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Müller-Wirtz LM, O'Gara B, Gama de Abreu M, Schultz MJ, Beitler JR, Jerath A, Meiser A. Volatile anesthetics for lung- and diaphragm-protective sedation. Crit Care 2024; 28:269. [PMID: 39217380 PMCID: PMC11366159 DOI: 10.1186/s13054-024-05049-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients.
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Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany
- Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Brian O'Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marcelo Gama de Abreu
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Division of Intensive Care and Resuscitation, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, New York-Presbyterian Hospital and Columbia University, New York, NY, USA
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany.
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Teiten C, Bailly P, Tonnelier JM, Bodenes L, de Longeaux K, L'Her E. Impact of inhaled sedation on delirium incidence and neurological outcome after cardiac arrest - A propensity-matched control study (Isocare). Resuscitation 2024:110358. [PMID: 39147307 DOI: 10.1016/j.resuscitation.2024.110358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 08/17/2024]
Abstract
RATIONALE Poor neurological outcome is common following a cardiac arrest. The use of volatile anesthetic agents has been proposed during post-resuscitation to improve outcome. OBJECTIVES To determine the effects of inhaled isoflurane on neurological outcome, delirium incidence, ICU length-of-stay, ventilation duration, mortality during post-resuscitation care of ICU patients. PATIENTS 510 patients were admitted within our medical ICU following a cardiac arrest during the study period, 401 of them being sedated using intravenous sedation prior to 2017 and 109 of them using inhaled isoflurane according to a standardized protocol following 2017. RESULTS Matched-pair analysis depicted a delirium incidence decrease, without improved neurologic outcome on ICU discharge (CPC ≤ 2) for isoflurane patients (16.1% vs 32.2%, p 0.03 and 29% vs 23%, p 0.47, respectively). Ventilation duration and ICU length of stay were shorter for isoflurane patients (78 vs 167 h, p 0.01 and 7.9 vs 8.5 days, p 0.01 respectively). Isoflurane had no impact on mortality. CONCLUSION In this propensity-matched control study, isoflurane sedation during the post-resuscitation care of ICU patients was associated with a lower incidence of delirium, a shorter duration of mechanical ventilation and a reduced ICU length of stay. Prospective data are needed before its widespread use.
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Affiliation(s)
- Christelle Teiten
- Médecine Intensive Réanimation, CHU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France
| | - Pierre Bailly
- Médecine Intensive Réanimation, CHU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Jean-Marie Tonnelier
- Médecine Intensive Réanimation, CHU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France
| | - Laetitia Bodenes
- Médecine Intensive Réanimation, CHU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France
| | - Kahaia de Longeaux
- Médecine Intensive Réanimation, CHU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France
| | - Erwan L'Her
- Médecine Intensive Réanimation, CHU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France; Laboratoire de Traitement de l'Information Médicale INSERM Mixte de Recherche Unité 1101, Université de Bretagne Occidentale, France
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Contreras S, Giménez-Esparza Vich C, Caballero J. Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2024; 48:467-476. [PMID: 38862301 DOI: 10.1016/j.medine.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/16/2024] [Indexed: 06/13/2024]
Abstract
The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.
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Affiliation(s)
- Sofía Contreras
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | | | - Jesús Caballero
- Servicio de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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Pellet PL, Stevic N, Degivry F, Louis B, Argaud L, Guérin C, Cour M. Effects on mechanical power of different devices used for inhaled sedation in a bench model of protective ventilation in ICU. Ann Intensive Care 2024; 14:18. [PMID: 38285231 PMCID: PMC10825094 DOI: 10.1186/s13613-024-01245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/06/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Inhaled sedation during invasive mechanical ventilation in patients with acute respiratory distress syndrome (ARDS) has received increasing attention. However, inhaled sedation devices increase dead-space ventilation and an undesirable effect is the increase in minute ventilation needed to maintain CO2 removal. A consequence of raising minute ventilation is an increase in mechanical power (MP) that can promote lung injury. However, the effect of inhaled sedation devices on MP remains unknown. METHODS We conducted a bench study to assess and compare the effects of three devices delivering inhaled sevoflurane currently available in ICU (AnaConDa-50 mL (ANA-50), AnaConDa-100 mL (ANA-100), and MIRUS) on MP by using a test lung model set with three compliances (20, 40, and 60 mL/cmH2O). We simulated lung-protective ventilation using a low tidal volume and two levels of positive end-expiratory pressure (5 and 15 cmH2O) under ambient temperature and dry conditions. Following the insertion of the devices, either the respiratory rate or tidal volume was increased in 15%-steps until end-tidal CO2 (EtCO2) returned to the baseline value. MP was calculated at baseline and after EtCO2 correction using a simplified equation. RESULTS Following device insertion, the EtCO2 increase was significantly greater with MIRUS (+ 78 ± 13%) and ANA-100 (+ 100 ± 11%) than with ANA-50 (+ 49 ± 7%). After normalizing EtCO2 by adjusting minute ventilation, MP significantly increased by more than 50% with all inhaled sedation devices compared to controls. The lowest increase in MP was observed with ANA-50 (p < 0.05 versus ANA-100 and MIRUS). The Costa index, another parameter assessing the mechanical energy delivered to the lungs, calculated as driving pressure × 4 + respiratory rate, significantly increased by more than 20% in all experimental conditions. Additional experiments performed under body temperature, ambient pressure, and gas saturated with water vapor conditions, confirmed the main results with an increase in MP > 50% with all devices after normalizing EtCO2 by adjusting minute ventilation. CONCLUSION Inhaled sedation devices substantially increased MP in this bench model of protective ventilation, which might limit their benefits in ARDS.
