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Flinspach AN, Raimann FJ, Kaiser P, Pfaff M, Zacharowski K, Neef V, Adam EH. Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial. Crit Care 2024; 28:111. [PMID: 38581030 PMCID: PMC10996161 DOI: 10.1186/s13054-024-04899-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/03/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Optimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required. METHODS We conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring. RESULTS We observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min; p < 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min; p < 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min; p < 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes p = 0.36. CONCLUSIONS Using volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population. TRIAL REGISTRATION Clinical trials registration (NCT04958668) was completed on 1 July 2021.
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Affiliation(s)
- Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany.
| | - Florian Jürgen Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Philipp Kaiser
- Department of Cardiothoracic Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Michaela Pfaff
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
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Wieruszewski ED, ElSaban M, Wieruszewski PM, Smischney NJ. Inhaled volatile anesthetics in the intensive care unit. World J Crit Care Med 2024; 13:90746. [PMID: 38633473 PMCID: PMC11019627 DOI: 10.5492/wjccm.v13.i1.90746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.
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Affiliation(s)
| | - Mariam ElSaban
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Nathan J Smischney
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Marcos-Vidal JM, González R, Merino M, Higuera E, García C. Sedation for Patients with Sepsis: Towards a Personalised Approach. J Pers Med 2023; 13:1641. [PMID: 38138868 PMCID: PMC10744994 DOI: 10.3390/jpm13121641] [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: 10/14/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.
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Affiliation(s)
- José Miguel Marcos-Vidal
- Department of Anesthesiology and Critical Care, Universitary Hospital of Leon, 24071 Leon, Spain; (R.G.); (M.M.); (E.H.); (C.G.)
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Cuninghame S, Jerath A, Gorsky K, Sivajohan A, Francoeur C, Withington D, Burry L, Cuthbertson BH, Orser BA, Martin C, Owen AM, Slessarev M. Effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults: a systematic review and meta-analysis. Br J Anaesth 2023; 131:314-327. [PMID: 37344338 DOI: 10.1016/j.bja.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 05/04/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Sedation of critically ill patients with inhaled anaesthetics may reduce lung inflammation, time to extubation, and ICU length of stay compared with intravenous (i.v.) sedatives. However, the impact of inhaled anaesthetics on cognitive and psychiatric outcomes in this population is unclear. In this systematic review, we aimed to summarise the effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults. METHODS We searched MEDLINE, EMBASE, and PsycINFO for case series, retrospective, and prospective studies in critically ill adults sedated with inhaled anaesthetics. Outcomes included delirium, psychomotor and neurological recovery, long-term cognitive dysfunction, ICU memories, anxiety, depression, post-traumatic stress disorder (PTSD), and instruments used for assessment. RESULTS Thirteen studies were included in distinct populations of post-cardiac arrest survivors (n=4), postoperative noncardiac patients (n=3), postoperative cardiac patients (n=2), and mixed medical-surgical patients (n=4). Eight studies reported delirium incidence, two neurological recovery, and two ICU memories. One study reported on psychomotor recovery, long-term cognitive dysfunction, anxiety, depression, and PTSD. A meta-analysis of five trials found no difference in delirium incidence between inhaled and i.v. sedatives (relative risk 0.95 [95% confidence interval: 0.59-1.54]). Compared with i.v. sedatives, inhaled anaesthetics were associated with fewer hallucinations and faster psychomotor recovery but no differences in other outcomes. There was heterogeneity in the instruments used and timing of these assessments. CONCLUSIONS Based on the limited evidence available, there is no difference in cognitive and psychiatric outcomes between adults exposed to volatile sedation or intravenous sedation in the ICU. Future studies should incorporate outcome assessment with validated tools during and after hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42021236455.
