matchett
- Department of Anesthesiology & Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA.
| | - Tiffany Sun Moon
- Department of Anesthesiology & Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA
| | - Jesse W Stewart
- Department of Anesthesiology & Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA
| | - Lawrence Liang
- Department of Anesthesiology & Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA
| | - Pamela E Fox
- Department of Anesthesiology & Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA
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24
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Brakke BD, Smischney NJ. Pro: The Best Induction for the Physiologically Difficult Airway is Ketamine-Propofol Admixture ("Ketofol"). J Cardiothorac Vasc Anesth 2023:S1053-0770(22)00931-4. [PMID: 36707380 DOI: 10.1053/j.jvca.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Benjamin D Brakke
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Nathan J Smischney
- Department of Anesthesiology & Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN.
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25
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Carsetti A, Vitali E, Pesaresi L, Antolini R, Casarotta E, Damiani E, Adrario E, Donati A. Anesthetic management of patients with sepsis/septic shock. Front Med (Lausanne) 2023; 10:1150124. [PMID: 37035341 PMCID: PMC10076637 DOI: 10.3389/fmed.2023.1150124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/28/2023] [Indexed: 04/11/2023] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, while septic shock is a subset of sepsis with persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg and having a serum lactate level of >2 mmol/L, despite adequate volume resuscitation. Sepsis and septic shock are medical emergencies and time-dependent diseases with a high mortality rate for which early identification, early antibiotic therapy, and early source control are paramount for patient outcomes. The patient may require surgical intervention or an invasive procedure aiming to control the source of infection, and the anesthesiologist has a pivotal role in all phases of patient management. During the preoperative assessment, patients should be aware of all possible organ dysfunctions, and the severity of the disease combined with the patient's physiological reserve should be carefully assessed. All possible efforts should be made to optimize conditions before surgery, especially from a hemodynamic point of view. Anesthetic agents may worsen the hemodynamics of shock patients, and the anesthesiologist must know the properties of each anesthetic agent. All possible efforts should be made to maintain organ perfusion supporting hemodynamics with fluids, vasoactive agents, and inotropes if required.
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Affiliation(s)
- Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- *Correspondence: Andrea Carsetti
| | - Eva Vitali
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia Pesaresi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Riccardo Antolini
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Damiani
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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26
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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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27
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Foster M, Self M, Gelber A, Kennis B, Lasoff DR, Hayden SR, Wardi G. Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation. Am J Emerg Med 2022; 61:131-136. [PMID: 36096015 PMCID: PMC10106101 DOI: 10.1016/j.ajem.2022.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/13/2022] [Accepted: 08/27/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.
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Affiliation(s)
- Mitchell Foster
- University of California San Diego School of Medicine, California, United States; Department of Emergency Medicine, NYU Langone Health and NYC Health + Hospitals/Bellevue, New York, United States.
| | - Michael Self
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, UC San Diego Health, California, United States.
| | - Alon Gelber
- University of California San Diego School of Medicine, California, United States; Department of Bioengineering, University of California at San Diego, California, United States.
| | - Brent Kennis
- University of California San Diego School of Medicine, California, United States.
| | - Daniel R Lasoff
- Department of Emergency Medicine, UC San Diego Health, California, United States; Division of Medical Toxicology, UC San Diego Health, California, United States.
| | - Stephen R Hayden
- Department of Emergency Medicine, UC San Diego Health, California, United States.
| | - Gabriel Wardi
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego Health, California, United States.
