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Woodward MR, Kardon A, Manners J, Schleicher S, Pergakis MB, Ciryam P, Podell J, Denney Zimmerman W, Galvagno SM, Butt B, Pritchard J, Parikh GY, Gilmore EJ, Badjatia N, Morris NA. Comparison of induction agents for rapid sequence intubation in refractory status epilepticus: A single-center retrospective analysis. Epilepsy Behav Rep 2024; 25:100645. [PMID: 38299124 PMCID: PMC10827579 DOI: 10.1016/j.ebr.2024.100645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
Endotracheal intubation, frequently required during management of refractory status epilepticus (RSE), can be facilitated by anesthetic medications; however, their effectiveness for RSE control is unknown. We performed a single-center retrospective review of patients admitted to a neurocritical care unit (NCCU) who underwent in-hospital intubation during RSE management. Patients intubated with propofol, ketamine, or benzodiazepines, termed anti-seizure induction (ASI), were compared to patients who received etomidate induction (EI). The primary endpoint was clinical or electrographic seizures within 12 h post-intubation. We estimated the association of ASI on post-intubation seizure using logistic regression. A sub-group of patients undergoing electroencephalography during intubation was identified to evaluate the immediate effect of ASI on RSE. We screened 697 patients admitted to the NCCU for RSE and identified 148 intubated in-hospital (n = 90 ASI, n = 58 EI). There was no difference in post-intubation seizure (26 % (n = 23) ASI, 29 % (n = 17) EI) in the cohort, however, there was increased RSE resolution with ASI in 24 patients with electrographic RSE during intubation (ASI: 61 % (n = 11/18) vs EI: 0 % (n = 0/6), p =.016). While anti-seizure induction did not appear to affect post-intubation seizure occurrence overall, a sub-group of patients undergoing electroencephalography during intubation had a higher incidence of seizure cessation, suggesting potential benefit in an enriched population.
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Affiliation(s)
- Matthew R. Woodward
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Adam Kardon
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Jody Manners
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Samantha Schleicher
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa B. Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Prajwal Ciryam
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Jamie Podell
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - William Denney Zimmerman
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Samuel M. Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bilal Butt
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Jennifer Pritchard
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gunjan Y. Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Emily J. Gilmore
- Department of Neurology, Yale University School of Medicine, 20 York Street, New Haven, CT, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
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Egan ED, Johnson KB. The Influence of Hemorrhagic Shock on the Disposition and Effects of Intravenous Anesthetics: A Narrative Review. Anesth Analg 2020; 130:1320-1330. [PMID: 32149755 DOI: 10.1213/ane.0000000000004654] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The need to reduce the dose of intravenous anesthetic in the setting of hemorrhagic shock is a well-established clinical dogma. Considered collectively,; the body of information concerning the behavior of intravenous anesthetics during hemorrhagic shock, drawn from animal and human data, confirms that clinical dogma and informs the rational selection and administration of intravenous anesthetics in the setting of hemorrhagic shock. The physiologic changes during hemorrhagic shock can alter pharmacokinetics and pharmacodynamics of intravenous anesthetics. Decreased size of the central compartment and central clearance caused by shock physiology lead to an altered dose-concentration relationship. For most agents and adjuncts, shock leads to substantially higher concentrations and increased effect. The notable exception is etomidate, which has relatively unchanged pharmacokinetics during shock. Increased concentrations lead to increased primary effect as well as increased side effects, notably cardiovascular effects. Pharmacokinetic changes are essentially reversed for all agents by fluid resuscitation. Propofol is unique among agents in that, in addition to the pharmacokinetic changes, it exhibits increased potency during shock. The pharmacodynamic changes of propofol persist despite fluid resuscitation. The persistence of these pharmacodynamic changes during shock is unlikely to be due to increased endogenous opiates, but is most likely due to increased fraction of unbound propofol. The stage of shock also appears to influence the pharmacologic changes. The changes are more rapid and pronounced as shock physiology progresses to the uncompensated stage. Although scant, human data corroborate the findings of animal studies. Both the animal and human data inform the rational selection and administration of intravenous anesthetics in the setting of hemorrhagic shock. The well-entrenched clinical dogma that etomidate is a preferred induction agent in patients experiencing hemorrhagic shock is firmly supported by the evidence. Propofol is a poor choice for induction or maintenance of anesthesia in severely bleeding patients, even with resuscitation; this can include emergent trauma cases or scheduled cases that routinely have mild or moderate blood loss.