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Affiliation(s)
- Sean Cuninghame
- Department of Medicine, Western University, London, ON, Canada
| | - 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; Schulich Heart Program, Sunnybrook Research Institute, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Kevin Gorsky
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Asaanth Sivajohan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Conall Francoeur
- Centre de Recherche CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Davinia Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Beverley A Orser
- 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
| | - Claudio Martin
- Department of Medicine, Western University, London, ON, Canada
| | - Adrian M Owen
- Western Institute for Neuroscience, Western University, London, ON, Canada; Department of Psychology and Department of Physiology and Pharmacology, Western University, London, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada; Western Institute for Neuroscience, Western University, London, ON, Canada.
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Martínez-Castro S, Monleón B, Puig J, Ferrer Gomez C, Quesada M, Pestaña D, Balvis A, Maseda E, de la Rica AS, Feijoo AM, Badenes R. Sedation with Sevoflurane versus Propofol in COVID-19 Patients with Acute Respiratory Distress Syndrome: Results from a Randomized Clinical Trial. J Pers Med 2023; 13:925. [PMID: 37373914 DOI: 10.3390/jpm13060925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) related to COVID-19 (coronavirus disease 2019) led to intensive care units (ICUs) collapse. Amalgams of sedative agents (including volatile anesthetics) were used due to the clinical shortage of intravenous drugs (mainly propofol and midazolam). METHODS A multicenter, randomized 1:1, controlled clinical trial was designed to compare sedation using propofol and sevoflurane in patients with ARDS associated with COVID-19 infection in terms of oxygenation and mortality. RESULTS Data from a total of 17 patients (10 in the propofol arm and 7 in the sevoflurane arm) showed a trend toward PaO2/FiO2 improvement and the sevoflurane arm's superiority in decreasing the likelihood of death (no statistical significance was found). CONCLUSIONS Intravenous agents are the most-used sedative agents in Spain, even though volatile anesthetics, such as sevoflurane and isoflurane, have shown beneficial effects in many clinical conditions. Growing evidence demonstrates the safety and potential benefits of using volatile anesthetics in critical situations.
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Affiliation(s)
- Sara Martínez-Castro
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Berta Monleón
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Jaume Puig
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Carolina Ferrer Gomez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Marta Quesada
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - David Pestaña
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Alberto Balvis
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Emilio Maseda
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Alejandro Suárez de la Rica
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario De La Princesa, 28006 Madrid, Spain
| | - Ana Monero Feijoo
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
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Gómez Duque M, Medina R, Enciso C, Beltran E, Hernandez K, Molano Franco D, Masclans JR. Usefulness of Inhaled Sedation in Patients With Severe ARDS Due to COVID-19. Respir Care 2023; 68:293-299. [PMID: 36414277 PMCID: PMC10027142 DOI: 10.4187/respcare.10371] [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] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sedation in intensive care is fundamental for optimizing clinical outcomes. For many years the world has been facing high rates of opioid use, and to combat the increasing opioid addiction plans at both national and international level have been implemented.1 The COVID-19 pandemic posed a major challenge for health systems and also increased the use of sedatives and opioid analgesia for prolonged periods of time, and at high doses, in a significant proportion of patients. In our institutions, the shortage of many drugs for intravenous (IV) analgosedation forces us to alternatives to replace out-of-stock drugs or to seek sedation goals, which are difficult to obtain with traditional drugs at high doses.2 METHODS: This was an analytical retrospective cohort study evaluating the follow-up of subjects with inclusion criteria from ICU admission to discharge (alive or dead). Five end points were measured: need for high-dose opioids (≥ 200 µg/h), comparison of inhaled versus IV sedation of opioid analgesic doses, midazolam dose, need for muscle relaxant, and risk of delirium. RESULTS A total of 283 subjects were included in the study, of whom 230 were administered IV sedation and 53 inhaled sedation. In the inhaled sedation group, the relative risks (RRs) were 0.5 (95% CI 0.4-0.8, P = .045) for need of high-dose fentanyl, 0.3 (95% CI 0.20-0.45, P < .001) for need of muscle relaxant, and 0.8 (95% CI 0.61-1.15, P = .25) for risk of delirium. The median difference of fentanyl dose between the inhaled sedation and IV sedation groups was 61 µg/h or 1,200 µg/d (2.2 ampules/d, P < .001), and that of midazolam dose was 5.7 mg/h. CONCLUSIONS Inhaled sedation was associated with lower doses of opioids, benzodiazepines, and muscle relaxants compared to IV sedation. This therapy should be considered as an alternative in critically ill patients requiring prolonged ventilatory support and where IV sedation is not possible, always under adequate supervision of ICU staff.