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Affiliation(s)
- Pierre-Louis Pellet
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Neven Stevic
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Florian Degivry
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM 955 CNRS 7000, Créteil, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Claude Guérin
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France.
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France.
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Müller-Wirtz LM, Becher T, Günther U, Bellgardt M, Sackey P, Volk T, Meiser A. Ventilatory Effects of Isoflurane Sedation via the Sedaconda ACD-S versus ACD-L: A Substudy of a Randomized Trial. J Clin Med 2023; 12:jcm12093314. [PMID: 37176754 PMCID: PMC10179426 DOI: 10.3390/jcm12093314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
Devices used to deliver inhaled sedation increase dead space ventilation. We therefore compared ventilatory effects among isoflurane sedation via the Sedaconda ACD-S (internal volume: 50 mL), isoflurane sedation via the Sedaconda ACD-L (100 mL), and propofol sedation with standard mechanical ventilation with heat and moisture exchangers (HME). This is a substudy of a randomized trial that compared inhaled isoflurane sedation via the ACD-S or ACD-L to intravenous propofol sedation in 301 intensive care patients. Data from the first 24 h after study inclusion were analyzed using linear mixed models. Primary outcome was minute ventilation. Secondary outcomes were tidal volume, respiratory rate, arterial carbon dioxide pressure, and isoflurane consumption. In total, 151 patients were randomized to propofol and 150 to isoflurane sedation; 64 patients received isoflurane via the ACD-S and 86 patients via the ACD-L. While use of the ACD-L was associated with higher minute ventilation (average difference (95% confidence interval): 1.3 (0.7, 1.8) L/min, p < 0.001), higher tidal volumes (44 (16, 72) mL, p = 0.002), higher respiratory rates (1.2 (0.1, 2.2) breaths/min, p = 0.025), and higher arterial carbon dioxide pressures (3.4 (1.2, 5.6) mmHg, p = 0.002), use of the ACD-S did not significantly affect ventilation compared to standard mechanical ventilation and sedation. Isoflurane consumption was slightly less with the ACD-L compared to the ACD-S (-0.7 (-1.3, 0.1) mL/h, p = 0.022). The Sedaconda ACD-S compared to the ACD-L is associated with reduced minute ventilation and does not significantly affect ventilation compared to a standard mechanical ventilation and sedation setting. The smaller ACD-S is therefore the device of choice to minimize impact on ventilation, especially in patients with a limited ability to compensate (e.g., COPD patients). Volatile anesthetic consumption is slightly higher with the ACD-S compared to the ACD-L.
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Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, Campus Kiel, University Medical Center Schleswig-Holstein, 24118 Kiel, Germany
| | - Ulf Günther
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, University Hospital Oldenburg, 26133 Oldenburg, Germany
| | - Martin Bellgardt
- Department of Anaesthesiology and Intensive Care Medicine, St. Josef-Hospital, University Hospital of the Ruhr-University Bochum, 44780 Bochum, Germany
| | - Peter Sackey
- Unit of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, 17177 Stockholm, Sweden
- Sedana Medical AB, 18232 Danderyd, Sweden
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Andreas Meiser
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Germany
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Beitler JR, Talmor D. Volatile anesthetics for ICU sedation: the future of critical care or niche therapy? Intensive Care Med 2022; 48:1413-1417. [PMID: 36057666 DOI: 10.1007/s00134-022-06842-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/23/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, New York-Presbyterian Hospital and Columbia University, New York, NY, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
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Müller‐Wirtz LM, Behne F, Kermad A, Wagenpfeil G, Schroeder M, Sessler DI, Volk T, Meiser A. Isoflurane promotes early spontaneous breathing in ventilated intensive care patients: A post hoc subgroup analysis of a randomized trial. Acta Anaesthesiol Scand 2022; 66:354-364. [PMID: 34870852 DOI: 10.1111/aas.14010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spontaneous breathing is desirable in most ventilated patients. We therefore studied the influence of isoflurane versus propofol sedation on early spontaneous breathing in ventilated surgical intensive care patients and evaluated potential mediation by opioids and arterial carbon dioxide during the first 20 h of study sedation. METHODS We included a single-center subgroup of 66 patients, who participated in a large multi-center trial assessing efficacy and safety of isoflurane sedation, with 33 patients each randomized to isoflurane or propofol sedation. Both sedatives were titrated to a sedation depth of -4 to -1 on the Richmond Agitation Sedation Scale. The primary outcome was the fraction of time during which patients breathed spontaneously. RESULTS Baseline characteristics of isoflurane and propofol-sedated patients were well balanced. There were no substantive differences in management or treatment aside from sedation, and isoflurane and propofol provided nearly identical sedation depths. The mean fraction of time spent spontaneously breathing was 82% [95% CI: 69, 90] in patients sedated with isoflurane compared to 35% [95% CI: 22, 51] in those assigned to propofol: median difference: 61% [95% CI: 14, 89], p < .001. After adjustments for sufentanil dose and arterial carbon dioxide partial pressure, patients sedated with isoflurane were twice as likely to breathe spontaneously than those sedated with propofol: adjusted risk ratio: 2.2 [95%CI: 1.4, 3.3], p < .001. CONCLUSIONS Isoflurane compared to propofol sedation promotes early spontaneous breathing in deeply sedated ventilated intensive care patients. The benefit appears to be a direct effect isoflurane rather than being mediated by opioids or arterial carbon dioxide.