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28
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Mazandi VM, Lang SS, Rahman RK, Nishisaki A, Beaulieu F, Zhang B, Griffis H, Tucker AM, Storm PB, Heuer GG, Gajjar AA, Ampah SB, Kirschen MP, Topjian AA, Yuan I, Francoeur C, Kilbaugh TJ, Huh JW. Co-administration of Ketamine in Pediatric Patients with Neurologic Conditions at Risk for Intracranial Hypertension. Neurocrit Care 2022; 38:242-253. [PMID: 36207491 DOI: 10.1007/s12028-022-01611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/15/2022] [Indexed: 10/10/2022]
Abstract
BACKGROUND Ketamine has traditionally been avoided as an induction agent for tracheal intubation in patients with neurologic conditions at risk for intracranial hypertension due to conflicting data in the literature. The objective of this study was to evaluate and compare the effects of ketamine versus other medications as the primary induction agent on peri-intubation neurologic, hemodynamic and respiratory associated events in pediatric patients with neurologic conditions at risk for intracranial hypertension. METHODS This retrospective observational study enrolled patients < 18 years of age at risk for intracranial hypertension who were admitted to a quaternary children's hospital between 2015 and 2020. Associated events included neurologic, hemodynamic and respiratory outcomes comparing primary induction agents of ketamine versus non-ketamine for tracheal intubation. RESULTS Of 143 children, 70 received ketamine as the primary induction agent prior to tracheal intubation. Subsequently after tracheal intubation, all the patients received adjunct analgesic and sedative medications (fentanyl, midazolam, and/or propofol) at doses that were inadequate to induce general anesthesia but would keep them comfortable for further diagnostic workup. There were no significant differences between associated neurologic events in the ketamine versus non-ketamine groups (p = 0.42). This included obtaining an emergent computed tomography scan (p = 0.28), an emergent trip to the operating room within 5 h of tracheal intubation (p = 0.6), and the need for hypertonic saline administration within 15 min of induction drug administration for tracheal intubation (p = 0.51). There were two patients who had clinical and imaging evidence of herniation, which was not more adversely affected by ketamine compared with other medications (p = 0.49). Of the 143 patients, 23 had pre-intubation and post-intubation intracranial pressure values recorded; 11 received ketamine, and 3 of these patients had intracranial hypertension that resolved or improved, whereas the remaining 8 children had intracranial pressure within the normal range that was not exacerbated by ketamine. There were no significant differences in overall associated hemodynamic or respiratory events during tracheal intubation and no 24-h mortality in either group. CONCLUSIONS The administration of ketamine as the primary induction agent prior to tracheal intubation in combination with other agents after tracheal intubation in children at risk for intracranial hypertension was not associated with an increased risk of peri-intubation associated neurologic, hemodynamic or respiratory events compared with those who received other induction agents.
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Affiliation(s)
- Vanessa M Mazandi
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.
| | - Shih-Shan Lang
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Raphia K Rahman
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Rowan School of Osteopathic Medicine, Stratford, NJ, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bingqing Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander M Tucker
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Phillip B Storm
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Greg G Heuer
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Avi A Gajjar
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Chemistry, Union College, Schenectady, NY, USA
| | - Steve B Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Conall Francoeur
- Department of Pediatrics, CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
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Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, Lascarrou JB, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Pesenti A, Valsecchi MG, Fumagalli R, Foti G, Bellani G, Laffey JG. Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study. Am J Respir Crit Care Med 2022; 206:449-458. [PMID: 35536310 DOI: 10.1164/rccm.202111-2575oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/FiO2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).
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Affiliation(s)
- Vincenzo Russotto
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Antolini
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia e le Neuroscienze, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington & Halton Teaching Hospitals National Health Service Foundation Trust, Warrington, United Kingdom
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesiology, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - John G Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland; and.,Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
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30
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Luan T, Li Y, Sun L, Xu S, Wang H, Wang J, Li C. Systemic immune effects of anesthetics and their intracellular targets in tumors. Front Med (Lausanne) 2022; 9:810189. [PMID: 35966857 PMCID: PMC9365985 DOI: 10.3389/fmed.2022.810189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 07/06/2022] [Indexed: 11/30/2022] Open
Abstract
According to the result released by the World Health Organization (WHO), non-communicable diseases have occupied four of the top 10 current causes for death in the world. Cancer is one of the significant factors that trigger complications and deaths; more than 80% cancer patients require surgical or palliative treatment. In this case, anesthetic treatment is indispensable. Since cancer is a heterogeneous disease, various types of interventions can activate oncogenes or mutate tumor suppressor genes. More and more researchers believe that anesthetics have a certain effect on the long-term recurrence and metastasis of tumors, but it is still controversial whether they promote or inhibit the progression of cancer. On this basis, a series of retrospective or prospective randomized clinical trials have been conducted, but it seems to be difficult to reach a conclusion within 5 years or longer. This article focuses on the effects of anesthetic drugs on immune function and cancer and reviews their latest targets on the tumor cells, in order to provide a theoretical basis for optimizing the selection of anesthetic drugs, exploring therapeutic targets, and improving the prognosis of cancer patients.