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Affiliation(s)
- Mario Gómez Duque
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Ronald Medina
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Cesar Enciso
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Edgar Beltran
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Kevin Hernandez
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Daniel Molano Franco
- Service of Intensive Care Medicine, Hospital de San José, Los Cobos Medical Center, Research Group GRIBOS, Bogotá, Colombia.
| | - Joan R Masclans
- Service of Intensive Care Medicine, Hospital del Mar de Barcelona, IMIM (GREPAC), Department of Medicine (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
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Ramos FJDS, dos Santos MHC, Pastore Junior L. Sedation with volatile anesthetics in the intensive care unit: a new option with old agents. CRITICAL CARE SCIENCE 2023; 35:100-101. [PMID: 37712735 PMCID: PMC10275303 DOI: 10.5935/2965-2774.20230394-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/10/2022] [Indexed: 09/16/2023]
Affiliation(s)
- Fernando José da Silva Ramos
- Department of Anesthesiology, Pain and Intensive Care Medicine,
Universidade Federal de São Paulo - São Paulo (SP), Brazil
- Adult Intensive Care Unit, Hospital Sírio-Libanês -
São Paulo (SP), Brazil
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Inhaled Sedation with Volatile Anesthetics for Mechanically Ventilated Patients in Intensive Care Units: A Narrative Review. J Clin Med 2023; 12:jcm12031069. [PMID: 36769718 PMCID: PMC9918250 DOI: 10.3390/jcm12031069] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Inhaled sedation was recently approved in Europe as an alternative to intravenous sedative drugs for intensive care unit (ICU) sedation. The aim of this narrative review was to summarize the available data from the literature published between 2005 and 2023 in terms of the efficacy, safety, and potential clinical benefits of inhaled sedation for ICU mechanically ventilated patients. The results indicated that inhaled sedation reduces the time to extubation and weaning from mechanical ventilation and reduces opioid and muscle relaxant consumption, thereby possibly enhancing recovery. Several researchers have reported its potential cardio-protective, anti-inflammatory or bronchodilator properties, alongside its minimal metabolism by the liver and kidney. The reflection devices used with inhaled sedation may increase the instrumental dead space volume and could lead to hypercapnia if the ventilator settings are not optimal and the end tidal carbon dioxide is not monitored. The risk of air pollution can be prevented by the adequate scavenging of the expired gases. Minimizing atmospheric pollution can be achieved through the judicious use of the inhalation sedation for selected groups of ICU patients, where the benefits are maximized compared to intravenous sedation. Very rarely, inhaled sedation can induce malignant hyperthermia, which prompts urgent diagnosis and treatment by the ICU staff. Overall, there is growing evidence to support the benefits of inhaled sedation as an alternative for intravenous sedation in ICU mechanically ventilated patients. The indication and management of any side effects should be clearly set and protocolized by each ICU. More randomized controlled trials (RCTs) are still required to investigate whether inhaled sedation should be prioritized over the current practice of intravenous sedation.
