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Lee J, Kim DH, Ju JW, Nam K, Cho YJ, Jeon Y, Lee S. Comparison of recovery profiles between total intravenous anaesthesia with propofol or remimazolam reversed with flumazenil in patients undergoing breast surgery: A randomised controlled trial. Eur J Anaesthesiol 2024; 41:199-207. [PMID: 38205822 DOI: 10.1097/eja.0000000000001951] [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: 01/12/2024]
Abstract
BACKGROUND Remimazolam, a short acting benzodiazepine, is being used for general anaesthesia. The results of studies comparing recovery after propofol with that of remimazolam are inconsistent. Given that flumazenil reverses the sedative effects of remimazolam, we hypothesised that it would speed up recovery from remimazolam general anaesthesia. OBJECTIVES The aim of this trial was to compare the speed of recovery from general anaesthesia between propofol and remimazolam reversed with flumazenil in patients undergoing minimally invasive breast surgery. DESIGN Randomised, single-centre, double-blind controlled trial. SETTING A tertiary teaching hospital in South Korea from August 2022 to December 2022. PATIENTS Adult patients (≥19 years of age) about to undergo general anaesthesia for scheduled breast cancer surgery. INTERVENTIONS Patients were randomly allocated to either the propofol or the remimazolam/flumazenil group. The emergence process was monitored by only one anaesthesiologist. MAIN OUTCOME MEASURES The primary outcome was the time to eye opening to command during recovery from the general anaesthesia. Time to removal of the supraglottic airway (SGA) time to discharge, and the Riker sedation agitation scale (SAS) score (1 to 4) during emergence were compared as secondary outcomes. RESULTS The remimazolam group had a significantly shorter mean time to eye opening than the propofol group [127 ± 51 vs. 314 ± 140 s; mean difference 187 s (95% confidence interval (CI), 133 to 241 s; P < 0.001]. The remimazolam group also had shorter times to SGA removal [169 ± 51 vs. 366 ± 149 s; mean difference 198 s (95% CI, 140 to 255 s); P < 0.001] and time to discharge from the operating room [243 ± 55 vs. 449 ± 159 s; mean difference 206 s (95% CI, 145 to 267 s); P < 0.001]. The SAS scores during emergence also differed significantly, with 1 patient in the propofol group and 25 in the remimazolam group attaining scores of 4 ( P < 0.001). CONCLUSION Administration of remimazolam with flumazenil may be a promising option for patients undergoing breast cancer surgery, providing faster recovery and better SAS scores than propofol during emergence from general anaesthesia. TRIAL REGISTRATION ClinicalTrials.gov (NCT05435911).
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Affiliation(s)
- Jaemoon Lee
- From the Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea (JL, DHK, JWJ, KN, YJC, YJ, SL) and Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University College of Medicine, Seoul, Republic of Korea (JL)
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Braithwaite HE, Payne T, Duce N, Lim J, McCulloch T, Loadsman J, Leslie K, Webster AC, Gaskell A, Sanders RD. Impact of female sex on anaesthetic awareness, depth, and emergence: a systematic review and meta-analysis. Br J Anaesth 2023; 131:510-522. [PMID: 37453840 DOI: 10.1016/j.bja.2023.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Suggested anaesthetic dose ranges do not differ by sex, likely because of limited studies comparing sexes. Our objective was to systematically synthesise studies with outcomes of unintended anaesthesia awareness under anaesthesia, intraoperative connected consciousness, time to emergence from anaesthesia, and dosing to achieve adequate depth of anaesthesia, and to compare between females and males. METHODS Studies were identified from MEDLINE, Embase, and the Cochrane library databases until August 2, 2022. Controlled clinical trials (randomised/non-randomised) and prospective cohort studies that reported outcomes by sex were included. Results were synthesised by random effects meta-analysis where possible, or narrative form. RESULTS Of the 19 749 studies identified, 64 (98 243 participants; 53 143 females and 45 100 males) were eligible for inclusion, and 44 citations contributed to meta-analysis. Females had a higher incidence of awareness with postoperative recall (33 studies, odds ratio 1.38, 95% confidence interval [CI] 1.09-1.75) and connected consciousness during anaesthesia (three studies, OR 2.09, 95% CI 1.04-4.23) than males. Time to emergence was faster in females, including time to eye-opening (10 studies, mean difference -2.28 min, 95% CI -3.58 to -0.98), and time to response to command (six studies, mean difference -2.84 min, 95% CI -4.07 to -1.62). Data on depth of anaesthesia were heterogenous, limiting synthesis to a qualitative review which did not identify sex differences. CONCLUSIONS Female sex was associated with a greater incidence of awareness under general anaesthesia, and faster emergence from anaesthesia. These data suggest reappraisal of anaesthetic care, including whether similar drug dosing for females and males represents best care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022336087.
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Affiliation(s)
- Hannah E Braithwaite
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia.
| | - Thomas Payne
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia; Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nicholas Duce
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia
| | - Jessica Lim
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia
| | - Tim McCulloch
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia
| | - John Loadsman
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Dentistry and Health Sciences, Monash University, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia; National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Amy Gaskell
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
| | - Robert D Sanders
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia; Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia; National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Diego LADS. Anesthesia and women's peculiarities. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023S103. [PMID: 37556622 PMCID: PMC10411693 DOI: 10.1590/1806-9282.2023s103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/23/2023] [Indexed: 08/11/2023]
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Vincent KF, Mallari OG, Dillon EJ, Stewart VG, Cho AJ, Dong Y, Edlow AG, Ichinose F, Xie Z, Solt K. Oestrous cycle affects emergence from anaesthesia with dexmedetomidine, but not propofol, isoflurane, or sevoflurane, in female rats. Br J Anaesth 2023; 131:67-78. [PMID: 37142466 PMCID: PMC10308440 DOI: 10.1016/j.bja.2023.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Although sex differences in anaesthetic sensitivity have been reported, what underlies these differences is unknown. In rodents, one source of variability in females is the oestrous cycle. Here we test the hypothesis that the oestrous cycle impacts emergence from general anaesthesia. METHODS Time to emergence was measured after isoflurane (2 vol% for 1 h), sevoflurane (3 vol% for 20 min), dexmedetomidine (50 μg kg-1 i.v., infused over 10 min), or propofol (10 mg kg-1 i.v. bolus) during proestrus, oestrus, early dioestrus, and late dioestrus in female Sprague-Dawley rats (n=24). EEG recordings were taken during each test for power spectral analysis. Serum was analysed for 17β-oestradiol and progesterone concentrations. The effect of oestrous cycle stage on return of righting latency was assessed using a mixed model. The association between righting latency and serum hormone concentration was tested by linear regression. Mean arterial blood pressure and arterial blood gases were assessed in a subset of rats after dexmedetomidine and compared in a mixed model. RESULTS Oestrous cycle did not affect righting latency after isoflurane, sevoflurane, or propofol. When in the early dioestrus stage, rats emerged more rapidly from dexmedetomidine than in the proestrus (P=0.0042) or late dioestrus (P=0.0230) stage and showed reduced overall power in frontal EEG spectra 30 min after dexmedetomidine (P=0.0049). 17β-Oestradiol and progesterone serum concentrations did not correlate with righting latency. Oestrous cycle did not affect mean arterial blood pressure or blood gases during dexmedetomidine. CONCLUSIONS In female rats, the oestrous cycle significantly impacts emergence from dexmedetomidine-induced unconsciousness. However, 17β-oestradiol and progesterone serum concentrations do not correlate with the observed changes.
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Affiliation(s)
- Kathleen F Vincent
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Olivia G Mallari
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Emmaline J Dillon
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Brigham Young University, Provo, UT, USA
| | - Victoria G Stewart
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Brigham Young University, Provo, UT, USA
| | - Angel J Cho
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Touro College of Osteopathic Medicine, New York, NY, USA
| | - Yuanlin Dong
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Andrea G Edlow
- Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Zhongcong Xie
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.
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Syeda S, Bansal S, Chakrabarti D, Bhadrinarayan V. The requirement of propofol for induction of anesthesia in patients with traumatic brain injury determined using bilateral bispectral index and target controlled infusion - An observational cohort study. J Anaesthesiol Clin Pharmacol 2023; 39:208-214. [PMID: 37564867 PMCID: PMC10410018 DOI: 10.4103/joacp.joacp_216_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 08/12/2023] Open
Abstract
Background and Aims Patients with traumatic brain injury (TBI) frequently require emergency surgery. There is a paucity of literature with regard to anesthetic requirements in these patients. The aim of the study was to compare the dose of propofol required for induction of anesthesia in patients with different grades of TBI. Material and Methods This prospective, observational study included patients with mild, moderate, and severe grades of TBI undergoing emergency surgery within 48 h of injury. Bispectral Index (BIS) values were recorded using a bilateral BIS sensor. Anesthesia was induced with a target controlled infusion (TCI) pump. Once BIS reached 40, plasma (Cp) and effect-site (Ce) concentration and total dose of propofol required were noted from the TCI pump. Results Of the 96 patients recruited, 27, 36, and 33 patients belonged to mild, moderate, and severe TBI (sTBI) groups, respectively. The Ce of propofol in mild, moderate, and sTBI groups was 6 ± 0.9, 5.82 ± 0.98, and 4.48 ± 1.5 μg/mL (P < 0.001), and the dose of propofol required was 1.9 ± 0.2, 1.8 ± 0.4, 1.41 ± 0.5 mg/kg, respectively (P < 0.001). Baseline BIS on the injured side was 80 ± 7.8, 71 ± 9.4, 55 ± 11.6, and on the uninjured side was 89 ± 5.5, 81 ± 8.4, and 65 ± 12 in mild, moderate, and sTBI groups, respectively. Conclusions The requirement of propofol was reduced in patients with sTBI. The dose of propofol required for induction of anesthesia as determined using Ce was significantly lower only between sTBI and mild TBI and not between patients with sTBI and moderate TBI or between mild and moderate head injury. BIS values were significantly different between the groups (highest in mild TBI and lowest in sTBI) and between normal and injured sides within each group.