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Affiliation(s)
- Ting Luan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Yunnan Institute of Urology, Kunming, China
| | - Yi Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Lihui Sun
- Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
- Zhongke Jianlan Medical Research Institute, Beijing, China
| | - Siqi Xu
- Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
- Zhongke Jianlan Medical Research Institute, Beijing, China
| | - Haifeng Wang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Yunnan Institute of Urology, Kunming, China
- *Correspondence: Haifeng Wang,
| | - Jiansong Wang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Yunnan Institute of Urology, Kunming, China
- Jiansong Wang,
| | - Chong Li
- Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
- Zhongke Jianlan Medical Research Institute, Beijing, China
- Chong Li,
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31
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Bali A, Dang AK, Gonzalez DA, Kumar R, Asif S. Clinical Uses of Ketamine in Children: A Narrative Review. Cureus 2022; 14:e27065. [PMID: 35989801 PMCID: PMC9389002 DOI: 10.7759/cureus.27065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/05/2022] Open
Abstract
Ketamine is a phencyclidine derivative that acts as a noncompetitive N-methyl-D-aspartate as well as a glutamate receptor antagonist. It also has other minor mechanisms that contribute to its extensive drug profile. Ketamine is a bronchodilator and maintains normal airway reflexes and, thus, permits spontaneous respiration. This, coupled with the fact that it produces potent analgesia, makes it highly suitable for children. Despite its many merits, the drug’s side effects, along with its cultural image of being a drug of abuse, a drug used in veterinary medicine, or a “date-rape drug” have sullied its reputation within the armamentarium of medicine. Even though it is widely used in developing countries, its use in Western nations has diminished. We have strived to explore the various clinical uses of ketamine in children through this article. In addition, the article also highlights how some of the fears associated with using the drug are unfounded and provides ways by which the drug’s side effects can be prevented and managed.
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32
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Li R, Jia Y, Kong X, Nie Y, Deng Y, Liu Y. Novel drug delivery systems and disease models for pulmonary fibrosis. J Control Release 2022; 348:95-114. [PMID: 35636615 DOI: 10.1016/j.jconrel.2022.05.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/17/2022] [Accepted: 05/21/2022] [Indexed: 12/19/2022]
Abstract
Pulmonary fibrosis (PF) is a serious and progressive lung disease which is possibly life-threatening. It causes lung scarring and affects lung functions including epithelial cell injury, massive recruitment of immune cells and abnormal accumulation of extracellular matrix (ECM). There is currently no cure for PF. Treatment for PF is aimed at slowing the course of the disease and relieving symptoms. Pirfenidone (PFD) and nintedanib (NDNB) are currently the only two FDA-approved oral medicines to slow down the progress of idiopathic pulmonary fibrosis, a specific type of PF. Novel drug delivery systems and therapies have been developed to improve the prognosis of the disease, as well as reduce or minimize the toxicities during drug treatment. The drug delivery routes for these therapies are various including oral, intravenous, nasal, inhalant, intratracheal and transdermal; although this is dependent on specific treatment mechanisms. In addition, researchers have also expanded current animal models that could not fully restore the clinicopathology, and developed a series of in vitro models such as organoids to study the pathogenesis and treatment of PF. This review describes recent advances on pathogenesis exploration, classifies and specifies the progress of drug delivery systems by their delivery routes, as well as an overview on the in vitro and in vivo models for PF research.