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Blondonnet R, Balde A, Zhai R, Pereira B, Futier E, Bazin JE, Godet T, Constantin JM, Lambert C, Jabaudon M. Use of volatile anesthetics for sedation in the ICU during the COVID-19 pandemic: A national survey in France (VOL'ICU 2 study). PLoS One 2022; 17:e0278090. [PMID: 36580451 PMCID: PMC9799316 DOI: 10.1371/journal.pone.0278090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/09/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has increased the number of patients in ICUs leading to a worldwide shortage of the intravenous sedative agents obligating physicians to find alternatives including inhaled sedation. Inhaled sedation in French ICU has been previously explored in 2019 (VOL'ICU study). This survey was designed to explore the use of inhaled sedation two years after our first survey and to evaluate how the COVID-19 pandemic has impacted the use of inhaled sedation. METHODS We designed a national survey, contacting medical directors of French ICUs between June and October 2021. Over a 50-item questionnaire, the survey covered the characteristics of the ICU, data on inhaled sedation, and practical aspects of inhaled ICU sedation for both COVID-19 and non-COVID-19 patients. Answers were compared with the previous survey, VOL'ICU. RESULTS Among the 405 ICUs contacted, 25% of the questionnaires were recorded. Most ICU directors (87%) knew about the use of inhaled ICU sedation and 63% of them have an inhaled sedation's device in their unit. The COVID-19 pandemic increased the use of inhaled sedation in French ICUs. The main reasons said by the respondent were "need for additional sedative" (62%), "shortage of intravenous sedatives" (38%) and "involved in a clinical trial" (30%). The main reasons for not using inhaled ICU sedation were "device not available" (76%), "lack of familiarity" (60%) and "no training for the teams" (58%). More than 70% of respondents were overall satisfied with the use of inhaled sedation. Almost 80% of respondents stated that inhaled sedation was a seducing alternative to intravenous sedation for management of COVID-19 patients. CONCLUSION The use of inhaled sedation in ICU has increased fastly in the last 2 years, and is frequently associated with a good satisfaction among the users. Even if the COVID-19 pandemic could have impacted the widespread use of inhaled sedation, it represents an alternative to intravenous sedation for more and more physicians.
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Affiliation(s)
- Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- * E-mail:
| | - Aissatou Balde
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ruoyang Zhai
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, GRC 29, AP-HP, DMU DREAM, Sorbonne University, Paris, France
| | - Céline Lambert
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, 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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Inhaled Sedation in Patients with COVID-19-Related Acute Respiratory Distress Syndrome: An International Retrospective Study. J Clin Med 2022; 12:jcm12010012. [PMID: 36614813 PMCID: PMC9821008 DOI: 10.3390/jcm12010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic and the shortage of intravenous sedatives has led to renewed interest in inhaled sedation for patients with acute respiratory distress syndrome (ARDS). We hypothesized that inhaled sedation would be associated with improved clinical outcomes in COVID-19 ARDS patients. METHODS Retrospective international study including mechanically ventilated patients with COVID-19 ARDS who required sedation and were admitted to 10 European and US intensive care units. The primary endpoint of ventilator-free days through day 28 was analyzed using zero-inflated negative binomial regression, before and after adjustment for site, clinically relevant covariates determined according to the univariate results, and propensity score matching. RESULTS A total of 196 patients were enrolled, 78 of whom died within 28 days. The number of ventilator-free days through day 28 did not differ significantly between the patients who received inhaled sedation for at least 24 h (n = 111) and those who received intravenous sedation only (n = 85), with medians of 0 (interquartile range [IQR] 0-8) and 0 (IQR 0-17), respectively (odds ratio for having zero ventilator-free days through day 28, 1.63, 95% confidence interval [CI], 0.91-2.92, p = 0.10). The incidence rate ratio for the number of ventilator-free days through day 28 if not 0 was 1.13 (95% CI, 0.84-1.52, p = 0.40). Similar results were found after multivariable adjustment and propensity matching. CONCLUSION The use of inhaled sedation in COVID-19 ARDS was not associated with the number of ventilator-free days through day 28.