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Affiliation(s)
- Lukas M. Müller‐Wirtz
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
- Outcomes Research Consortium Cleveland Ohio USA
| | - Florian Behne
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Azzeddine Kermad
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry Epidemiology and Medical Informatics (IMBEI) Saarland University Faculty of Medicine Homburg Germany
| | - Matthias Schroeder
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Daniel I. Sessler
- Outcomes Research Consortium Cleveland Ohio USA
- Department of Outcomes Research Anesthesiology Institute Cleveland Clinic Cleveland Ohio USA
| | - Thomas Volk
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
- Outcomes Research Consortium Cleveland Ohio USA
| | - Andreas Meiser
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
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Blondonnet R, Quinson A, Lambert C, Audard J, Godet T, Zhai R, Pereira B, Futier E, Bazin JE, Constantin JM, Jabaudon M. Use of volatile agents for sedation in the intensive care unit: A national survey in France. PLoS One 2021; 16:e0249889. [PMID: 33857185 PMCID: PMC8049230 DOI: 10.1371/journal.pone.0249889] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/27/2021] [Indexed: 02/07/2023] Open
Abstract
Background Current intensive care unit (ICU) sedation guidelines recommend strategies using non-benzodiazepine sedatives. This survey was undertaken to explore inhaled ICU sedation practice in France. Methods In this national survey, medical directors of French adult ICUs were contacted by phone or email between July and August 2019. ICU medical directors were questioned about the characteristics of their department, their knowledge on inhaled sedation, and practical aspects of inhaled sedation use in their department. Results Among the 374 ICUs contacted, 187 provided responses (50%). Most ICU directors (73%) knew about the use of inhaled ICU sedation and 21% used inhaled sedation in their unit, mostly with the Anaesthetic Conserving Device (AnaConDa, Sedana Medical). Most respondents had used volatile agents for sedation for <5 years (63%) and in <20 patients per year (75%), with their main indications being: failure of intravenous sedation, severe asthma or bronchial obstruction, and acute respiratory distress syndrome. Sevoflurane and isoflurane were mainly used (88% and 20%, respectively). The main reasons for not using inhaled ICU sedation were: “device not available” (40%), “lack of medical interest” (37%), “lack of familiarity or knowledge about the technique” (35%) and “elevated cost” (21%). Most respondents (80%) were overall satisfied with the use of inhaled sedation. Almost 75% stated that inhaled sedation was a seducing alternative to intravenous sedation. Conclusion This survey highlights the widespread knowledge about inhaled ICU sedation in France but shows its limited use to date. Differences in education and knowledge, as well as the recent and relatively scarce literature on the use of volatile agents in the ICU, might explain the diverse practices that were observed. The low rate of mild adverse effects, as perceived by respondents, and the users’ satisfaction, are promising for this potentially important tool for ICU sedation.
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Affiliation(s)
- Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- * E-mail:
| | - Audrey Quinson
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Biostatistical and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jules Audard
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ruoyang Zhai
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistical and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, Paris, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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Paccaud P, Dechamps M, Jacquet L. Feasibility of sedation with sevoflurane inhalation via AnaConDa for Covid-19 patients under venovenous extracorporeal membrane oxygenation. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.4.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Critical care centers around the world have faced a shortage of intravenous sedatives caused by the coronavirus pandemic. Many patients infected with SARS-CoV-2 virus develop severe Acute Respiratory Distress syndrome (ARDS) for which some of them are supported by extra corporeal membrane oxygenation. Under these circumstances, the pharmacokinetics of the sedatives is modified. We observed that many of our COVID-19 infected patients receiving Extracorporeal Membrane Oxygenator (ECMO) require high doses of intravenous drugs. Continuous sedation with halogenated gases in the intensive care unit has shown many benefits on systemic inflammation and offers the possibility of a rapid recovery of consciousness. In this article we describe 3 cases that show the feasibility of sedation with sevoflurane via AnaConDa (Sedana Medical AB, Danderyd, Sweden) for Covid-19 patients under ECMO. Halogenated drugs could be considered as an interesting alternative to intravenous sedatives especially in the context of drug shortage.