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Affiliation(s)
- Seham Syeda
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sonia Bansal
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - V. Bhadrinarayan
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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Ito T, Utsumi N, Baba Y, Matsumura T, Wakita R, Maeda S. Considerations for Satisfactory Sedation during Dental Implant Surgery. J Pers Med 2023; 13:461. [PMID: 36983643 PMCID: PMC10054855 DOI: 10.3390/jpm13030461] [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: 01/24/2023] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Implant surgery is a lengthy dental procedure, and sedation is often used to reduce discomfort. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Additionally, adequate pain control is a necessary requirement for patient and surgeon satisfaction. Most patients undergoing implant surgery are middle-aged or older, and a relatively large number of them have cardiovascular disease. Infiltration anesthesia using articaine or lidocaine in combination with adrenaline is widely used, but its use in patients with cardiovascular disease is limited because of adrenaline's effects on the cardiovascular system. The use of long-acting local anesthetics and the potential efficacy of ultrasound-guided jaw nerve block have been investigated to enhance analgesia without resorting to adrenaline. Midazolam and propofol are usually used for sedation, but dexmedetomidine, which causes less respiratory depression, and the ultrashort-acting benzodiazepine remimazolam are emerging as potential alternatives. Monitoring of anesthetic depth using electroencephalography is effective in maintaining a constant level of sedation. In addition, sedation promotes the stabilization of heart rate and blood pressure, reducing the risks associated with adrenaline and allowing for safer management.
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Affiliation(s)
| | | | | | | | | | - Shigeru Maeda
- Department of Dental Anesthesiology and Orofacial Pain Management, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
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Oner S, Onen E, Caglayan V, Avci S, Erdogan A, Kilic M, Topal S. The effect of anesthesia type on the outcomes of percutaneous nephrolithotomy in elderly males. Ann Med 2023; 55:2238185. [PMID: 37480584 PMCID: PMC10364566 DOI: 10.1080/07853890.2023.2238185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/08/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023] Open
Abstract
Objective: To compare the anaesthesia methods in percutaneous nephrolithotomy in terms of safety and effectiveness in elderly men.Methods: Elderly male patients who had undergone percutaneous nephrolithotomy were screened retrospectively and divided into 2 groups: percutaneous nephrolithotomy under combined spino-epidural anaesthesia (Group CSEA, n = 70) and percutaneous nephrolithotomy under general anaesthesia (Group GA, n = 114). Preoperative, perioperative and postoperative outcome measures were examined.Results: Between the two groups, there was no statistically significant difference in terms of stone burden, stone location, presence of the previous operation in the same kidney, presence of staghorn stones, mean American Society of Anesthesiologists scores and presence of abnormal kidney (p > 0.05). The mean duration time in the operation room and post-anaesthesia care unit (PACU) was statistically shorter in the Group CSEA (p < 0.01). There was no significant difference between the two groups in terms of Clavien Grade 1 and above complications (p > 0.05). Stone-free rates and success rates were similar in both groups (p = 0.133 and p = 0.273, respectively).Conclusion: The type of anaesthesia does not affect the success rate and complication rate of percutaneous nephrolithotomy in elderly male patients. Patients who underwent percutaneous nephrolithotomy under CSEA needed less analgesic injection during the postoperative period. CSEA can shorten the time a patient spends in the operating room and PACU, which provides more effective use of operation room working hours.
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Affiliation(s)
- Sedat Oner
- Department of Urology, University of Health Sciences Bursa City Hospital, Bursa, Turkey
| | - Efe Onen
- Department of Urology, University of Health Sciences Bursa City Hospital, Bursa, Turkey
| | - Volkan Caglayan
- Department of Urology, University of Health Sciences Bursa City Hospital, Bursa, Turkey
| | - Sinan Avci
- Department of Urology, University of Health Sciences Bursa City Hospital, Bursa, Turkey
| | - Abdullah Erdogan
- Department of Urology, University of Health Sciences Bursa City Hospital, Bursa, Turkey
| | - Metin Kilic
- Department of Urology, University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Serra Topal
- Department of Anesthesiology, University of Health Sciences Bursa City Hospital, Bursa, Turkey
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Zhang Y, Li H, Zhang X, Wang S, Wang D, Wang J, Tong T, Zhang Z, Yang Q, Dong H. Estrogen Receptor-A in Medial Preoptic Area Contributes to Sex Difference of Mice in Response to Sevoflurane Anesthesia. Neurosci Bull 2022; 38:703-719. [PMID: 35175557 PMCID: PMC9276904 DOI: 10.1007/s12264-022-00825-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/20/2021] [Indexed: 11/26/2022] Open
Abstract
A growing number of studies have identified sex differences in response to general anesthesia; however, the underlying neural mechanisms are unclear. The medial preoptic area (MPA), an important sexually dimorphic structure and a critical hub for regulating consciousness transition, is enriched with estrogen receptor alpha (ERα), particularly in neuronal clusters that participate in regulating sleep. We found that male mice were more sensitive to sevoflurane. Pharmacological inhibition of ERα in the MPA abolished the sex differences in sevoflurane anesthesia, in particular by extending the induction time and facilitating emergence in males but not in females. Suppression of ERα in vitro inhibited GABAergic and glutamatergic neurons of the MPA in males but not in females. Furthermore, ERα knockdown in GABAergic neurons of the male MPA was sufficient to eliminate sex differences during sevoflurane anesthesia. Collectively, MPA ERα positively regulates the activity of MPA GABAergic neurons in males but not in females, which contributes to the sex difference of mice in sevoflurane anesthesia.
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Affiliation(s)
- Yunyun Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Huiming Li
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Xinxin Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Sa Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Dan Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Jiajia Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Tingting Tong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Zhen Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Qianzi Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China.
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China.
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Joksimovic SM, Sampath D, Krishnan K, Covey DF, Jevtovic-Todorovic V, Raol YH, Todorovic SM. Differential effects of the novel neurosteroid hypnotic (3β,5β,17β)-3-hydroxyandrostane-17-carbonitrile on electroencephalogram activity in male and female rats. Br J Anaesth 2021; 127:435-446. [PMID: 33972091 PMCID: PMC8451239 DOI: 10.1016/j.bja.2021.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We recently showed that a neurosteroid analogue, (3β,5β,17β)-3-hydroxyandrostane-17-carbonitrile (3β-OH), induced hypnosis in rats. The aim of the present study was to evaluate the hypnotic and anaesthetic potential of 3β-OH further using electroencephalography. METHODS We used behavioural assessment and cortical electroencephalogram (EEG) spectral power analysis to examine hypnotic and anaesthetic effects of 3β-OH (30 and 60 mg kg-1) administered intraperitoneally or intravenously to young adult male and female rats. RESULTS We found dose-dependent sex differences in 3β-OH-induced hypnosis and EEG changes. Both male and female rats responded similarly to i.p. 3β-OH 30 mg kg-1. However, at the higher dose (60 mg kg-1, i.p.), female rats had two-fold longer duration of spontaneous immobility than male rats (203.4 [61.6] min vs 101.3 [32.1] min), and their EEG was suppressed in the low-frequency range (2-6 Hz), in contrast to male rats. Although a sex-dependent hypnotic effect was not confirmed after 30 mg kg-1 i.v., female rats appeared more sensitive to 3β-OH with relatively small changes within delta (1-4 Hz) and alpha (8-13 Hz) bands. Finally, 3β-OH had a rapid onset of action and potent hypnotic/anaesthetic effect after 60 mg kg-1 i.v. in rats of both sexes; however, all female rats and only half of the male rats reached burst suppression, an EEG pattern usually associated with profound inhibition of thalamocortical networks. CONCLUSIONS Based on its behavioural effects and EEG signature, 3β-OH is a potent hypnotic in rats, with female rats being more sensitive than male rats.
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Affiliation(s)
- Srdjan M Joksimovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA.
| | - Dayalan Sampath
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University System, College Station, TX, USA
| | - Kathiresan Krishnan
- Department of Developmental Biology, Washington University School of Medicine, St Louis, MO, USA
| | - Douglas F Covey
- Department of Developmental Biology, Washington University School of Medicine, St Louis, MO, USA; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St Louis, MO, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Yogendra H Raol
- Department of Pediatrics, Division of Neurology, Translational Epilepsy Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Slobodan M Todorovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Neuroscience Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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Moody OA, Vincent KF, Solt K. Sex, drugs, and anaesthesia research. Br J Anaesth 2021; 127:340-343. [PMID: 34330415 DOI: 10.1016/j.bja.2021.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/29/2022] Open
Abstract
In this issue of the British Journal of Anaesthesia, Joksimovic and colleagues report significant sex differences in sensitivity to the behavioural and neurophysiological effects of 3β-OH, a novel neurosteroid anesthetic. Female rats were more sensitive to the effects of 3β-OH than male rats, although the mechanims remain unclear. Sex differences have been understudied in anaesthesia research, and this article by Joksimovic and colleagues emphasizes the need to devote more effort to understanding these differences.
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Affiliation(s)
- Olivia A Moody
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Kathleen F Vincent
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.