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Affiliation(s)
- Rui Li
- School of Pharmaceutical Sciences (Shenzhen), Sun Yat-sen University, Guangzhou 510275, China
| | - Yizhen Jia
- School of Pharmaceutical Sciences (Shenzhen), Sun Yat-sen University, Guangzhou 510275, China
| | - Xiaohan Kong
- School of Pharmaceutical Sciences (Shenzhen), Sun Yat-sen University, Guangzhou 510275, China
| | - Yichu Nie
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan 528000, China
| | - Yang Deng
- School of Pharmaceutical Sciences (Shenzhen), Sun Yat-sen University, Guangzhou 510275, China
| | - Yang Liu
- School of Pharmaceutical Sciences (Shenzhen), Sun Yat-sen University, Guangzhou 510275, China; School of Pharmaceutical Sciences (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China.
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Andrade SM, Cecília de Araújo Silvestre M, Tenório de França EÉ, Bezerra Sales Queiroz MH, de Jesus Santana K, Lima Holmes Madruga ML, Torres Teixeira Mendes CK, Araújo de Oliveira E, Bezerra JF, Barreto RG, Alves Fernandes da Silva SM, Alves de Sousa T, Medeiros de Sousa WC, Patrícia da Silva M, Cintra Ribeiro VM, Lucena P, Beltrammi D, Catharino RR, Caparelli-Dáquer E, Hampstead BM, Datta A, Teixeira AL, Fernández-Calvo B, Sato JR, Bikson M. Efficacy and safety of HD-tDCS and respiratory rehabilitation for critically ill patients with COVID-19 The HD-RECOVERY randomized clinical trial. Brain Stimul 2022; 15:780-788. [PMID: 35568312 PMCID: PMC9093082 DOI: 10.1016/j.brs.2022.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/19/2022] [Accepted: 05/05/2022] [Indexed: 11/28/2022] Open
Abstract
Background and purpose Acute Respiratory Distress Syndrome (ADRS) due to coronavirus disease 2019 (COVID-19) has been associated with muscle fatigue, corticospinal pathways dysfunction, and mortality. High-Definition transcranial Direct Current Stimulation (HD-tDCS) may be used to attenuate clinical impairment in these patients. The HD-RECOVERY randomized clinical trial was conducted to evaluate the efficacy and safety of HD-tDCS with respiratory rehabilitation in patients with moderate to severe ARDS due to COVID-19. Methods Fifty-six critically ill patients were randomized 1:1 to active (n = 28) or sham (n = 28) HD-tDCS (twice a day, 30-min, 3-mA) plus respiratory rehabilitation for up to 10 days or until intensive care unit discharge. The primary outcome was ventilator-free days during the first 28 days, defined as the number of days free from mechanical ventilation. Furthermore, secondary outcomes such as delirium, organ failure, hospital length of stay and adverse effects were investigated. Results Active HD-tDCS induced more ventilator-free days compared to sham HD-tDCS. Patients in the active group vs in the sham group experienced lower organ dysfunction, delirium, and length of stay rates over time. In addition, positive clinical response was higher in the active vs sham group. There was no significant difference in the prespecified secondary outcomes at 5 days. Adverse events were similar between groups. Conclusions Among patients with COVID-19 and moderate to severe ARDS, use of active HD-tDCS compared with sham HD-tDCS plus respiratory rehabilitation resulted in a statistically significant increase in the number of ventilator-free days over 28 days. HD-tDCS combined with concurrent rehabilitation therapy is a safe, feasible, potentially add-on intervention, and further trials should examine HD-tDCS efficacy in a larger sample of patients with COVID-19 and severe hypoxemia.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paulo Lucena
- Health Secretary, Government of Paraíba, João Pessoa, Brazil
| | | | - Rodrigo Ramos Catharino
- Thomson Mass Spectrometry Laboratory, Institute of Chemistry, State University of Campinas, UNICAMP, Campinas, SP, Brazil
| | - Egas Caparelli-Dáquer
- Nervous System Electric Stimulation Lab, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Benjamin M Hampstead
- Research Program on Cognition and Neuromodulation Based Interventions, Department of Psychiatry, University of Michigan & Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, Ann Arbor, United States
| | - Abhishek Datta
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, United States
| | - Antonio Lucio Teixeira
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, United States
| | - Bernardino Fernández-Calvo
- Department of Psychology, University of Cordoba, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - João Ricardo Sato
- Center of Mathematics, Computing and Cognition. Federal University of ABC, Santo André, Brazil
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, United States
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M S, Ross H, KT S, I Z, Robert G. Rapid Sequence Induction/Intubation: What needs to be fast? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Midega TD, Chaves RCDF, Ashihara C, Alencar RM, Queiroz VNF, Zelezoglo GR, Vilanova LCDS, Olivato GB, Cordioli RL, Bravim BDA, Corrêa TD. Ketamine use in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2022; 34:287-294. [PMID: 35946660 DOI: 10.5935/0103-507x.20220027-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022] Open
Abstract
Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.