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Bomberg H, Meiser F, Daume P, Bellgardt M, Volk T, Sessler DI, Groesdonk HV, Meiser A. Halving the Volume of AnaConDa: Evaluation of a New Small-Volume Anesthetic Reflector in a Test Lung Model. Anesth Analg 2020; 129:371-379. [PMID: 29787413 DOI: 10.1213/ane.0000000000003452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Volatile anesthetics are increasingly used for sedation in intensive care units. The most common administration system is AnaConDa-100 mL (ACD-100; Sedana Medical, Uppsala, Sweden), which reflects volatile anesthetics in open ventilation circuits. AnaConDa-50 mL (ACD-50) is a new device with half the volumetric dead space. Carbon dioxide (CO2) can be retained with both devices. We therefore compared the CO2 elimination and isoflurane reflection efficiency of both devices. METHODS A test lung constantly insufflated with CO2 was ventilated with a tidal volume of 500 mL at 10 breaths/min. End-tidal CO2 (EtCO2) partial pressure was measured using 3 different devices: a heat-and-moisture exchanger (HME, 35 mL), ACD-100, and ACD-50 under 4 different experimental conditions: ambient temperature pressure (ATP), body temperature pressure saturated (BTPS) conditions, BTPS with 0.4 Vol% isoflurane (ISO-0.4), and BTPS with 1.2 Vol% isoflurane. Fifty breaths were recorded at 3 time points (n = 150) for each device and each condition. To determine device dead space, we adjusted the tidal volume to maintain normocapnia (n = 3), for each device. Thereafter, we determined reflection efficiency by measuring isoflurane concentrations at infusion rates varying from 0.5 to 20 mL/h (n = 3), for each device. RESULTS EtCO2 was consistently greater with ACD-100 than with ACD-50 and HME (ISO-0.4, mean ± standard deviations: ACD-100, 52.4 ± 0.8; ACD-50, 44.4 ± 0.8; HME, 40.1 ± 0.4 mm Hg; differences of means of EtCO2 [respective 95% confidence intervals]: ACD-100 - ACD-50, 8.0 [7.9-8.1] mm Hg, P < .001; ACD-100 - HME, 12.3 [12.2-12.4] mm Hg, P < .001; ACD-50 - HME, 4.3 [4.2-4.3] mm Hg, P < .001). It was greatest under ATP, less under BTPS, and least with ISO-0.4 and BTPS with 1.2 Vol% isoflurane. In addition to the 100 or 50 mL "volumetric dead space" of each AnaConDa, "reflective dead space" was 40 mL with ACD-100 and 25 mL with ACD-50 when using isoflurane. Isoflurane reflection was highest under ATP. Under BTPS with CO2 insufflation and isoflurane concentrations around 0.4 Vol%, reflection efficiency was 93% with ACD-100 and 80% with ACD-50. CONCLUSIONS Isoflurane reflection remained sufficient with the ACD-50 at clinical anesthetic concentrations, while CO2 elimination was improved. The ACD-50 should be practical for tidal volumes as low as 200 mL, allowing lung-protective ventilation even in small patients.
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Affiliation(s)
- Hagen Bomberg
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, University of Saarland, Homburg/Saar, Germany
| | - Franziska Meiser
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, University of Saarland, Homburg/Saar, Germany
| | - Philipp Daume
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, University of Saarland, Homburg/Saar, Germany
| | - Martin Bellgardt
- Department of Anesthesiology and Intensive Care Medicine, St Josef Hospital, Katholisches Klinikum Bochum, University Hospital, Ruhr-University of Bochum, Bochum, Germany
| | - Thomas Volk
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, University of Saarland, Homburg/Saar, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Heinrich V Groesdonk
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, University of Saarland, Homburg/Saar, Germany
| | - Andreas Meiser
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, University of Saarland, Homburg/Saar, Germany
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11
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Badenes R, Bilotta F. Inhaled sedation in acute brain injury patients. Br J Anaesth 2019; 116:883-4. [PMID: 27199322 DOI: 10.1093/bja/aew132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Comparison of the use of AnaConDa® versus AnaConDa-S® during the post-operative period of cardiac surgery under standard conditions of practice. J Clin Monit Comput 2019; 34:89-95. [PMID: 30784010 PMCID: PMC7222112 DOI: 10.1007/s10877-019-00285-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 02/13/2019] [Indexed: 01/16/2023]
Abstract
Changes have been made to the AnaConDa device (Sedana Medical, Stockholm, Sweden), decreasing its size to reduce dead space and carbon dioxide (CO2) retention. However, this also involves a decrease in the surface area of the activated carbon filter. The CO2 elimination and sevoflurane (SEV) reflection of the old device (ACD-100) were thus compared with the new version (ACD-50) in patients sedated after coronary artery bypass graft surgery. After ERC approval and written informed consent, 23 patients were sedated with SEV, using first the ACD-100 and then the ACD-50 for 60 min each. With each device, patients were ventilated with tidal volumes (TV) of 5 ml/kg of ideal body weight for the first 30 min, and with 7 ml/kg for the next 30 min. Ventilation parameters, arterial blood gases, Bispectral-Index™ (BIS, Aspect Medical Systems Inc., Newton, MA, USA), SEV concentrations exhaled by the patient (SEV-exhaled) and from the expiratory hose (SEV-lost) were recorded every 30 min. A SEV reflection index was calculated: SRI [%] = 100 × (1 − (SEV-lost/SEV-exhaled)). Data were compared using ANOVA with repeated measurements and Student’s T-tests for pairs. Respiratory rates, tidal and minute volumes were not significantly different between the two devices. End tidal and arterial CO2 partial pressures were significantly higher with the ACD-100 as compared with the ACD-50. SEV infusion rate remained constant. SEV reflection was higher (SRI: ACD-100 vs. ACD-50, TV 5 ml/kg: 95.29 ± 6.45 vs. 85.54 ± 11.15, p = 0.001; 7 ml/kg: 93.42 ± 6.55 vs. 88.77 ± 12.26, p = 0.003). BIS was significantly lower when using the higher TV (60.91 ± 9.99 vs. 66.57 ± 8.22, p = 0.012), although this difference was not clinically relevant. During postoperative sedation, the use of ACD-50 significantly reduced CO2 retention. SEV reflection was slightly reduced. However, patients remained sufficiently sedated without increasing SEV infusion.