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11
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Tams C, Dooley FC, Sangari TS, Gonzalez-Rodriguez SN, Stoker RE, Phillips SA, Koenig M, Wishin JM, Molinari SC, Blakemore LC, Seubert CN. Methadone and a Clinical Pathway in Adolescent Idiopathic Scoliosis Surgery: A Historically Controlled Study. Global Spine J 2020; 10:837-843. [PMID: 32905725 PMCID: PMC7485079 DOI: 10.1177/2192568219878135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
STUDY DESIGN Historically controlled clinical trial. OBJECTIVES Patients presenting for correction of adolescent idiopathic scoliosis (AIS) by posterior spinal fusion may benefit from structured clinical pathways. We studied the effects of implementing a published clinical pathway for the perioperative care of patients with AIS that required intraoperative use of methadone at our institution. METHODS We performed a historically controlled clinical trial of patients undergoing posterior spinal fusion for AIS by comparing a retrospectively collected control group of 25 patients with a prospective experimental group of 14 patients receiving methadone, gabapentin, propofol, and remifentanil as part of a new clinical pathway. RESULTS Use of the pathway decreased average pain scores evaluated by the Numeric Rating Scale in the 24 hours following surgery (4.8 [4-6] to 3.4 [2-4], P = .03 [-2.6 to -0.2; t = -2.3]) and postoperative opioid consumption by 76% (41 [29-51] mg to 10 [4-17] mg, P < .001 [-45 to -15; Welch's t = 4.9]) during the same period. Improved analgesia and reduced reliance on opioids facilitated other postoperative elements of the clinical pathway and shortened the average hospital length of stay by 1 day (4 [3-6] days to 3 [3-5] days, P = .001 [-2 to -1; U = 67, Z = -3.3]). CONCLUSIONS Multimodal analgesia and a clinical pathway add value in the perioperative care of patients undergoing posterior spinal fusion for AIS by improving analgesia and shortening hospitalization. The prospective arm of the trial was registered at clinicaltrials.gov under NCT02481570.
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Affiliation(s)
- Carl Tams
- University of Utah, Salt Lake City, UT, USA,University of Utah Hospital, Salt Lake City, UT, USA
| | - F. Cole Dooley
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | | | | | | | - Megan Koenig
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | | | | | - Christoph N. Seubert
- University of Utah Hospital, Salt Lake City, UT, USA,Christoph N. Seubert, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA.
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12
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Simonovsky E, Schuster R, Yeger-Lotem E. Large-scale analysis of human gene expression variability associates highly variable drug targets with lower drug effectiveness and safety. Bioinformatics 2020; 35:3028-3037. [PMID: 30649201 PMCID: PMC6735839 DOI: 10.1093/bioinformatics/btz023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 12/02/2018] [Accepted: 01/08/2019] [Indexed: 01/31/2023] Open
Abstract
Motivation The effectiveness of drugs tends to vary between patients. One of the well-known reasons for this phenomenon is genetic polymorphisms in drug target genes among patients. Here, we propose that differences in expression levels of drug target genes across individuals can also contribute to this phenomenon. Results To explore this hypothesis, we analyzed the expression variability of protein-coding genes, and particularly drug target genes, across individuals. For this, we developed a novel variability measure, termed local coefficient of variation (LCV), which ranks the expression variability of each gene relative to genes with similar expression levels. Unlike commonly used methods, LCV neutralizes expression levels biases without imposing any distribution over the variation and is robust to data incompleteness. Application of LCV to RNA-sequencing profiles of 19 human tissues and to target genes of 1076 approved drugs revealed that drug target genes were significantly more variable than protein-coding genes. Analysis of 113 drugs with available effectiveness scores showed that drugs targeting highly variable genes tended to be less effective in the population. Furthermore, comparison of approved drugs to drugs that were withdrawn from the market showed that withdrawn drugs targeted significantly more variable genes than approved drugs. Last, upon analyzing gender differences we found that the variability of drug target genes was similar between men and women. Altogether, our results suggest that expression variability of drug target genes could contribute to the variable responsiveness and effectiveness of drugs, and is worth considering during drug treatment and development. Availability and implementation LCV is available as a python script in GitHub (https://github.com/eyalsim/LCV). Supplementary information Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Eyal Simonovsky
- Department of Clinical Biochemistry & Pharmacology, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ronen Schuster
- Department of Clinical Biochemistry & Pharmacology, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Esti Yeger-Lotem
- Department of Clinical Biochemistry & Pharmacology, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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13
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Mansouri MT, Fidler JA, Meng QC, Eckenhoff RG, García PS. Sex effects on behavioral markers of emergence from propofol and isoflurane anesthesia in rats. Behav Brain Res 2019; 367:59-67. [PMID: 30898682 DOI: 10.1016/j.bbr.2019.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 01/18/2023]
Abstract
Clinical studies have demonstrated sex-related differences in recovery from surgical anesthesia. This study aimed to characterize the emergence pattern following two anesthesia regimens in both sexes of rats. We considered six different markers of emergence from anesthesia: sigh, eye blinking, forelimb movement, mastication, neck extension, and recovery of the righting reflex (RORR). Spontaneous motor activity 24 h after the anesthesia induction was also examined. Our results showed that the rank order of the emergence latency after intraperitoneal propofol, PRO, exposure was forelimb movement < sigh < blink < mastication < neck extension < RORR, while after inhaled isoflurane, ISO, anesthesia the sequence was changed as sigh < blink < mastication < forelimb movement < neck extension < RORR in both male and female rats. Moreover, the latency to emergence after PRO in female rats was significantly higher than male rats, although following ISO there was no difference between the sexes (P < 0.001; P > 0.05, respectively). Open-field testing revealed no difference in PRO and ISO spontaneous locomotor activity due to drug administration (P > 0.05). These two anesthetics presented different emergence sequences. Although clinical data suggests that females arouse faster than males from anesthesia with propofol, our intraperitoneal technique in a rodent model had the opposite effect. Pharmacokinetic analysis demonstrated increased absorption of injected propofol for the female rats in our study, emphasizing the role of sexual dimorphism in drug distribution in rodents. Despite these pharmacokinetic differences, the pharmacodynamic effects of the drugs were remarkably consistent among both sexes through emergence.
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Affiliation(s)
- Mohammed Taghi Mansouri
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory University, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Jonathan A Fidler
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory University, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Qing Cheng Meng
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul S García
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory University, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA.
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14
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Women awaken faster than men after electroencephalogram-monitored propofol sedation for colonoscopy: A prospective observational study. Eur J Anaesthesiol 2018; 34:681-687. [PMID: 28873076 DOI: 10.1097/eja.0000000000000665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sedation for colonoscopy using intravenous propofol has become standard in many Western countries. OBJECTIVE Gender-specific differences have been shown for general anaesthesia in dentistry, but no such data existed for gastrointestinal endoscopy. DESIGN A prospective observational study. SETTING An academic teaching hospital of Hannover Medical School. PATIENTS A total of 219 patients (108 women and 111 men) scheduled for colonoscopy. INTERVENTION Propofol sedation using electroencephalogram monitoring during a constant level of sedation depth (D0 to D2) performed by trained nurses or physicians after a body-weight-adjusted loading dose. MAIN OUTCOME MEASURES The primary end-point was the presence of gender-specific differences in awakening time (time from end of sedation to eye-opening and complete orientation); secondary outcome parameters analysed were total dose of propofol, sedation-associated complications (bradycardia, hypotension, hypoxaemia and apnoea), patient cooperation and patient satisfaction. Multivariate analysis was performed to correct confounding factors such as age and BMI. RESULTS Women awakened significantly faster than men, with a time to eye-opening of 7.3 ± 3.7 versus 8.4 ± 3.4 min (P = 0.005) and time until complete orientation of 9.1 ± 3.9 versus 10.4 ± 13.7 min (P = 0.008). The propofol dosage was not significantly different, with some trend towards more propofol per kg body weight in women (3.98 ± 1.81 mg versus 3.72 ± 1.75 mg, P = 0.232). CONCLUSION The effect of gender aspects should be considered when propofol is used as sedation for gastrointestinal endoscopy. That includes adequate dosing for women as well as caution regarding potential overdosing of male patients. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT02687568).
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15
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Fujita A, Hayamizu K, Yoshihara T, Zaitsu M, Shiraishi F, Arima H, Matsuo K, Shiokawa K, Setoguchi H, Sasaguri T. Effect of sex and polymorphisms of CYP2B6 and UGT1A9 on the difference between the target-controlled infusion predicted and measured plasma propofol concentration. JA Clin Rep 2018; 4:59. [PMID: 32025958 PMCID: PMC6966915 DOI: 10.1186/s40981-018-0196-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/03/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction To examine whether sex and polymorphisms of cytochrome P450 (CYP) 2B6 and UDP-glucuronosyltransferase (UGT) 1A9 affect the difference between predicted and measured plasma propofol concentration during continuous infusion by target-controlled infusion. Results Blood samples of 69 patients (48 men and 21 women) were obtained at 4 h after initial propofol infusion. Percentage performance error (PE) was calculated to assess the difference between measured and predicted propofol concentration. Regression coefficients (β) and 95% confidence intervals (CI) of sex and the polymorphisms of CYP2B6 and UGT1A9 for PE were, separately and mutually, estimated with linear regression. Covariates included age and body mass index in the minimal adjusted model, and additionally included clinical factors (mean blood pressure, heart rate, volume of intravenous fluid, surgical site, surgical position, and pneumoperitoneum) in the full adjusted model. PE was higher in men than in women (28.7% versus 10.5%, p = 0.015). Female sex was inversely associated with PE: the minimal adjusted β = − 8.84 (95% CI, − 16.26 to − 1.43); however, the fully adjusted β with clinical factors became not significant. The average of PE did not differ between polymorphisms of CYP2B6 and UGT1A9, and β of CYP2B6 516G>T polymorphisms mutually adjusted with female sex was not significant. Mean blood pressure, heart rate, and volume of intravenous fluid were independently associated with PE in the full adjusted model. Conclusions Under 4 h anesthesia with propofol target-controlled infusion in our population, sex differences appeared to exist in the propofol concentration, which might be largely mediated by clinical factors, such as hemodynamic status. Trial registration UMIN-CTR UMIN000009015, Registered 1 October 2012 Electronic supplementary material The online version of this article (10.1186/s40981-018-0196-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ai Fujita
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Anesthesiology, Chihaya Hospital, Chihaya 2-30-1, Higashi-ku, Fukuoka, Japan
| | - Kengo Hayamizu
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Anesthesiology and Critical Care Medicine, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tatsuya Yoshihara
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan. .,Clinical Research Center, Fukuoka Mirai Hospital, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka, 813-0017, Japan.