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Affiliation(s)
- Thais Dias Midega
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Carolina Ashihara
- Departamento de Anestesiologia, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Roger Monteiro Alencar
- Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | | | | | | | - Ricardo Luiz Cordioli
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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Casamento A, Niccol T. Efficacy and safety of ketamine in mechanically ventilated intensive care unit patients: a scoping review. CRIT CARE RESUSC 2022; 24:71-82. [PMID: 38046843 PMCID: PMC10692604 DOI: 10.51893/2022.1.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Mechanically ventilated patients account for about one-third of all admissions to the intensive care unit (ICU). Ketamine has been conditionally recommended to aid with analgesia in such patients, with low quality of evidence available to support this recommendation. We aimed to perform a narrative scoping review of the current knowledge of the use of ketamine, with a specific focus on mechanically ventilated ICU patients. Methods: We searched MEDLINE and EMBASE for relevant articles. Bibliographies of retrieved articles were examined for references of potential relevance. We included studies that described the use of ketamine for postoperative and emergency department management of pain and in the critically unwell, mechanically ventilated population. Results: There are few randomised controlled trials evaluating ketamine's utility in the ICU. The evidence is predominantly retrospective and observational in nature and the results are heterogeneous. Available evidence is summarised in a descriptive manner, with a division made between high dose and low dose ketamine. Ketamine's pharmacology and use as an analgesic agent outside of the ICU is briefly discussed, followed by evidence for use in the ICU setting, with particular emphasis on analgesia, sedation and intubation. Finally, data on adverse effects including delirium, coma, haemodynamic adverse effects, raised intracranial pressure, hypersalivation and laryngospasm are presented. Conclusions: Ketamine is used in mechanically ventilated ICU patients with several potentially positive clinical effects. However, it has a significant side effect profile, which may limit its use in these patients. The role of low dose ketamine infusion in mechanically ventilated ICU patients is not well studied and requires investigation in high quality, prospective randomised trials.
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Affiliation(s)
- Andrew Casamento
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Intensive Care Unit, Northern Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Thomas Niccol
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
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Barthélémy R, Mebazaa A, Chousterman BG. Anesthetic drugs for rapid sequence intubation: ketamine, but what dose? Intensive Care Med 2022; 48:632-633. [PMID: 35244744 DOI: 10.1007/s00134-022-06661-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Romain Barthélémy
- Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, 75010, Paris, France.
- Réanimation Chirurgicale Polyvalente, Hôpital Lariboisière, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France.
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, 75010, Paris, France
- Université de Paris, Inserm, UMRS, 942 Mascot, 75006, Paris, France
| | - Benjamin Glenn Chousterman
- Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, 75010, Paris, France
- Université de Paris, Inserm, UMRS, 942 Mascot, 75006, Paris, France
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Gil-Jardiné C, Jabre P, Adnet F, Nicol T, Ecollan P, Guihard B, Ferdynus C, Bocquet V, Combes X. Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial. Intern Emerg Med 2022; 17:611-617. [PMID: 35037125 DOI: 10.1007/s11739-021-02903-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.