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13
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Sturesson LW, Malmkvist G, Allvin S, Collryd M, Bodelsson M, Jonson B. An appropriate inspiratory flow pattern can enhance CO2 exchange, facilitating protective ventilation of healthy lungs. Br J Anaesth 2018; 117:243-9. [PMID: 27440637 DOI: 10.1093/bja/aew194] [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] [Accepted: 05/29/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In acute lung injury, CO2 exchange is enhanced by prolonging the volume-weighted mean time for fresh gas to mix with resident alveolar gas, denoted mean distribution time (MDT), and by increasing the flow rate immediately before inspiratory flow interruption, end-inspiratory flow (EIF). The objective was to study these effects in human subjects without lung disease and to analyse the results with respect to lung-protective ventilation of healthy lungs. METHODS During preparation for intracranial surgery, the lungs of eight subjects were ventilated with a computer-controlled ventilator, allowing breath-by-breath modification of the inspiratory flow pattern. The durations of inspiration (TI) and postinspiratory pause (TP) were modified, as was the profile of the inspiratory flow wave (i.e. constant, increasing, or decreasing). The single-breath test for CO2 was used to quantify airway dead space (VDaw) and CO2 exchange. RESULTS A long MDT and a high EIF augment CO2 elimination by reducing VDaw and promoting mixing of tidal gas with resident alveolar gas. A heat and moisture exchanger had no other effect than enlarging VDaw. A change of TI from 33 to 15% and of TP from 10 to 28%, leaving the time for expiration unchanged, would augment tidal elimination of CO2 by 14%, allowing a 10% lower tidal volume. CONCLUSIONS In anaesthetized human subjects without lung disease, CO2 exchange is enhanced by a long MDT and a high EIF. A short TI and a long TP allow significant reduction of tidal volume when lung-protective ventilation is required. CLINICAL TRIAL REGISTRATION NCT01686984.
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Affiliation(s)
- L W Sturesson
- Lund University, Department of Clinical Sciences, Lund, Sweden Anaesthesiology and Intensive Care, and Clinical Physiology, Skane University Hospital, SE-221 85 Lund, Sweden
| | - G Malmkvist
- Lund University, Department of Clinical Sciences, Lund, Sweden Anaesthesiology and Intensive Care, and Clinical Physiology, Skane University Hospital, SE-221 85 Lund, Sweden
| | - S Allvin
- Lund University, Department of Clinical Sciences, Lund, Sweden Anaesthesiology and Intensive Care, and Clinical Physiology, Skane University Hospital, SE-221 85 Lund, Sweden
| | - M Collryd
- Lund University, Department of Clinical Sciences, Lund, Sweden Anaesthesiology and Intensive Care, and Clinical Physiology, Skane University Hospital, SE-221 85 Lund, Sweden
| | - M Bodelsson
- Lund University, Department of Clinical Sciences, Lund, Sweden Anaesthesiology and Intensive Care, and Clinical Physiology, Skane University Hospital, SE-221 85 Lund, Sweden
| | - B Jonson
- Clinical Physiology, Skane University Hospital, SE-221 85 Lund, Sweden
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Staudacher DL, Hamilton SK, Duerschmied D, Biever PM, Zehender M, Bode C, Wengenmayer T. Isoflurane or propofol sedation in patients with targeted temperature management after cardiopulmonary resuscitation: A single center study. J Crit Care 2018; 45:40-44. [DOI: 10.1016/j.jcrc.2018.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/19/2017] [Accepted: 01/15/2018] [Indexed: 12/31/2022]
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Halving the volume of AnaConDa: initial clinical experience with a new small-volume anaesthetic reflector in critically ill patients-a quality improvement project. J Clin Monit Comput 2018; 32:639-646. [PMID: 29700664 DOI: 10.1007/s10877-018-0146-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
AnaConDa-100 ml (ACD-100, Sedana Medical, Uppsala, Sweden) is well established for inhalation sedation in the intensive care unit. But because of its large dead space, the system can retain carbon dioxide (CO2) and increase ventilatory demands. We therefore evaluated whether AnaConDa-50 ml (ACD-50), a device with half the internal volume, reduces CO2 retention and ventilatory demands during sedation of invasively ventilated, critically ill patients. Ten patients participated in this cross-over protocol. After sedation with isoflurane via ACD-100 for 24 h, the 5-h observation period started. During the first hour, ACD-100 was used; for the next 2 h, ACD-50; and for the last 2 h, ACD-100 was used again. Sedation was titrated to Richmond Agitation and Sedation Scale (RASS) score - 3 to - 4 and a processed electroencephalogram (Narcotrend Index, Narcotrend-Gruppe, Hannover, Germany) was recorded. Minute ventilation, CO2 elimination, and isoflurane consumption were compared. All patients were deeply sedated (Narcotrend Index, mean ± SD: 38 ± 10; RASS scores - 3 to - 5) and breathed spontaneously with pressure support throughout the observation period. Infusion rates of isoflurane and opioid, either remifentanil or sufentanil, as well as ventilator settings were unchanged. Minute ventilation and end-tidal CO2 were significantly reduced with the ACD-50, respiratory rate remained unchanged, and tidal volume decreased by 66 ± 43 ml. End-tidal isoflurane concentrations were also slightly reduced while haemodynamic measures remained constant. The ACD-50 reduces the tidal volume needed to eliminate carbon dioxide without augmenting isoflurane consumption.