| | - Masayoshi Zaitsu
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.,Department of Public Health, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Fumie Shiraishi
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Nanakuma 8-19-1, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Kazumasa Matsuo
- Department of Anesthesiology, Kyushu Medical Center, Jigyohama 1-8-1, Chuo-ku, Fukuoka, 810-8563, Japan.,Yamamoto Memorial Hospital, Hachiyagarami 88-4, Niricho, Imari, Saga, 848-0031, Japan
| | - Kanako Shiokawa
- Department of Anesthesiology, Kyushu Medical Center, Jigyohama 1-8-1, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Hidekazu Setoguchi
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Anesthesiology, Kyushu Medical Center, Jigyohama 1-8-1, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Toshiyuki Sasaguri
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
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16
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Impact of clinical factors and UGT1A9 and CYP2B6 genotype on inter-individual differences in propofol pharmacokinetics. J Anesth 2018; 32:236-243. [PMID: 29468507 DOI: 10.1007/s00540-018-2470-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/17/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE Propofol is one of the most widely used fast-acting intravenously administered anesthetics. However, although large inter-individual differences in dose requirements and recovery time have been observed, there are few previous studies in which the association between several potential covariates, including genetic factors such as the UGT1A9 and CYP2B6 genotypes, and propofol pharmacokinetics was simultaneously examined. This study aimed to identify factors determining propofol pharmacokinetics. METHODS Eighty-three patients were enrolled, and their blood samples were collected 1, 5, 10, and 15 min after administering a single intravenous bolus of propofol at a dose of 2.0 ml/kg to measure propofol plasma concentration. Area under the time-plasma concentration curve from zero up to the last measurable time point (AUC15min) was determined from the concentration data. The inter-individual variability of the propofol pharmacokinetics was evaluated by investigating relationships between AUC15min and genotype of UGT1A9 and CYP2B6; clinical factors, such as age, sex, body mass index (BMI), and preoperative hematological examination; and hemodynamic variables measured by a pulse dye densitogram analyzer. The Spearman rank correlation coefficient and the Mann-Whitney U test were used for the statistical analysis of continuous and categorical values, respectively. Subsequently, clinical factors that had p values of < 0.05 in the univariate analysis were examined in a multivariate analysis using multiple linear regression analysis. RESULTS Age, BMI, indocyanine green disappearance ratio (K-ICG), hepatic blood flow (HBF), preoperative hemoglobin level, and sex were correlated with AUC15min (p < 0.05) in univariate analysis. Multivariate analysis performed to adjust for age, BMI, K-ICG, HBF, preoperative hemoglobin level, and sex revealed only BMI as an independent factor associated with AUC15min. CONCLUSIONS This study demonstrated that BMI influences propofol pharmacokinetics after its administration as a single intravenous injection, while UGT1A9 and CYP2B6 SNPs, other clinical factors, and hemodynamic variables do not. These results suggest that BMI is an independent factor associated with propofol pharmacokinetics in several potential covariates. CLINICAL TRIALS REGISTRATION NUMBER University Hospital Medical Information Network (UMIN000022948).
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17
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Han MM, Xue FS, Kang F, Huang X, Li J. Male requires a higher median target effect-site concentration of propofol for I-gel placement when combined with dexmedetomidine. Anaesth Crit Care Pain Med 2018; 38:57-61. [PMID: 29452333 DOI: 10.1016/j.accpm.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/10/2017] [Accepted: 01/21/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The supraglottic airway device (SAD) can be used for airway management of spontaneous breathing patients, and propofol is commonly applied for the SAD placement. This study was designed to assess the effect of gender on median target effect-site concentration (Ce50) of propofol for I-gel placement when combined with dexmedetomidine. MATERIAL AND METHOD 19 males and 18 females, aged 18 to 59 and undergoing elective surgery, were enrolled. After intravenous infusion of dexmedetomidine 1.0μg/kg over 10min followed by continuous infusion of 0.4μg/kg/h, target-controlled infusion of propofol under Marsh model was started and the initial Ce of propofol was set at 4.79μg/mL and 4.35μg/mL in the male and female patients, respectively. The I-gel was inserted when the Ce of propofol reached the pre-set concentration and bispectral index value was less than 60. The Ce of propofol required for I-gel placement was determined by the Dixon up-and-down method. RESULTS The Ce50 (95% confidence interval) of propofol required for I-gel placement were 4.082μg/mL (3.798-4.332μg/mL) and 3.509μg/mL (3.266-3.749μg/mL) in male and female patients, respectively, with a significantly higher Ce50 in males. CONCLUSION When combined with dexmedetomidine, males require a higher Ce50 of propofol for I-gel placement compared to females.
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Affiliation(s)
- M-M Han
- Department of Anaesthesiology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China.
| | - F-S Xue
- Department of Anaesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - F Kang
- Department of Anaesthesiology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China.
| | - X Huang
- Department of Anaesthesiology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China.
| | - J Li
- Department of Anaesthesiology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China.
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18
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Greer A, Treston G. Factors associated with patient-reported procedural memory following emergency department procedural sedation with ketamine and propofol: A prospective cohort of 563 patients. Emerg Med Australas 2017; 30:200-208. [DOI: 10.1111/1742-6723.12884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 08/16/2017] [Accepted: 09/09/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Greer
- Paediatric Intensive Care; Starship Children's Health; Auckland New Zealand
| | - Greg Treston
- Emergency Department; Mater Hospital; Brisbane Queensland Australia
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19
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McGregor AJ, Beauchamp GA, Wira CR, Perman SM, Safdar B. Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review. West J Emerg Med 2017; 18:1079-1090. [PMID: 29085541 PMCID: PMC5654878 DOI: 10.5811/westjem.2017.8.34997] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 12/16/2022] Open
Abstract
The National Institutes of Health recently highlighted the significant role of sex as a biological variable (SABV) in research design, outcome and reproducibility, mandating that this variable be accounted for in all its funded research studies. This move has resulted in a rapidly increasing body of literature on SABV with important implications for changing the clinical practice of emergency medicine (EM). Translation of this new knowledge to the bedside requires an understanding of how sex-based research will ultimately impact patient care. We use three case-based scenarios in acute myocardial infarction, acute ischemic stroke and important considerations in pharmacologic therapy administration to highlight available data on SABV in evidence-based research to provide the EM community with an important foundation for future integration of patient sex in the delivery of emergency care as gaps in research are filled.
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Affiliation(s)
- Alyson J McGregor
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Division of Sex and Gender in Emergency Medicine, Providence, Rhode Island
| | - Gillian A Beauchamp
- Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon
| | - Charles R Wira
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Sarah M Perman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Basmah Safdar
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
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Abstract
The purpose of the study was to investigate the effects of total intravenous anesthesia (TIVA) and combined of intravenous and inhaled anesthesia (CIIA) on intraoperative awareness in surgical patients.A total of 678 patients were recruited in the CIIA group, while TIVA group included 566 patients. The clinical characteristics and the occurrence of intraoperative awareness were compared between the groups. Mini-Mental State Examination, Generalized Anxiety Disorder 7, and Patient Health Questionnaire 9 tests were performed to estimate cognitive and psychological functions of the patients. In addition, logistic regression analysis was applied to identify the risk factors for intraoperative awareness in surgical patients.In CIIA group, 3 patients (0.44%) were confirmed with intraoperative awareness, while 11 patients (1.94%) in TIVA group underwent intraoperative awareness. The occurrence rate of intraoperative awareness was significantly higher in VITA group than that in the CIIA group (P = .029). Awareness classification demonstrated that intraoperative awareness mainly included auditory, tactile, and pain perceptions. Moreover, 4 patients showed distress after operation. Patients with intraoperative awareness exhibited poor performance in cognitive and psychological tests (P < .001 for all). Logistic regression analysis demonstrated that CIIA (odds ratio [OR] = 0.198, 95% confidence interval [CI] = 0.047-0.827), age (OR = 0.951, 95% CI = 0.908-0.997), midazolam application (OR = 0.158, 95% CI = 0.034-0.736), awareness history (OR = 10.131, 95% CI = 2.206-45.517), and duration of surgery (OR = 1.016, 95% CI = 1.001-1.032) were significantly associated with intraoperative awareness.Intraoperative awareness can significantly influence the cognitive and psychological functions of surgical patients. CIIA and midazolam application may lower the risk of intraoperative awareness.