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Affiliation(s)
- Ezekiel D Egan
- From the Department of Anesthesiology, University of Utah, Salt Lake City, Utah
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Abstract
Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.
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Affiliation(s)
- Nicholas Kramer
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Lebowitz
- Office of Faculty and Academic Affairs, University of Central Florida College of Medicine, Orlando, USA
| | - Michael Walsh
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Latha Ganti
- Clinical Sciences, University of Central Florida College of Medicine, Orlando, USA
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Yu JB, Dong SA, Gong LR, Wang M, Mu R, Li C, Zhang Y, Li ZD. Effect of electroacupuncture at Zusanli (ST36) and Sanyinjiao (SP6) acupoints on adrenocortical function in etomidate anesthesia patients. Med Sci Monit 2014; 20:406-12. [PMID: 24621826 PMCID: PMC3958570 DOI: 10.12659/msm.890111] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background We aimed to investigate the effect of electroacupuncture at Zusanli (ST36) and Sanyinjiao (SP6) on adrenocortical function in patients with etomidate anesthesia. Material/Methods We randomly divided 80 patients who underwent elective surgery into 4 groups: group etomidate (ETO), group etomidate + electroacupuncture (ETO+EA), group etomidate + sham acupuncture (ETO+SEA), and group propofol (PRO). The patients in group ETO, ETO+EA, and ETO+SEA were induced with etomidate and sufentanil and maintained with intravenous infusion of etomidate and remifentanil. Group PRO was induced with propofol and sufentanil and maintained with propofol and remifentanil. Group ETO+EA received electro-acupuncture stimulation at Zusanli and Sanyinjiao throughout the operation, while group ETO+SEA received electro-acupuncture stimulation at non-acupoints. We recorded the values of MAP, HR, BIS, CVP, cortisol, ACTH, epinephrine, norepinephrine, and arterial blood gas during the perioperative period. Results Cortisol concentrations were significantly higher at all times except T0 in group ETO+EA compared with group ETO. The ACTH concentrations were lower in group ETO+EA than that in group ETO at point T3. Conclusions Electroacupuncture at ST 36 and SP 6 can mitigate the adrenal cortical inhibition induced by etomidate and can reduce the secretion of catecholamines during surgery.
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Affiliation(s)
- Jian-bo Yu
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Shu-an Dong
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Li-rong Gong
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Man Wang
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Rui Mu
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Cui Li
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Yuan Zhang
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
| | - Zhao-duan Li
- Department of Anesthesiology, Nankai Hospital, Tianjin Medical University, Tianjin, China (mainland)
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The Effect of a Bolus Dose of Etomidate on Cortisol Levels, Mortality, and Health Services Utilization: A Systematic Review. Ann Emerg Med 2010; 56:105-13.e5. [DOI: 10.1016/j.annemergmed.2010.01.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 01/21/2010] [Accepted: 01/29/2010] [Indexed: 11/23/2022]
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Talavera JA, Esser SK, Amzica F, Hill S, Antognini JF. Modeling the GABAergic action of etomidate on the thalamocortical system. Anesth Analg 2009; 108:160-7. [PMID: 19095844 DOI: 10.1213/ane.0b013e31818d40aa] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We have used a computational model of the thalamocortical system to investigate the effects of a GABAergic anesthetic (etomidate) on cerebral cortical and thalamic neuronal function. We examined the effects of phasic and tonic inhibition, as well as the relative importance of anesthetic action in the thalamus and cortex. METHODS The amount of phasic GABAergic inhibition was adjusted in the model to simulate etomidate concentrations of between 0.25 and 2 microM, with the concentration range producing unconsciousness assumed to be between 0.25 and 0.5 microM. In addition, we modeled tonic inhibition separately, and then phasic and tonic inhibition together. We also introduced phasic and tonic inhibition into the cerebral cortex and thalamus separately to determine the relative importance of each of these structures to anesthetic-induced depression of the thalamocortical system. RESULTS Phasic inhibition decreased cortical neuronal firing by 11%-18% in the 0.25-0.5 microM range and by 38% at 2 microM. Tonic inhibition produced similar depression (11%-21%) in the 0.25-0.5 microM range but 65% depression at 2 microM; phasic and tonic inhibition combined produced the most inhibition (76% depression at 2 microM). When the thalamus and cortex were separately subjected to phasic and tonic inhibition, cortical firing rates decreased less compared to when both structures were targeted. In the 0.25-0.5 microM range, cortical firing rate was minimally affected when etomidate action was simulated in the thalamus only. CONCLUSIONS This computational model of the thalamocortical system indicated that tonic GABAergic inhibition seems to be more important than phasic GABAergic inhibition (especially at larger etomidate concentrations), although both combined had the most effect on cerebral cortical firing rates. Furthermore, etomidate action in the thalamus, by itself, does not likely explain etomidate-induced unconsciousness.