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Mashari A, Fedorko L, Fisher JA, Klein M, Wąsowicz M, Meineri M. High volatile anaesthetic conservation with a digital in-line vaporizer and a reflector. Acta Anaesthesiol Scand 2018; 62:177-185. [PMID: 29068042 DOI: 10.1111/aas.13017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 06/29/2017] [Accepted: 09/29/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND A volatile anaesthetic (VA) reflector can reduce VA consumption (VAC) at the cost of fine control of its delivery and CO2 accumulation. A digital in-line vaporizer and a second CO2 absorber circumvent both of these limitations. We hypothesized that the combination of a VA reflector with an in-line vaporizer would yield substantial VA conservation, independent of fresh gas flow (FGF) in a circle circuit, and provide fine control of inspired VA concentrations. METHOD Prospective observational study on six Yorkshire pigs. A secondary anaesthetic circuit consisting of a Y-piece with 2 one-way valves, an in-line vaporizer and a CO2 absorber in the inspiratory limb was connected to the patient's side of the VA reflector. The other side was connected to the Y-piece of a circle anaesthetic circuit. In six pigs, an inspired concentration of sevoflurane of 2.5% was maintained by the in-line vaporizer. We measured VAC at FGF of 1, 4 and 10 l/min. RESULTS With the secondary circuit, VAC was 55% less than with the circle system alone at FGF 1 l/min, and independent of FGF over the range of 1-10 l/min. Insertion of a CO2 absorber in the secondary circuit reduced Pet CO2 by 1.3-2.0 kpa (10-15 mmHg). CONCLUSION A secondary circuit with reflector and in-line vaporizer provides highly efficient anaesthetic delivery, independent of FGF. A second CO2 absorber was necessary to scavenge the CO2 reflected by the anaesthetic reflector. This secondary circuit may turn any open circuit ventilator into an anaesthetic delivery unit.
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Affiliation(s)
- A. Mashari
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
| | - L. Fedorko
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
- Thornhill Research Inc.; Toronto Canada
| | - J. A. Fisher
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
- Thornhill Research Inc.; Toronto Canada
| | - M. Klein
- Department of Engineering; Thornhill Research Inc.; Toronto Canada
| | - M. Wąsowicz
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
| | - M. Meineri
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
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Farrell R, Oomen G, Carey P. A technical review of the history, development and performance of the anaesthetic conserving device "AnaConDa" for delivering volatile anaesthetic in intensive and post-operative critical care. J Clin Monit Comput 2018; 32:595-604. [PMID: 29388094 PMCID: PMC6061082 DOI: 10.1007/s10877-017-0097-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/21/2017] [Indexed: 12/11/2022]
Abstract
There is a shift in critical care to adopt volatile anaesthetics as sedatives for certain patients using mechanical ventilation. Accompanying this shift is a growing body of literature describing the advantages or disadvantages of using isoflurane or sevoflurane for long term sedation. This practise requires a cost effective, efficient and safe means to deliver these drugs that can simultaneously operate with modern critical care ventilators and ventilation protocols while protecting the care environment and care workers from excessive exposure to the drugs. The anaesthetic conserving device (“AnaConDa”, Sedana Medical) is one device that delivers a safe sedative dose of either isoflurane or sevoflurane to a patient using existing critical care ventilators, common syringe pumps and gas monitors. The device is essentially a small disposable anaesthetic vaporizer and HME filter combined into one airway component. Similar to an HME filter, the device reflects moisture back to the patient, but also reflects 90% of the anaesthetic by adsorbing and releasing the drug using a proprietary carbon filament reflecting medium. This reflection reduces the total amount of anaesthetic needed, reducing that which is exhausted or scavenged upon exhalation. It can be used for 24 h of sedation, and fits into current critical care ventilator circuits almost without modifications. This article will describe the physical characteristics of the device, how it works, its development history and the performance parameters under which it can be used.
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Affiliation(s)
- Ron Farrell
- Sedana Medical, The Village Center, Two Mile House, Naas, Co. Kildare, Ireland.
| | - Glen Oomen
- Sedana Medical, Unit 306, 397 King Street West, Dundas, ON, L9H 1W9, Canada
| | - Pauric Carey
- Sedana Medical, The Village Center, Two Mile House, Naas, Co. Kildare, Ireland
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Volumetric and reflective device dead space of anaesthetic reflectors under different conditions. J Clin Monit Comput 2018; 32:1073-1080. [PMID: 29374847 DOI: 10.1007/s10877-018-0105-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/20/2018] [Indexed: 01/15/2023]
Abstract
Inhalation sedation is increasingly performed in intensive care units. For this purpose, two anaesthetic reflectors, AnaConDa™ and Mirus™ are commercially available. However, their internal volume (100 ml) and possible carbon dioxide reflection raised concerns. Therefore, we compared carbon dioxide elimination of both with a heat moisture exchanger (HME, 35 ml) in a test lung model. A constant flow of carbon dioxide was insufflated into the test lung, ventilated with 500 ml, 10 breaths per minute. HME, MIRUS and AnaConDa were connected successively. Inspired (insp-CO2) and end-tidal carbon dioxide concentrations (et-CO2) were measured under four conditions: ambient temperature pressure (ATP), body temperature pressure saturated (BTPS), BTPS with 0.4 Vol% (ISO-0.4), and 1.2 Vol% isoflurane (ISO-1.2). Tidal volume increase to maintain normocapnia was also determined. Insp-CO2 was higher with AnaConDa compared to MIRUS and higher under ATP compared to BTPS. Isoflurane further decreased insp-CO2 and abolished the difference between AnaConDa and MIRUS. Et-CO2 showed similar effects. In addition to volumetric dead space, reflective dead space was determined as 198 ± 6/58 ± 6/35 ± 0/25 ± 0 ml under ATP/BTPS/ISO-0.4/ISO-1.2 conditions for AnaConDa, and 92 ± 6/25 ± 0/25 ± 0/25 ± 0 ml under the same conditions for MIRUS, respectively. Under BTPS conditions and with the use of moderate inhaled agent concentrations, reflective dead space is small and similar between the two devices.