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Affiliation(s)
- Cédric Gil-Jardiné
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France
| | - Patricia Jabre
- AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Frederic Adnet
- Urgences-SAMU 93, Unite Recherche-Enseignement-Qualite, Hopital Avicenne, Bobigny, France
| | - Thomas Nicol
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Patrick Ecollan
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Bertrand Guihard
- Department of Emergency, CHU de la Réunion, Université de La Réunion, Réunion, France
| | - Cyril Ferdynus
- INSERM CIC 1410 Clinical and Epidemiology/CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
| | - Valery Bocquet
- Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Xavier Combes
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France.
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Ketamine inhibits TNF-α-induced cecal damage by enhancing RIP1 ubiquitination to attenuate lethal SIRS. Cell Death Dis 2022; 8:72. [PMID: 35184141 PMCID: PMC8857635 DOI: 10.1038/s41420-022-00869-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/22/2022] [Accepted: 02/03/2022] [Indexed: 01/02/2023]
Abstract
Systemic inflammatory response syndrome (SIRS) is a sepsis-associated inflammatory state and a self-defense mechanism against specific and nonspecific stimuli. Ketamine influences many key processes that are altered during sepsis. However, the underlying mechanisms remain incompletely understood. In this study, TNF-α-treated mice, as well as HT-29 and L929 cell models, were applied to characterize TNF-α-induced systemic and local cecal tissue inflammatory responses. Behavioral, biochemical, histological, and molecular biological approaches were applied to illustrate the related processes. Mice with TNF-α-induced SIRS showed systemic and local cecal tissue inflammatory responses, as indicated by increased levels of high mobility group box 1 protein (HMGB1), chemokines (C-X-C motif) ligand 10 (CXCL10), interleukin-6 (IL-6), and IL-10, as well as high mortality. Ketamine pretreatment alleviated death rates, symptoms, and the production of inflammatory cytokines induced by TNF-α in mice. Moreover, ketamine also protected the mice from TNF-α-induced cecal damage by suppressing the phosphorylation of receptor-interacting serine/threonine-protein kinase 3 (RIP3) and mixed lineage kinase domain-like protein (MLKL). In addition, our results showed that ketamine efficiently inhibited TNF-α-induced necroptosis in HT-29 and L929 cells. Furthermore, we explored the mechanism using different L929 cell lines. The results displayed that ketamine inhibited TNF-α-induced necroptosis by enhancing RIP1 ubiquitination and reducing the RIP1-RIP3 and RIP3-MLKL interactions, as well as the formation of necrosomes. Thus, our study may provide a new theoretical and experimental basis for treating diseases characterized by SIRS-associated inflammatory factor storms. Moreover, our exploration may provide potential molecular mechanisms and targets for therapeutic intervention and clinical application of ketamine.
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Kunkel S, Lenz T. Hemodynamics in Helicopter Emergency Medical Services (HEMS) Patients Undergoing Rapid Sequence Intubation With Etomidate or Ketamine. J Emerg Med 2022; 62:163-170. [PMID: 35031173 DOI: 10.1016/j.jemermed.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rapid sequence intubation (RSI) is performed by helicopter emergency medical services (HEMS) providers to establish airway control. Common induction agents are etomidate and ketamine, both touted to have relatively stable hemodynamic profiles. Limited data comparing these medications in the air medical setting exist. OBJECTIVE Compare administration of ketamine and etomidate on peri-intubation hemodynamics. METHODS A retrospective chart review of intubations performed by a HEMS program over 69 months was completed. Heart rate (HR) change, systolic blood pressure (SBP) change, and hypotension with etomidate or ketamine use were measured. RESULTS There were 258 patients induced with etomidate and 48 with ketamine. Etomidate patients showed a +1.161% change in HR (SD ± 22.7) and -0.49% change in SBP (SD ± 25.0). Ketamine patients showed a -4.7% change in HR (SD ± 16.7) and 17.2% change in SBP (SD ± 43.4). The p-values for percentage change in HR and SBP between etomidate and ketamine were 0.0830 and 0.0018, respectively. Twenty-five episodes of postadministration hypotension occurred with etomidate, and two with ketamine (p = 0.028). CONCLUSION Both ketamine and etomidate are appropriate for intubation of HEMS patients. Ketamine was preferentially selected for hypotensive patients with statistically significant improvement in SBP. Although statistically significant, both ketamine and etomidate had relative low incidences of hypotension.