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MESH Headings
- Adult
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, General/psychology
- Anesthesia, Inhalation/adverse effects
- Anesthesia, Inhalation/psychology
- Anesthesia, Intravenous/adverse effects
- Anesthesia, Intravenous/psychology
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Inhalation/adverse effects
- Female
- Humans
- Intraoperative Awareness/psychology
- Logistic Models
- Male
- Methyl Ethers/administration & dosage
- Methyl Ethers/adverse effects
- Middle Aged
- Operative Time
- Postoperative Complications/chemically induced
- Postoperative Complications/psychology
- Postoperative Period
- Propofol/administration & dosage
- Propofol/adverse effects
- Sevoflurane
- Stress, Psychological/chemically induced
- Stress, Psychological/psychology
- Treatment Outcome
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Minert A, Yatziv SL, Devor M. Location of the Mesopontine Neurons Responsible for Maintenance of Anesthetic Loss of Consciousness. J Neurosci 2017; 37:9320-9331. [PMID: 28821646 PMCID: PMC6596743 DOI: 10.1523/jneurosci.0544-17.2017] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 08/06/2017] [Accepted: 08/09/2017] [Indexed: 12/14/2022] Open
Abstract
The transition from wakefulness to general anesthesia is widely attributed to suppressive actions of anesthetic molecules distributed by the systemic circulation to the cerebral cortex (for amnesia and loss of consciousness) and to the spinal cord (for atonia and antinociception). An alternative hypothesis proposes that anesthetics act on one or more brainstem or diencephalic nuclei, with suppression of cortex and spinal cord mediated by dedicated axonal pathways. Previously, we documented induction of an anesthesia-like state in rats by microinjection of small amounts of GABAA-receptor agonists into an upper brainstem region named the mesopontine tegmental anesthesia area (MPTA). Correspondingly, lesioning this area rendered animals resistant to systemically delivered anesthetics. Here, using rats of both sexes, we applied a modified microinjection method that permitted localization of the anesthetic-sensitive neurons with much improved spatial resolution. Microinjected at the MPTA hotspot identified, exposure of 1900 or fewer neurons to muscimol was sufficient to sustain whole-body general anesthesia; microinjection as little as 0.5 mm off-target did not. The GABAergic anesthetics pentobarbital and propofol were also effective. The GABA-sensitive cell cluster is centered on a tegmental (reticular) field traversed by fibers of the superior cerebellar peduncle. It has no specific nuclear designation and has not previously been implicated in brain-state transitions.SIGNIFICANCE STATEMENT General anesthesia permits pain-free surgery. Furthermore, because anesthetic agents have the unique ability to reversibly switch the brain from wakefulness to a state of unconsciousness, knowing how and where they work is a potential route to unraveling the neural mechanisms that underlie awareness itself. Using a novel method, we have located a small, and apparently one of a kind, cluster of neurons in the mesopontine tegmentum that are capable of effecting brain-state switching when exposed to GABAA-receptor agonists. This action appears to be mediated by a network of dedicated axonal pathways that project directly and/or indirectly to nearby arousal nuclei of the brainstem and to more distant targets in the forebrain and spinal cord.
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Affiliation(s)
- Anne Minert
- Department of Cell and Developmental Biology, Institute of Life Sciences, and Center for Research on Pain, The Hebrew University of Jerusalem, Jerusalem 91904, Israel
| | - Shai-Lee Yatziv
- Department of Cell and Developmental Biology, Institute of Life Sciences, and Center for Research on Pain, The Hebrew University of Jerusalem, Jerusalem 91904, Israel
| | - Marshall Devor
- Department of Cell and Developmental Biology, Institute of Life Sciences, and Center for Research on Pain, The Hebrew University of Jerusalem, Jerusalem 91904, Israel
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McGregor AJ, Greenberg MR, Choo EK, Safdar B. Advancing Emergency Medicine by Incorporating Sex and Gender: It Benefits Women, It Benefits Men. Ann Emerg Med 2017; 70:363-365. [DOI: 10.1016/j.annemergmed.2017.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Indexed: 11/25/2022]
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Telles JL, Agarwal S, Monagle J, Stough C, King R, Downey L. Driving Impairment Due to Propofol at Effect-Site Concentrations Relevant after Short Propofol-Only Sedation. Anaesth Intensive Care 2016; 44:696-703. [DOI: 10.1177/0310057x1604400602] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Australian guidelines state “Following brief surgery or procedures with short acting anaesthetic drugs, the patient may be fit to drive after a normal night's sleep. After long surgery or procedures requiring longer lasting anaesthesia, it may not be safe to drive for 24 hours or more”. The increasing use of the short-acting anaesthetic drug propofol as a solitary sedative medication for simple endoscopy procedures suggests a need to review this blanket policy. Thirty patients presenting for elective day surgery were recruited as volunteers for a pre-procedure driving simulation study and randomised to propofol or placebo arms. Driving ability was assessed at baseline and then, in the propofol group, at three effect-site concentrations. Driving impairment at these concentrations of propofol was compared to that of a third group of volunteers with a blood alcohol concentration of 0.05% (g/100 ml). Driving impairment at 0.2 μg/ml propofol effect-site concentration was not statistically different to placebo. Impairment increased with propofol effect-site concentration ( P=0.002) and at 0.4 μg/ml it was similar to that found with a blood alcohol concentration of 50 mg/100 ml (0.05%). Plasma propofol concentrations of 0.2 μg/ml, as might be found approximately an hour after short (<1 hour duration) propofol-only sedation for endoscopy, were not associated with driving impairment in our young cohort of volunteers.
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Affiliation(s)
- J. L. Telles
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Melbourne, Victoria
| | - S. Agarwal
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Melbourne, Victoria
| | - J. Monagle
- Department of Anaesthesia and Perioperative Medicine, Monash Medical Centre, Monash Health, Melbourne, Victoria
| | - C. Stough
- Centre for Human Psychopharmacology, Swinburne University, Melbourne, Victoria
| | - R. King
- Centre for Human Psychopharmacology, Swinburne University, Melbourne, Victoria
| | - L. Downey
- Centre for Human Psychopharmacology, Swinburne University, Melbourne, Victoria, Division on Addiction, Cambridge Health Alliance, Medford, Massachusetts, USA
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Jung YS, Paik H, Min SH, Choo H, Seo M, Bahk JH, Seo JH. Calling the patient's own name facilitates recovery from general anaesthesia: a randomised double-blind trial. Anaesthesia 2016; 72:197-203. [DOI: 10.1111/anae.13688] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Y. S. Jung
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - H. Paik
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - S.-H. Min
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - H. Choo
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - M. Seo
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - J.-H. Bahk
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
- Seoul National University College of Medicine; Seoul Korea
| | - J.-H. Seo
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
- Seoul National University College of Medicine; Seoul Korea
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Messina AG, Wang M, Ward MJ, Wilker CC, Smith BB, Vezina DP, Pace NL. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev 2016; 10:CD007272. [PMID: 27755648 PMCID: PMC6461159 DOI: 10.1002/14651858.cd007272.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND General anaesthesia is usually associated with unconsciousness. 'Awareness' is when patients have postoperative recall of events or experiences during surgery. 'Wakefulness' is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. OBJECTIVES To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016; MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a handsearch of the citations in the review. We did not search trial registries. SELECTION CRITERIA We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteer studies, studies of patients prior to skin incision, intensive care unit studies, and studies that only randomized different word presentations for memory tests (not anaesthetic interventions).Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. DATA COLLECTION AND ANALYSIS At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. MAIN RESULTS We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review.The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503 participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87 to have possible awareness, and 65 to have definite awareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75).We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness.We graded the quality of the evidence as low or very low in the 'Summary of findings' tables for the five comparisons.Most of the secondary outcomes in this review were not reported in the included RCTs. AUTHORS' CONCLUSIONS Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses, reduced the risk of awareness.
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Affiliation(s)
- Anthony G Messina
- School of Management, University of Texas at DallasThe Alliance for Medical Management EducationBox 2331920 N. Coit RoadRichardsonTXUSA75080
| | - Michael Wang
- University of LeicesterClinical Psychology UnitLancaster RoadLeicesterUKLE1 7HA
| | - Marshall J Ward
- Dartmouth‐Hitchcock Medical Center1 Medical Center DrLebanonNHUSA03766
| | - Chase C Wilker
- ARUP LaboratoriesClinical Toxicology IIISalt Lake CityUTUSA
| | - Brett B Smith
- University of UtahUniversity of Utah School of MedicineSalt Lake CityUTUSA84112
| | - Daniel P Vezina
- University of UtahDepartment of Anesthesiology, Department of Internal Medicine, Division of CardiologySalt Lake CityUTUSA
- Veteran's AdministrationEchocardiography LaboratorySalt Lake CityUTUSA
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
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Joe HB, Kim JY, Kwak HJ, Oh SE, Lee SY, Park SY. Effect of sex differences in remifentanil requirements for the insertion of a laryngeal mask airway during propofol anesthesia: A prospective randomized trial. Medicine (Baltimore) 2016; 95:e5032. [PMID: 27684878 PMCID: PMC5265971 DOI: 10.1097/md.0000000000005032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Remifentanil can improve insertion of a laryngeal mask airway (LMA) during induction with propofol. Recently, it has been suggested that there is a sex difference in opioid requirements for this procedure. The purposes of this study were to determine the effective effect-site concentration (Ce) of remifentanil for the facilitation of LMA insertion in male and female patients during propofol anesthesia without neuromuscular blockade and to evaluate whether there are sex differences in the Ce of remifentanil required for successful LMA insertion. METHODS Forty-eight patients (24 male, 24 female) with American Society of Anesthesiologists physical status 1 or 2, aged 20 to 60 years, scheduled for minor orthopedic surgery under general anesthesia were enrolled. Anesthesia was induced by target-controlled infusion (TCI) of propofol and remifentanil. The target Ce of propofol was 5 μg/mL initially and was reduced to 3.5 μg/mL after loss of consciousness. The Ce of remifentanil given to each patient was determined by the response of the previously tested patient using 0.5 ng/mL as a step size. The 1st patient was tested at a Ce of 3.0 ng/mL of remifentanil. Successful LMA insertion was defined as smooth insertion without patient movement or significant resistance to mouth opening. RESULTS The effective Ce of remifentanil required for successful LMA insertion on 50% of occasions (effective effect-site concentration for 50% [EC50]) as estimated by Dixon method was significantly lower in women (2.18 ± 0.35 ng/mL) than in men (2.82 ± 0.53 ng/mL) (P = 0.02). Using the isotonic regression method, the effective Ce of remifentanil required for successful LMA insertion on 95% of occasions (EC95) (95% confidence interval [CI]) was significantly lower in women (3.38 [3.0-3.48] ng/mL) than in men (3.94 [3.80-3.98] ng/mL). CONCLUSION The Ce of remifentanil required to facilitate successful LMA insertion is higher during propofol induction by TCI in men than in women. When using remifentanil for LMA insertion, patient sex should be taken into account for appropriate dosing.