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Mashari A, Fisher JA, Fedorko L, Wąsowicz M, Meineri M. Technology III: in-line vaporizer with reflector. J Clin Monit Comput 2017; 32:647-650. [PMID: 29124561 DOI: 10.1007/s10877-017-0078-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 10/28/2017] [Indexed: 01/21/2023]
Abstract
As the clinical advantages of vapor anesthesia (VA) for sedation of patients in ICU become more apparent, the ergonomics, economy and safety issues need to be better addressed. Here we describe the use of a new commercial digital in-line anesthetic vaporizer that can be attached to the inspiratory limb of a ventilator. If used with a simple, and easily assembled secondary circuit and anesthetic reflector, the circuit remains remote from the patient, the VA consumption approaches a physical minimum, VA level is controlled and monitored, and the tidal volume size is not limited.
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Affiliation(s)
- A Mashari
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - J A Fisher
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada. .,Thornhill Research Inc., Toronto, Canada.
| | - L Fedorko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Thornhill Research Inc., Toronto, Canada
| | - M Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - M Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Meiser A, Bomberg H, Volk T, Groesdonk HV. [New technical developments for inhaled sedation]. Anaesthesist 2017; 66:274-282. [PMID: 28144686 DOI: 10.1007/s00101-017-0269-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The circle system has been in use for more than 100 years, whereas the first clinical application of an anaesthetic reflector was reported just 15 years ago. In the circle system, all breathing gas is rebreathed after carbon dioxide absorption. A reflector, on the other hand, with the breathing gas flowing to and fro, specifically retains the anaesthetic during expiration and resupplies it during the next inspiration. A high reflection efficiency (number of molecules resupplied/number of molecules exhaled, RE 80-90%) decreases consumption. In analogy to the fresh gas flow of a circle system, pulmonary clearance ((1-RE) × minute ventilation) defines the opposition between consumption and control of the concentration.It was not until reflection systems became available that volatile anaesthetics were used routinely in some intensive care units. Their advantages, such as easy handling, and better ventilatory capabilities of intensive care versus anaesthesia ventilators, were basic preconditions for this. Apart from AnaConDa™ (Sedana Medical, Uppsala, Sweden), the new MIRUS™ system (Pall Medical, Dreieich, Germany) represents a second, more sophisticated commercially available system.Organ protective effects, excellent control of sedation, and dose-dependent deep sedation while preserving spontaneous breathing with hardly any accumulation or induction of tolerance, make volatile anaesthetics an interesting alternative, especially for patients needing deep sedation or when intravenous drugs are no longer efficacious.But obviously, the outcome is most important. We know that deep intravenous sedation increases mortality, whereas inhalational sedation could prove beneficial. We now need prospective clinical trials examining mortality, but also the psychological outcome of those most critically ill patients sedated by inhalation or intravenously.
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Affiliation(s)
- A Meiser
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg/Saar, Deutschland.
| | - H Bomberg
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg/Saar, Deutschland
| | - T Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg/Saar, Deutschland
| | - H V Groesdonk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg/Saar, Deutschland
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Meiser A, Bomberg H, Lepper PM, Trudzinski FC, Volk T, Groesdonk HV. Inhaled Sedation in Patients With Acute Respiratory Distress Syndrome Undergoing Extracorporeal Membrane Oxygenation. Anesth Analg 2017; 125:1235-1239. [DOI: 10.1213/ane.0000000000001915] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Herzog-Niescery J, Seipp HM, Weber TP, Bellgardt M. Inhaled anesthetic agent sedation in the ICU and trace gas concentrations: a review. J Clin Monit Comput 2017; 32:667-675. [PMID: 28861655 DOI: 10.1007/s10877-017-0055-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/15/2017] [Indexed: 12/12/2022]
Abstract
There is a growing interest in the use of volatile anesthetics for inhalational sedation of adult critically ill patients in the ICU. Its safety and efficacy has been demonstrated in various studies and technical equipment such as the anaesthetic conserving device (AnaConDa™; Sedana Medical, Uppsala, Sweden) or the MIRUS™ system (Pall Medical, Dreieich, Germany) have significantly simplified the application of volatile anesthetics in the ICU. However, the personnel's exposure to waste anesthetic gas during daily work is possibly disadvantageous, because there is still uncertainty about potential health risks. The fact that average threshold limit concentrations for isoflurane, sevoflurane and desflurane either differ significantly between countries or are not even defined at all, leads to raising concerns among ICU staff. In this review, benefits, risks, and technical aspects of inhalational sedation in the ICU are discussed. Further, the potential health effects of occupational long-term low-concentration agent exposure, the staffs' exposure levels in clinical practice, and strategies to minimize the individual gas exposure are reviewed.