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Affiliation(s)
- Scott Kunkel
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Flight For Life, Waukesha, Wisconsin
| | - Timothy Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Flight For Life, Waukesha, Wisconsin
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Ferguson I, Buttfield A, Burns B, Reid C, Shepherd S, Milligan J, Harris IA, Aneman A. Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial. Acad Emerg Med 2022; 29:719-728. [PMID: 35064992 PMCID: PMC9314707 DOI: 10.1111/acem.14446] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/30/2021] [Accepted: 01/10/2022] [Indexed: 01/21/2023]
Abstract
Objective The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre‐specified target range of 100–150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight‐based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100–150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first‐pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator‐free days 30 days following enrollment. Results A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = −10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First‐pass success rate, 30 day mortality, and ventilator‐free days were similar. Conclusions and Relevance There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.
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Affiliation(s)
- Ian Ferguson
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Emergency Department Liverpool Hospital Sydney New South Wales Australia
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
| | - Alexander Buttfield
- University of Western Sydney Sydney New South Wales Australia
- Campbelltown Hospital Sydney New South Wales Australia
| | - Brian Burns
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
- University of Sydney, Discipline of Emergency Medicine Sydney New South Wales Australia
- Northern Beaches Hospital Sydney New South Wales Australia
| | - Cliff Reid
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
- University of Sydney, Discipline of Emergency Medicine Sydney New South Wales Australia
- Northern Beaches Hospital Sydney New South Wales Australia
| | - Shamus Shepherd
- Orange Health Service Orange New South Wales Australia
- University of New South Wales Rural Clinical School Orange New South Wales Australia
| | - James Milligan
- Royal North Shore Hospital, St Leonards Sydney New South Wales Australia
- CareFlight Ltd Sydney New South Wales Australia
| | - Ian A. Harris
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Liverpool New South Wales Australia
| | - Anders Aneman
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Intensive Care Unit, Liverpool Hospital Liverpool New South Wales Australia
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Tarwade P, Smischney NJ. Endotracheal intubation sedation in the intensive care unit. World J Crit Care Med 2022; 11:33-39. [PMID: 35433310 PMCID: PMC8788207 DOI: 10.5492/wjccm.v11.i1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/21/2021] [Accepted: 11/04/2021] [Indexed: 02/06/2023] Open
Abstract
Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.
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Affiliation(s)
- Pritee Tarwade
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan J Smischney
- Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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George B, Joachim N. Evolving Techniques in RSI: Can the Choice of Induction Agent Matter in Securing a Definitive Airway in Emergency Settings? Indian J Crit Care Med 2022; 26:15-17. [PMID: 35110838 PMCID: PMC8783234 DOI: 10.5005/jp-journals-10071-24100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: George B, Joachim N. Evolving Techniques in RSI: Can the Choice of Induction Agent Matter in Securing a Definitive Airway in Emergency Settings? Indian J Crit Care Med 2022;26(1):15-17.
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Affiliation(s)
- Bindu George
- Department of Anaesthesiology, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Nayanthara Joachim
- Department of Anaesthesiology, St John's Medical College and Hospital, Bengaluru, Karnataka, India
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Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2022; 48:78-91. [PMID: 34904190 DOI: 10.1007/s00134-021-06577-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/02/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation. METHODS A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival. RESULTS Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294). CONCLUSION While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.