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Affiliation(s)
- Han Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Namdong-gu, Incheon, Republic of Korea
| | - Sang Eon Oh
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
- Correspondence: Sung Yong Park, Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World Cup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea (e-mail: )
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Yao Y, Yu C, Yuan Y, Huang G, Li S. Median effective concentration of remifentanil in target controlled infusion for smooth tracheal extubation during emergence from general anesthesia in elderly patients. J Clin Anesth 2016; 31:13-8. [DOI: 10.1016/j.jclinane.2015.12.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/08/2015] [Accepted: 12/28/2015] [Indexed: 12/17/2022]
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Stankovski T, Petkoski S, Raeder J, Smith AF, McClintock PVE, Stefanovska A. Alterations in the coupling functions between cortical and cardio-respiratory oscillations due to anaesthesia with propofol and sevoflurane. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2016; 374:rsta.2015.0186. [PMID: 27045000 PMCID: PMC4822446 DOI: 10.1098/rsta.2015.0186] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 05/24/2023]
Abstract
The precise mechanisms underlying general anaesthesia pose important and still open questions. To address them, we have studied anaesthesia induced by the widely used (intravenous) propofol and (inhalational) sevoflurane anaesthetics, computing cross-frequency coupling functions between neuronal, cardiac and respiratory oscillations in order to determine their mutual interactions. The phase domain coupling function reveals the form of the function defining the mechanism of an interaction, as well as its coupling strength. Using a method based on dynamical Bayesian inference, we have thus identified and analysed the coupling functions for six relationships. By quantitative assessment of the forms and strengths of the couplings, we have revealed how these relationships are altered by anaesthesia, also showing that some of them are differently affected by propofol and sevoflurane. These findings, together with the novel coupling function analysis, offer a new direction in the assessment of general anaesthesia and neurophysiological interactions, in general.
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Affiliation(s)
- Tomislav Stankovski
- Department of Physics, Lancaster University, Lancaster LA1 4YB, UK Faculty of Medicine, Ss. Cyril and Methodius University, 50 Divizija 6, Skopje 1000, Macedonia
| | - Spase Petkoski
- Institut de Neurosciences des Systèmes UMR_S 1106, Aix-Marseille Université, Marseille 13005, France
| | - Johan Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo 0424, Norway
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP, UK
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Choi JJ, Kim JY, Lee D, Chang YJ, Cho NR, Kwak HJ. Male patients require higher optimal effect-site concentrations of propofol during i-gel insertion with dexmedetomidine 0.5 μg/kg. BMC Anesthesiol 2016; 16:20. [PMID: 27004426 PMCID: PMC4804608 DOI: 10.1186/s12871-016-0186-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 03/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pharmacokinetics and pharmacodynamics of an anesthetic drug may be influenced by gender. The purpose of this study was to compare effect-site half maximal effective concentrations (EC50) of propofol in male and female patients during i-gel insertion with dexmedetomidine 0.5 μg/kg without muscle relaxants. METHODS Forty patients, aged 20-46 years of ASA physical status I or II, were allocated to one of two groups by gender (20 patients per group). After the infusion of dexmedetomidine 0.5 μg/kg over 2 min, anesthesia was induced with a pre-determined effect-site concentration of propofol by target controlled infusion. Effect-site EC50 values of propofol for successful i-gel insertion were determined using the modified Dixon's up-and-down method. RESULTS Mean effect-site EC50 ± SD of propofol for successful i-gel insertion was significantly higher for men than women (5.46 ± 0.26 μg/ml vs. 3.82 ± 0.34 μg/ml, p < 0.01). The EC50 of propofol in men was approximately 40% higher than in women. Using isotonic regression with a bootstrapping approach, the estimated EC50 (95% confidence interval) of propofol was also higher in men [5.32 (4.45-6.20) μg/ml vs. 3.75 (3.05-4.43) μg/ml]. The estimated EC95 (95% confidence interval) of propofol in men and women were 5.93 (4.72-6.88) μg/ml and 4.52 (3.02-5.70) μg/ml, respectively. CONCLUSIONS During i-gel insertion with dexmedetomidine 0.5 μg/kg without muscle relaxant, male patients had higher effect-site EC50 for propofol using Schnider's model. Based on the results of this study, patient gender should be considered when determining the optimal dose of propofol during supraglottic airway insertion. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02268656. Registered August 26, 2014.
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Affiliation(s)
- Jung Ju Choi
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesiology and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Dongchul Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Young Jin Chang
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Noo Ree Cho
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea.
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Abou-Arab MH, Feiner JR, Spigset O, Heier T. Alfentanil during rapid sequence induction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg: tracheal intubation conditions. Acta Anaesthesiol Scand 2015; 59:1278-86. [PMID: 26176994 DOI: 10.1111/aas.12584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Opioids have become an integral part of anaesthesia induction. We aimed to determine the dose of alfentanil needed to obtain perfect tracheal intubation conditions during rapid sequence induction with standard doses of thiopental and rocuronium, where laryngoscopy was initiated 55 s after commencement of drug administration. The influence of covariates (sex, body weight, age, alfentanil plasma concentration at laryngoscopy) was tested. METHODS Eighty-four healthy individuals were randomly assigned to receive one of the seven assessor-blinded alfentanil doses (0, 10, 20, 30, 40, 50 and 60 μg/kg) in conjunction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg. For drug administration, 15 s was allowed. Laryngoscopy was initiated 40 s after rocuronium and tracheal intubation concluded within 70 s after commencement of drug administration. Alfentanil doses associated with 50%, 90% and 95% probability of perfect intubation conditions were determined with logistic regression. Multiple logistic regressions were used to test the influence of covariates. The relationship between alfentanil dose and concentration at laryngoscopy was analysed with linear regression. The effects of covariates on plasma concentrations of alfentanil were tested with multiple linear regressions. RESULTS Perfect intubation conditions of 95% probability was obtained with 56 μg/kg (confidence intervals 44-68). None of the covariates were significant predictors of perfect intubation conditions. Alfentanil plasma concentration correlated with dose and increased with increasing body weight (1.7 ng/ml/kg). CONCLUSION Perfect intubation conditions during rapid sequence induction can be obtained with clinically relevant doses of alfentanil in most healthy patients anaesthetized with thiopental 4 mg/kg and rocuronium 0.6 mg/kg.
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Affiliation(s)
- M. H. Abou-Arab
- Department of Anesthesia; Division of Emergencies and Critical Care Medicine; Oslo University Hospital; Oslo Norway
| | - J. R. Feiner
- Department of Anesthesia and Perioperative Care; University of California; UCSF; San Francisco CA USA
| | - O. Spigset
- Department of Clinical Pharmacology; St. Olav University Hospital; Trondheim Norway
- Department of Laboratory Medicine, Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
| | - T. Heier
- Department of Anesthesia; Division of Emergencies and Critical Care Medicine; Oslo University Hospital and University of Oslo; Oslo Norway
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Kivlehan F, Chaum E, Lindner E. Propofol detection and quantification in human blood: the promise of feedback controlled, closed-loop anesthesia. Analyst 2015; 140:98-106. [PMID: 25327876 DOI: 10.1039/c4an01483a] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The performance of a membrane-coated voltammetric sensor for propofol (2,6-diisopropylphenol) has been characterized in long term monitoring experiments using an automated flow analytical system (AFAS) and by analyzing human serum and whole blood samples by standard addition. It is shown that the signal of the membrane-coated electrochemical sensor for propofol is not influenced by the components of the pharmaceutical formulation of propofol (propofol injectable emulsion). The current values recorded with the electrochemical propofol sensor in buffer solutions and human serum samples spiked with propofol injectable emulsion showed excellent correlation with the peak heights recorded with an UV-Vis detector during the HPLC analysis of these samples (R(2) = 0.997 in PBS and R(2) = 0.975 in human serum). However, the determination of propofol using the electrochemical method is simpler, faster and has a better detection limit (0.08 ± 0.05 μM) than the HPLC method (0.4 ± 0.2 μM). As a first step towards feedback controlled closed-loop anesthesia, the membrane-coated electrochemical sensor has been implemented onto surface of an intravenous catheter. The response characteristics of the membrane-coated carbon fiber electrode on the catheter surface were very similar to those seen using a macroelectrode.
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Affiliation(s)
- Francine Kivlehan
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee 38152, USA.
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Karim K, Giannoudi L, Piletska E, Chianella I, Henry OY, Laitenberger P, Piletsky SA, Cowen T. Development of MIP sensor for monitoring propofol in clinical procedures. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/22243682.2015.1031278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yoo JY, Kwak HJ, Lee KC, Kim GW, Kim JY. Predicted EC₅₀ and EC₉₅ of Remifentanil for Smooth Removal of a Laryngeal Mask Airway Under Propofol Anesthesia. Yonsei Med J 2015; 56:1128-33. [PMID: 26069139 PMCID: PMC4479844 DOI: 10.3349/ymj.2015.56.4.1128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The purpose of this study was to determine the effect-site concentration (Ce) of remifentanil in 50% of patients (EC₅₀) and 95% of patients (EC₉₅) for smooth laryngeal mask airway (LMA) removal in adults under propofol and remifentanil anesthesia. MATERIALS AND METHODS Twenty-five patients of ASA physical status I-II and ages 18-60 years who were to undergo minor gynecological or orthopedic surgery were assessed in this study. Anesthesia was induced and maintained with propofol and remifentanil target-controlled infusion (TCI). Remifentanil was maintained at a predetermined Ce during the emergence period. The modified Dixon's up-and-down method was used to determine the remifentanil concentration, starting from 1.0 ng/mL (step size of 0.2 ng/mL). Successful removal of the LMA was regarded as absence of coughing/gagging, clenched teeth, gross purposeful movements, breath holding, laryngospasm, or desaturation to SpO₂<90%. RESULTS The mean±SD Ce of remifentanil for smooth LMA removal after propofol anesthesia was 0.83±0.16 ng/mL. Using isotonic regression with a bootstrapping approach, the estimated EC₅₀ and EC₉₅ of remifentanil Ce were 0.91 ng/mL [95% confidence interval (CI), 0.77-1.07 ng/mL] and 1.35 ng/mL (95% CI, 1.16-1.38 ng/mL), respectively. CONCLUSION Our results showed that remifentanil TCI at an established Ce is a reliable technique for achieving safe and smooth emergence without coughing, laryngospasm, or other airway reflexes.