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Affiliation(s)
- Jennifer Herzog-Niescery
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.
| | - Hans-Martin Seipp
- Department of Life Science Engineering, University of Applied Sciences, Wiesenstr. 14, 35390, Giessen, Germany
| | - Thomas Peter Weber
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Martin Bellgardt
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
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Karnjuš I, Mekiš D, Križmarić M. Uncontrolled delivery of liquid volatile anaesthetic when using the anaesthetic conserving device. J Clin Monit Comput 2017; 32:629-638. [PMID: 28567612 DOI: 10.1007/s10877-017-0022-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 04/24/2017] [Indexed: 11/30/2022]
Abstract
During patient sedation with liquid volatile anaesthetic, some problems may occur through a process called auto-pumping, defined as an expansion of bubbles inside the syringe, which can lead to uncontrolled anaesthetic delivery. The study examined how the temperature of liquid volatile anaesthetics (sevoflurane and isoflurane) and the presence of gas bubbles in the syringe affect the occurrence of auto-pumping when using the anaesthetic conserving device (ACD, AnaConDa™, Sedana Medical, Uppsala, Sweden). Four different circumstances for each volatile anaesthetic were tested with a bench study: volatile anaesthetic at room temperature or precooled with and without the presence of gas bubbles in the syringe. Liquid volatile anaesthetic was infused into the ACD via a syringe pump at a fixed rate and heated gradually until the temperature of the syringe surface reached 50 °C. A main-stream gas monitor was used to measure the expired fraction of volatile anaesthetic (FE vol%). The occurrence of auto-pumping was observed only in the subgroups containing gas bubbles, with both anaesthetics. In these subgroups, the values of the expired anaesthetic gas fraction increased dramatically with the expansion of gas bubbles in the syringe (ΔFE ranged from +1.6 to 2.4 vol% for sevoflurane and +2.3 to 3.4 vol% for isoflurane). Furthermore, when the heat source was removed, a substantial decline in anaesthetic agent values below the baseline was observed with both anaesthetics. The presence of gas bubbles in the syringe, especially when exposed to a heat source, may provoke auto-pumping with uncontrolled excessive anaesthetic delivery. If auto-pumping is suspected, the syringe pump must be stopped and the ACD removed from the breathing circuit at once.
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Affiliation(s)
- Igor Karnjuš
- Department of Nursing, Faculty of Health Sciences, University of Primorska, Polje 42, 6310, Izola, Slovenia.
| | - Dušan Mekiš
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia.,Department of Anaesthesiology and Reanimation, Faculty of Medicine, University of Maribor, Taborska 8, 2000, Maribor, Slovenia
| | - Miljenko Križmarić
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, University of Maribor, Taborska 8, 2000, Maribor, Slovenia.,Department of Bioinformatics, Faculty of Health Sciences, University of Maribor, Žitna ulica 15, 2000, Maribor, Slovenia
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Isoflurane Sedation on the ICU in Cardiac Arrest Patients Treated With Targeted Temperature Management. Crit Care Med 2017; 45:e384-e390. [DOI: 10.1097/ccm.0000000000002185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Jabaudon M, Boucher P, Imhoff E, Chabanne R, Faure JS, Roszyk L, Thibault S, Blondonnet R, Clairefond G, Guérin R, Perbet S, Cayot S, Godet T, Pereira B, Sapin V, Bazin JE, Futier E, Constantin JM. Sevoflurane for Sedation in Acute Respiratory Distress Syndrome. A Randomized Controlled Pilot Study. Am J Respir Crit Care Med 2017; 195:792-800. [DOI: 10.1164/rccm.201604-0686oc] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | | | | | | | | | - Laurence Roszyk
- Department of Medical Biochemistry and Molecular Biology, and
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Sandrine Thibault
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France; and
| | - Raiko Blondonnet
- Department of Perioperative Medicine
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Gael Clairefond
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | | | - Sébastien Perbet
- Department of Perioperative Medicine
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | | | | | - Bruno Pereira
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France; and
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Biology, and
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | | | - Emmanuel Futier
- Department of Perioperative Medicine
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Perioperative Medicine
- Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
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Purrucker JC, Renzland J, Uhlmann L, Bruckner T, Hacke W, Steiner T, Bösel J. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: an observational study. Br J Anaesth 2015; 114:934-43. [PMID: 25823541 DOI: 10.1093/bja/aev070] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The anaesthetic conserving device, AnaConDa(®), allows use of inhaled anaesthetics for sedation in the intensive care unit. We prospectively measured cerebral and cardiopulmonary parameters in patients with acute stroke or subarachnoid haemorrhage during a switch from i.v. to inhalative sedation. METHODS 25 patients were switched from i.v. to an indefinite period of inhaled sedation with sevoflurane. Mean arterial (MAP), intracranial (ICP), and cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (MFV) and fractional tissue oxygen extraction (FTOE), systemic cardiopulmonary parameters, and administered drugs were assessed before and after the change (-6 to +12 h). RESULTS In 8 patients, critically reduced MAP or ICP crisis led to premature termination of sevoflurane sedation. In the other 17 patients, after the first hour, mean ICP increased [2.4 (4.5) mm Hg; P=0.046], MAP decreased [7.8 (14.1) mm Hg; P=0.036] and thus CPP decreased also [-10.2 (15.1) mm Hg; P=0.014]. MFV and FTOE did not change. Over a 12 hour post switch observational period, [Formula: see text] increased slightly [0.3 (0.8) kPa; P=0.104], ICP did not change [0.2 (3.9) mm Hg; P=0.865], but MAP [-6 (6.9) mm Hg; P=0.002] and thus CPP decreased [-6 (8.5) mm Hg; P=0.010]. CONCLUSION Sevoflurane led to sufficient sedation, but decreased MAP and CPP in a selected cerebrovascular neurocritical care population. In about a third of these patients, severe adverse reactions, including intolerable ICP increases, were observed.
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Affiliation(s)
- J C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - J Renzland
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - L Uhlmann
- Department of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - T Bruckner
- Department of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - W Hacke
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - T Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt am Main, Germany
| | - J Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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