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Affiliation(s)
- Gerald Matchett
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Christina A Riccio
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Dawood Nasir
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Mary C Sunna
- Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA
| | - Brian J Bravenec
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Omaira Azizad
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Brian Farrell
- Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA
| | - Abu Minhajuddin
- Department of Population and Data Sciences, UT-Southwestern Medical Center, Dallas, TX, USA
- Department of Psychiatry, UT-Southwestern Medical Center, Dallas, TX, USA
| | - Jesse W Stewart
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Lawrence W Liang
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Tiffany Sun Moon
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Pamela E Fox
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Callie G Ebeling
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Miakka N Smith
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Devin Trousdale
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Babatunde O Ogunnaike
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022; 26:108-113. [PMID: 35110853 PMCID: PMC8783236 DOI: 10.5005/jp-journals-10071-24086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS AND OBJECTIVES The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. MATERIALS AND METHODS For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and ClinicalTrials.gov between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. RESULTS Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31-0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95-1.36; I 2 = 16%). CONCLUSION The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. HOW TO CITE THIS ARTICLE Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108-113.
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Affiliation(s)
- Saurabh C Sharda
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandip S Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Bandyopadhyay D, Lai C, Pulido JN, Restrepo-Jaramillo R, Tonelli AR, Humbert M. Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery. Eur Respir Rev 2021; 30:30/162/210166. [PMID: 34937705 DOI: 10.1183/16000617.0166-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/12/2021] [Indexed: 01/02/2023] Open
Abstract
Pulmonary hypertension (PH) confers a significant challenge in perioperative care. It is associated with substantial morbidity and mortality. A considerable amount of information about management of patients with PH has emerged over the past decade. However, there is still a paucity of information to guide perioperative evaluation and management of these patients. Yet, a satisfactory outcome is feasible by focusing on elaborate disease-adapted anaesthetic management of this complex disease with a multidisciplinary approach. The cornerstone of the peri-anaesthetic management of patients with PH is preservation of right ventricular (RV) function with attention on maintaining RV preload, contractility and limiting increase in RV afterload at each stage of the patient's perioperative care. Pre-anaesthetic evaluation, choice of anaesthetic agents, proper fluid management, appropriate ventilation, correction of hypoxia, hypercarbia, acid-base balance and pain control are paramount in this regard. Essentially, the perioperative management of PH patients is intricate and multifaceted. Unfortunately, a comprehensive evidence-based guideline is lacking to navigate us through this complex process. We conducted a literature review on patients with PH with a focus on the perioperative evaluation and suggest management algorithms for these patients during non-cardiac, non-obstetric surgery.
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Affiliation(s)
- Debabrata Bandyopadhyay
- Center for Advanced Lung Disease and Lung Transplant, University of South Florida - Tampa General Hospital, Tampa, FL, USA
| | - Christopher Lai
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,Assistance Publique Hôpitaux de Paris, Service de médecine intensive - réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Juan N Pulido
- Dept of Anesthesiology and Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA and US Anesthesia Partners - Washington, Seattle, WA, USA
| | - Ricardo Restrepo-Jaramillo
- Center for Advanced Lung Disease and Lung Transplant, University of South Florida - Tampa General Hospital, Tampa, FL, USA
| | - Adriano R Tonelli
- Dept of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA
| | - Marc Humbert
- Assistance Publique Hôpitaux de Paris, Service de médecine intensive - réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Peksa GD, Gottlieb M. Ketamine Should be the Preferred Agent for Rapid Sequence Intubation. Ann Emerg Med 2021; 78:722-723. [PMID: 34802588 DOI: 10.1016/j.annemergmed.2021.07.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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April MD, Long B, Brown CA. Etomidate Should be the Default Agent for Rapid Sequence Intubation in the Emergency Department. Ann Emerg Med 2021; 78:720-721. [PMID: 34802587 DOI: 10.1016/j.annemergmed.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Michael D April
- 40th Forward Resuscitative Surgical Detachment, 627 Hospital Center, Fort Carson, CO; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Airway management in critically ill patients. From International Studies to Clinical Practice – A summary from an EAMS webinar. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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