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Affiliation(s)
- Ji Young Yoo
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Kyung Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Go Wun Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea.
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Chan SM, Lee MS, Lu CH, Cherng CH, Huang YS, Yeh CC, Kuo CY, Wu ZF. Confounding factors to predict the awakening effect-site concentration of propofol in target-controlled infusion based on propofol and fentanyl anesthesia. PLoS One 2015; 10:e0124343. [PMID: 25938415 PMCID: PMC4418734 DOI: 10.1371/journal.pone.0124343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/28/2015] [Indexed: 11/24/2022] Open
Abstract
We conducted a large retrospective study to investigate the confounding factors that predict Ce ROC under propofol-based TIVA with TCI. We recorded sex, age, height, weight, Ce LOC, Ce ROC, total propofol and fentanyl consumption dose, and anesthetic time. Simple linear regression models were used to identify potential predictors of Ce ROC, and multiple linear regression models were used to identify the confounding predictors of Ce ROC. We found that Ce ROC correlated with age, sex, Ce LOC, and both total fentanyl and propofol consumption dose. The prediction formula was: Ce ROC = 0.87 - 0.06 × age + 0.18 × Ce LOC + 0.04 (if fentanyl consumption > 150 μg; if not, ignore this value) + 0.07 × (1 or 2, according to the total propofol consumption dose, 1 for a propofol amount 1000-2000 mg and 2 for a propofol amount > 2000 mg). We simplified the formula further as Ce ROC = 0.87 - 0.06 × age + 0.18 × Ce LOC. In conclusion, Ce ROC can be predicted under TCI with propofol- and fentanyl-based TIVA. The confounding factors that predicted propofol Ce ROC are age, sex, Ce LOC, and total consumption dose of propofol and fentanyl.
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Affiliation(s)
- Shun-Ming Chan
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Meei-Shyuan Lee
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chueng-He Lu
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chen-Hwan Cherng
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yuan-Shiou Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chun-Chang Yeh
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chan-Yang Kuo
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Zhi-Fu Wu
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- * E-mail:
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35
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Panditrao MM, Panditrao MM, Fernandes AJ, Gill GS. A study of psycho-behavioral patterns in patients emerging from general anesthesia using sevoflurane, propofol and their combination in early, intermediate and late post-operative period: A randomized controlled trial. Anesth Essays Res 2015; 7:257-62. [PMID: 25885843 PMCID: PMC4173538 DOI: 10.4103/0259-1162.118984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: It has been contended the general anesthetic agents also may affect the psycho-social behavior of the patients, especially during the emergence from GA. This assumes much significance in day cases where, patients have to be roadworthy and mentally stable before discharge. Aims: We compared the psycho-behavioral effects of propofol, sevoflurane and their combination, while emerging from anesthesia. Settings and Design: The patients coming for short duration day care anesthesia were studied in a prospective randomized controlled comparison. Materials and Methods: The psycho-behavioral changes in early, intermediate and late recovery period were studied in 60 consenting patients undergoing Total Intra Venous Anesthesia (TIVA) using Propofol, Volatile Induction and Maintenance Anesthesia (VIMA) using Sevoflurane and the combination of these two agents. Statistical Analysis: Statistical Analysis of the data and application of various statistical tests was carried out with help of Statistical Package for Social Services (SPSS version 18). Data were compiled, analyzed and presented as frequency, proportions, mean and standard deviation. The tests of significance, like Chi-square test, percentages, independent sample t test, paired t test, and P value were used in the study. Results and Conclusions: Both the modalities of GA, viz; TIVA and VIMA, do produce significant psycho-behavioral changes in the patients after GA, though transiently. So it is imperative for the Clinicians to anticipate the entire aspect of Psycho-behavioral patterns before discharging the day cases from the Post anesthesia Care Unit (PACU).
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Affiliation(s)
- Mridul M Panditrao
- Department of Anesthesiology and Intensive Care, Public Hospitals Authority's Rand Memorial Hospital, Freeport, Grand Bahama, Commonwealth of The Bahamas, Pimpri, Pune, Maharashtra, India
| | - Minnu M Panditrao
- Department of Anesthesiology and Intensive Care, Public Hospitals Authority's Rand Memorial Hospital, Freeport, Grand Bahama, Commonwealth of The Bahamas, Pimpri, Pune, Maharashtra, India
| | - Alister J Fernandes
- Department of Anaesthesiology and Critical Care, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India
| | - Gurpreet Singh Gill
- Department of Anaesthesiology and Critical Care, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India
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36
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Chander D, García PS, MacColl JN, Illing S, Sleigh JW. Electroencephalographic variation during end maintenance and emergence from surgical anesthesia. PLoS One 2014; 9:e106291. [PMID: 25264892 PMCID: PMC4180055 DOI: 10.1371/journal.pone.0106291] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/29/2014] [Indexed: 12/16/2022] Open
Abstract
The re-establishment of conscious awareness after discontinuing general anesthesia has often been assumed to be the inverse of loss of consciousness. This is despite the obvious asymmetry in the initiation and termination of natural sleep. In order to characterize the restoration of consciousness after surgery, we recorded frontal electroencephalograph (EEG) from 100 patients in the operating room during maintenance and emergence from general anesthesia. We have defined, for the first time, 4 steady-state patterns of anesthetic maintenance based on the relative EEG power in the slow-wave (<14 Hz) frequency bands that dominate sleep and anesthesia. Unlike single-drug experiments performed in healthy volunteers, we found that surgical patients exhibited greater electroencephalographic heterogeneity while re-establishing conscious awareness after drug discontinuation. Moreover, these emergence patterns could be broadly grouped according to the duration and rapidity of transitions amongst these slow-wave dominated brain states that precede awakening. Most patients progressed gradually from a pattern characterized by strong peaks of delta (0.5-4 Hz) and alpha/spindle (8-14 Hz) power ('Slow-Wave Anesthesia') to a state marked by low delta-spindle power ('Non Slow-Wave Anesthesia') before awakening. However, 31% of patients transitioned abruptly from Slow-Wave Anesthesia to waking; they were also more likely to express pain in the post-operative period. Our results, based on sleep-staging classification, provide the first systematized nomenclature for tracking brain states under general anesthesia from maintenance to emergence, and suggest that these transitions may correlate with post-operative outcomes such as pain.
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Affiliation(s)
- Divya Chander
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Paul S. García
- Department of Anesthesiology, Atlanta VA Medical Center/Emory University, Atlanta, Georgia, United States of America
| | - Jono N. MacColl
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Sam Illing
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Jamie W. Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
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37
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Conti D, Ballo P, Boccalini R, Boccherini A, Cantini S, Venni A, Pezzati S, Gori S, Franconi F, Zuppiroli A, Pedullà A. The effect of patient sex on the incidence of early adverse effects in a population of elderly patients. Anaesth Intensive Care 2014; 42:455-9. [PMID: 24967759 DOI: 10.1177/0310057x1404200405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Patient sex is known to influence the response to general and regional anaesthesia and recovery after surgery. However, most studies come from analyses carried out on middle-aged patients. As most of the patients admitted to the post-anaesthesia recovery room in our institution are elderly, we took the opportunity to investigate the association between sex and incidence of early adverse events in this older population of patients after major surgery. Consecutive patients undergoing general, orthopaedic, urological and gynaecological surgery, admitted to the recovery room of our institution over a 15-month period, were retrospectively studied. The following adverse events were considered in the analysis: shivering, postoperative nausea and vomiting, hypotension and hypertensive responses, new arrhythmias requiring treatment, acute respiratory failure and desaturation. A total of 1347 patients (mean age 73.3±15.1 years, 61.4% women) were included. Women showed a higher incidence of shivering (relative difference +48%, P=0.0003), postoperative nausea and vomiting (+91%, P<0.0001), hypotension (+32%, P=0.044) and desaturation (+60%, P=0.0030) than men. The incidence of hypertensive response, arrhythmias and acute respiratory failure were not statistically significantly different. The findings of this exploratory study suggest that women have a higher risk of early postoperative adverse events even in a more elderly population.
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Affiliation(s)
- D Conti
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Florence, Italy
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38
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Chung HS. Awareness and recall during general anesthesia. Korean J Anesthesiol 2014; 66:339-45. [PMID: 24910724 PMCID: PMC4041951 DOI: 10.4097/kjae.2014.66.5.339] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/07/2014] [Accepted: 04/08/2014] [Indexed: 11/18/2022] Open
Abstract
Anesthesia awareness is defined as both consciousness and recall of surgical events. New research has been conducted out to test this phenomenon. However, testing methods have not proven reliable, including those using devices based on electroencephalographic techniques to detect and prevent intraoperative awareness. The limitations of a standard intraoperative brain monitor reflect our insufficient understanding of consciousness. Moreover, patients who experience an intraoperative awareness can develop serious post-traumatic stress disorders that should not be overlooked. In this review, we introduce the incidence of intraoperative awareness during general anesthesia and discuss the mechanisms of consciousness, as well as risk factors, various monitoring methods, outcome and prevention of intraoperative awareness.