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Affiliation(s)
- Jason A Talavera
- Department of Anesthesiology and Pain Medicine, University of California, Davis, CA 95616, USA
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Abstract
The major advantage of etomidate is its lack of cardiovascular side effects. In addition, etomidate is supposed to be neuroprotective. The side effects of etomidate include adrenal suppression and myocloni. A review of the recent literature on etomidate, its clinical use, its side effects and its mechanism of action was performed. Among others, major recent advances include a new drug preparation devoid of propylene glycol and its side effects, a new pretreatment technique that may reduce the incidence of myocloni, and the identification of its site of action in the central nervous system.
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Affiliation(s)
- P Ostwald
- Institute of Anaesthesiology, Ludwig-Maximilians-University, Munich, Germany.
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Kox WJ, von Heymann C, Heinze J, Prichep LS, John ER, Rundshagen I. Electroencephalographic Mapping During Routine Clinical Practice: Cortical Arousal During Tracheal Intubation? Anesth Analg 2006; 102:825-31. [PMID: 16492836 DOI: 10.1213/01.ane.0000197776.26307.fa] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We used quantitative analysis of the electroencephalogram (EEG) in 42 patients to assess the effect of tracheal intubation after induction of anesthesia with etomidate and sufentanil using standard clinical practice. The EEG was recorded from eight bipolar electrode derivations and Z-transformed relative to age expected normative data for relative power in the delta, theta, alpha, and beta frequency bands. Tracheal intubation resulted in classical cortical arousal, as indicated by acceleration of the EEG frequencies. Significant effects were seen in all frequency bands, most pronounced in the alpha frequency band, with the largest increase bilaterally in the fronto-temporal regions (F-values: Delta - 9.592, P < 0.001; theta - 1.691, P < 0.001; alpha - 18.439, P < 0.001; beta - 4.504, P < 0.001). Changes in alpha and delta power during induction of anesthesia were correlated with the dose of etomidate (P < 0.05). Changes in alpha after tracheal intubation were correlated at the parietooccipital brain regions to the dose of sufentanil (P < 0.05). Individual titration of the dose of etomidate and sufentanil, as during routine clinical practice, is not sufficient to block the strong noxious stimulation of tracheal intubation and results in cortical arousal. The clinical impact of this cortical wake-up phenomenon is undetermined.
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Johnson KB, Egan TD, Layman J, Kern SE, White JL, McJames SW. The influence of hemorrhagic shock on etomidate: a pharmacokinetic and pharmacodynamic analysis. Anesth Analg 2003; 96:1360-1368. [PMID: 12707134 DOI: 10.1213/01.ane.0000055804.30509.69] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We studied the influence of hemorrhagic shock on the pharmacology of etomidate in swine. Sixteen swine were randomly assigned to control and shock groups. The shock group was bled to a mean arterial blood pressure of 50 mm Hg and held there until 30 mL/kg blood was removed. Etomidate 300 micro g x kg(-1) x min(-1) was infused for 10 min to both groups. Fifteen arterial samples were collected until 180 min after the infusion began to determine drug concentration. Pharmacokinetic variables for each group were estimated by using a three-compartment model. The bispectral index scale was used as a measure of drug effect. The pharmacodynamics were characterized by using a sigmoid inhibitory maximal effect model. The raw data revealed a 25% increase in the plasma etomidate concentration at the end of the 10-min infusion which resolved after termination of the infusion in the shock group. The pharmacokinetic analysis revealed subtle changes in the variable estimates between groups. The etomidate infusion produced a similar Bispectral Index Scale change in both groups. These results demonstrated that, unlike the influence of hemorrhagic shock on other sedative hypnotics and opioids, moderate hemorrhagic shock produced minimal changes in the pharmacokinetics and no change in the pharmacodynamics of etomidate. IMPLICATIONS Hemorrhagic shock produced minimal changes in the pharmacokinetics and no change in the pharmacodynamics of etomidate in swine. These results suggest that, unlike other sedative hypnotics and opioids, minimal adjustment in the dose of etomidate is required to achieve the same drug effect during hemorrhagic shock.
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Affiliation(s)
- Ken B Johnson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
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Kociszewski C, Thomas SH, Harrison T, Wedel SK. Etomidate versus succinylcholine for intubation in an air medical setting. Am J Emerg Med 2000; 18:757-63. [PMID: 11103724 DOI: 10.1053/ajem.2000.18033] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The objective was to compare rates of successful endotracheal intubation (ETI) and requirement for multiple ETI attempts in patients receiving etomidate (ETOM) versus succinylcholine (SUX). This retrospective study analyzed adults in whom oral ETI was attempted by a helicopter EMS (HEMS) service between July 1997 to July 1999. Data were from records of the HEMS service, which uses a RN/EMTP crew; analysis was with chi-square and logistic regression (P = .05). ETI was successful in 269 (97.8%) of 275 patients, with multiple attempts occurring in 54 (20.1%) of 269. Success rates for SUX (209 of 213, 98.1%) and ETOM (60 of 62, 96.8%) were similar (P = .62). However, of 60 ETOM patients successfully intubated, 7 (11.7%) required rescue succinylcholine. When these patients are tallied as ETOM failures and SUX successes, resultant success rates for ETOM (86.9%) and SUX (98.2%) are different (P = .001). ETOM patients were more likely (P = .004) than SUX patients to require multiple attempts (33.3% versus 16.3%). ETI success rates were high in patients receiving SUX or ETOM as primary adjuncts for airway control, but initial success was more likely with SUX, and ETOM patients were more likely to require multiple attempts.
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Affiliation(s)
- C Kociszewski
- Boston Medflight Critical Care Transport Service, MA, USA
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Roso NDC, Abrão J, Alves Neto J. [Etomidate and vecuronium in induction of anesthesia of chronic Chagas' cardiopathy]. Rev Soc Bras Med Trop 1999; 32:41-6. [PMID: 9927824 DOI: 10.1590/s0037-86821999000100008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Fifteen chagasic and 26 non-chagasic patients were evaluated for hemodynamic and cardiovascular responses during induction of anesthesia with etomidate (a hypnotic agent) and Vecuronium (a neuromuscular blocker). Blood for serum testing was collected during anesthesia. Blood pressure, heart rate and rhythm, mean arterial pressure and arterial oxygen saturation were also monitored on six different occasions during anesthesia. When the various stages of anesthesia were compared, significant differences in blood pressure and heart rate were observed. For any of the given stages of anesthesia blood pressure and heart rate did not show significant differences when chagasic were compared to non-chagasic patients. Arterial oxygen saturation remained steady in all cases. We conclude that both drugs are safe for use during the induction of anesthesia in chronic chagasic patients.
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Affiliation(s)
- N de C Roso
- Disciplina de Anestesiologia da Faculdade de Medicina do Triângulo Mineiro, Uberaba, MG, Brasil
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