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Affiliation(s)
- Hyun Sik Chung
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
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39
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Liu N, Le Guen M, Boichut N, Genty A, Hérail T, Schmartz D, Khefif G, Landais A, Bussac J, Charmeau A, Baars J, Rehberg B, Tricoche S, Chazot T, Sessler D, Fischler M. Nitrous oxide does not produce a clinically important sparing effect during closed-loop delivered propofol–remifentanil anaesthesia guided by the bispectral index: a randomized multicentre study. Br J Anaesth 2014; 112:842-51. [DOI: 10.1093/bja/aet479] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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40
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MacGregor K. A waking nightmare: how can we avoid accidental awareness during general anaesthesia? J Perioper Pract 2013; 23:185-90. [PMID: 24245360 DOI: 10.1177/175045891302300902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anaesthesia awareness is a terrifying prospect for any patient undergoing a surgical procedure and can cause considerable physical and psychological distress. Recommendations to reduce the risk of anaesthesia awareness include: undertaking a thorough preoperative assessment, ensuring that equipment has been checked, reducing drug error, consistent monitoring, and investment in safer technology. By implementing these recommendations it is hoped that patient safety and care can be improved during clinical anaesthesia.
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Affiliation(s)
- Kerry MacGregor
- Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, BH15 2JB.
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41
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Seo JH, Goo EK, Song IA, Park SH, Park HP, Jeon YT, Hwang JW. Influence of a modified propofol equilibration rate constant (k(e0)) on the effect-site concentration at loss and recovery of consciousness with the Marsh model. Anaesthesia 2013; 68:1232-8. [PMID: 24032636 DOI: 10.1111/anae.12419] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2013] [Indexed: 11/30/2022]
Abstract
This study compared the predicted effect-site concentration of propofol at loss and recovery of consciousness when using target-controlled infusion devices with the same pharmacokinetic model (Marsh) but a different plasma effect-site equilibration rate constant (ke0 ), the Diprifusor(TM) (ke0 0.26 min(-1) ) and Base Primea™ (ke0 1.21 min(-1) ). We studied 60 female patients undergoing minor gynaecological surgery under general anaesthesia. Although the total dose of propofol and time until loss of consciousness were comparable, the effect-site concentration at loss of consciousness was significantly lower with the Diprifusor than with the Base Primea (1.2 (0.3) μg.ml(-1) vs 4.5 (0.9) μg.ml(-1) , respectively, p < 0.001). The effect-site concentration at recovery of consciousness was significantly higher with the Diprifusor than with the Base Primea (1.8 (0.4) μg.ml(-1) vs 1.5 (0.2) μg.ml(-1) , respectively, p = 0.01). In conclusion, the effect-site concentration of propofol differs depending on the ke0 , despite the use of the same pharmacokinetic model. Therefore, the ke0 should be considered when predicting loss and recovery of consciousness based on the effect-site concentration of propofol.
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Affiliation(s)
- J H Seo
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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42
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Affiliation(s)
- S Bala Bhaskar
- Department of Anaesthesiology and Critical Care, Vijayanagar Institute of Medical Sciences (VIMS), Bellary, Karnataka, India. E-mail:
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Choong E, Loryan I, Lindqvist M, Nordling Å, el Bouazzaoui S, van Schaik RH, Johansson I, Jakobsson J, Ingelman-Sundberg M. Sex Difference in Formation of Propofol Metabolites: A Replication Study. Basic Clin Pharmacol Toxicol 2013; 113:126-31. [DOI: 10.1111/bcpt.12070] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/07/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Eva Choong
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
| | - Irena Loryan
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
| | - Marja Lindqvist
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
| | - Åsa Nordling
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
| | - Samira el Bouazzaoui
- Department of Clinical Chemistry; Erasmus MC Rotterdam; Rotterdam; The Netherlands
| | - Ron H. van Schaik
- Department of Clinical Chemistry; Erasmus MC Rotterdam; Rotterdam; The Netherlands
| | - Inger Johansson
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
| | - Jan Jakobsson
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
| | - Magnus Ingelman-Sundberg
- Section of Pharmacogenetics; Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm; Sweden
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Abstract
The influence of sex and gender on anesthesia and analgesic therapy remains poorly understood, nevertheless the numerous physiological and pharmacological differences present between men and women. Although in anesthesiology sex-gender aspects have attracted little attention, it has been reported that women have a greater sensitivity to the non-depolarizing neuroblocking agents, whereas males are more sensitive than females to propofol. It has been suggested that men wake slower than women after general anesthesia and have less postoperative nausea and vomiting. Sexual hormones seem to be of importance in the onset of differences. Nevertheless, in the last years, sex-gender influences on pain and analgesia have become a hot topic and data regarding sex-gender differences in response to pharmacologic and non-pharmacologic pain treatments are still scanty, inconsistent, and non-univocal. In particular, females seem to be more sensitive than males to opioid receptor agonists. Women may experience respiratory depression and other adverse effects more easily if they are given the same doses as males. Evidently, there is an obvious need for more research, which should include psychological and social factors in experimental preclinical and clinical paradigms in view of their importance on pain mechanism, in order to individualize analgesia to optimize pain relief.
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Affiliation(s)
- Ilaria Campesi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
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45
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Risk factor for intraoperative awareness. Rev Bras Anestesiol 2012; 62:365-74. [PMID: 22656682 DOI: 10.1016/s0034-7094(12)70137-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 08/03/2011] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The intraoperative awareness is an adverse event in the general anesthesia, and may occur in approximately 20,000 cases per year, which justifies the study of the risk factors for this event. The objective of this study was to review this subject in order to reduce the incidence of intraoperative awareness and psychological sequelae incurring from this incident, which may result in post-traumatic stress disorder with negative repercussions on the surgical patient social, psychic and functional development. CONTENT It was conducted a review of the intraoperative awareness assessing its different phases during general anesthesia such as dreaming, wakefulness, explicit and implicit memory, as well as the analysis, consequences and prevention of its main related factors. CONCLUSIONS The reduction of awareness incidence during anesthesia is related to the anesthesiologist improved scientific and technical performance, involving issues such as monitoring, comprehension of the anesthesia activity components, hypnotic and analgesic drugs, neuromuscular blocking agents, autonomic and motor reflex control, in addition to the risk factors involved in this event.
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Shibuta S, Kanemura S, Uchida O, Mashimo T. The influence of initial target effect-site concentrations of propofol on the similarity of effect-sites concentrations at loss and return of consciousness in elderly female patients with the Diprifusor system. J Anaesthesiol Clin Pharmacol 2012; 28:194-9. [PMID: 22557742 PMCID: PMC3339724 DOI: 10.4103/0970-9185.94851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Whether effect-site concentrations of propofol (Cep) at loss of consciousness and return of consciousness (LOC and ROC, respectively) in elderly women using Diprifusor are similar is unclear. We investigated whether differences in initial target Cep (Ctarget) alter similarities between Cep values at LOC and ROC. Materials and Methods: In this study, female patients (n = 58, age = 72.5 ± 1.1 years) undergoing knee arthroplasty were administered propofol with Diprifusor. Cep at LOC and ROC were estimated for different Ctarget values (3.0–4.5 μg/ml). Pearson's correlation coefficient analysis and simple regression were performed to assess the relationship between Cep at LOC and ROC for each Ctarget. Differences in correlation coefficients of regression lines obtained from each Ctarget group were determined using the t-test. Results: The different Ctarget groups did not show significant differences in total propofol levels and in Cep values at LOC or ROC. However, Cep at ROC was significantly higher than Cep at LOC when Ctarget was 4.0 and 4.5 μg/ml, whereas these Cep values were not significantly different in low Ctarget groups. Strong positive correlations were observed between Cep at LOC and ROC for all Ctarget groups. Regression coefficients for the different Ctarget groups were not significantly different. Compared to low (≤3.5 μg/ml) Ctarget groups, high Ctarget groups showed significantly shorter time until LOC. Induction quality was not significantly different among the groups. Conclusions: In elderly women, Cep values at LOC are strong predictors of Cep at ROC when Ctarget is 3.0–4.5 μg/ml. High Ctarget groups (≥4.0 μg/ml) exhibited shorter induction times with normal cardiovascular stability.
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Affiliation(s)
- Satoshi Shibuta
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine D7, Osaka University, Yamadaoka, Suita, Japan
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47
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Temporal pattern of locomotor activity recuperation after administration of propofol in Japanese quail (Coturnix coturnix japonica). Res Vet Sci 2012; 93:156-62. [DOI: 10.1016/j.rvsc.2011.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 05/09/2011] [Accepted: 06/07/2011] [Indexed: 11/23/2022]
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Abstract
Authors Nieuwenhoven and Klinge (Journal of Women's Health 2010;19:1-6) argue that despite advances, sex and gender are not well treated in the biomedical literature. Many studies in which males and females are represented do not address the similarities or differences between sexes, sometimes adjusting for (thereby obscuring) sex differences and sometimes ignoring sex altogether. Women continue to be underrepresented in randomized drug trials, excluded from some by potential reproductive effects, and perhaps frightened from others by IRB-required warnings. Although recognized, sex disparities in treatment, for example, for acute cardiac syndrome, persist. As electronic abstracts become a prime means of communicating research results, they must adequately and accurately represent a study's findings.
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Occurrence of and risk factors for electroencephalogram burst suppression during propofol–remifentanil anaesthesia. Br J Anaesth 2011; 107:749-56. [DOI: 10.1093/bja/aer235] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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50
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Influence of sex on propofol metabolism, a pilot study: implications for propofol anesthesia. Eur J Clin Pharmacol 2011; 68:397-406. [DOI: 10.1007/s00228-011-1132-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 09/26/2011] [Indexed: 02/03/2023]
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