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Duan X, Lacko LA, Chen S. Druggable targets and therapeutic development for COVID-19. Front Chem 2022; 10:963701. [PMID: 36277347 PMCID: PMC9581228 DOI: 10.3389/fchem.2022.963701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease (COVID-19), which is caused by SARS-CoV-2, is the biggest challenge to the global public health and economy in recent years. Until now, only limited therapeutic regimens have been available for COVID-19 patients, sparking unprecedented efforts to study coronavirus biology. The genome of SARS-CoV-2 encodes 16 non-structural, four structural, and nine accessory proteins, which mediate the viral life cycle, including viral entry, RNA replication and transcription, virion assembly and release. These processes depend on the interactions between viral polypeptides and host proteins, both of which could be potential therapeutic targets for COVID-19. Here, we will discuss the potential medicinal value of essential proteins of SARS-CoV-2 and key host factors. We summarize the most updated therapeutic interventions for COVID-19 patients, including those approved clinically or in clinical trials.
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Peng L, Liu S, Xu J, Xie W, Fang X, Xia T, Gu X. Metformin alleviates prolonged isoflurane inhalation induced cognitive decline via reducing neuroinflammation in adult mice. Int Immunopharmacol 2022; 109:108903. [PMID: 35709590 PMCID: PMC9190296 DOI: 10.1016/j.intimp.2022.108903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/12/2022]
Abstract
With the widespread use of volatile anesthetic agents in the prolonged sedation for COVID-19 pneumonia and ARDS, there is an urgent need to investigate the effects and treatments of lengthy low-concentration inhaled anesthetics exposure on cognitive function in adults. Previous studies showed that general anesthetics dose- and exposure length-dependently induced neuroinflammatory response and cognitive decline in neonatal and aging animals. The anti-diabetes drug metformin has anti-neuroinflammation effects by modulating microglial polarization and inhibiting astrocyte activation. In this study, we demonstrated that the inhalation of 1.3% isoflurane (a sub-minimal alveolar concentration, sub-MAC) for 6 h impaired recognition of novel objects from Day 1 to Day3 in adult mice. Prolonged sub-MAC isoflurane exposure also triggered typically reactive microglia and A1-like astrocytes in the hippocampus of adult mice on Day 3 after anesthesia. In addition, prolonged isoflurane inhalation switched microglia into a proinflammatory M1 phenotype characterized by elevated CD68 and iNOS as well as decreased arginase-1 and IL-10. Metformin pretreatment before anesthesia enhanced cognitive performance in the novel object test. The positive cellular modifications promoted by metformin pretreatment included the inhibition of reactive microglia and A1-like astrocytes and the polarization of microglia into M2 phenotype in the hippocampus of adult mice. In conclusion, prolonged sub-MAC isoflurane exposure triggered significant hippocampal neuroinflammation and cognitive decline in adult mice which can be alleviated by metformin pretreatment via inhibiting reactive microglia and A1-like astrocytes and promoting microglia polarization toward anti-inflammatory phenotype in the hippocampus.
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Affiliation(s)
- Liangyu Peng
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Shuai Liu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Jiyan Xu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Wenjia Xie
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Xin Fang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China
| | - Tianjiao Xia
- Medical School of Nanjing University, Nanjing 210093, Jiangsu, China; Jiangsu Key Laboratory of Molecular Medicine, Nanjing University, Nanjing 210093, Jiangsu, China.
| | - Xiaoping Gu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
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Jabaudon M, Zhai R, Blondonnet R, Bonda WLM. Inhaled sedation in the intensive care unit. Anaesth Crit Care Pain Med 2022; 41:101133. [PMID: 35907598 DOI: 10.1016/j.accpm.2022.101133] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022]
Abstract
Inhaled sedation with halogenated agents, such as isoflurane or sevoflurane, is now feasible in intensive care unit (ICU) patients through dedicated vaporisers and scavenging systems. Such a sedation strategy requires specific equipment and adequate training of ICU teams. Isoflurane and sevoflurane have ideal pharmacological properties that allow efficient, well-tolerated, and titratable light-to-deep sedation. In addition to their function as sedative agents, these molecules may have clinical benefits that could be especially relevant to ICU patients. Our goal was to summarise the pharmacological basis and practical aspects of inhaled ICU sedation, review the available evidence supporting inhaled sedation as a viable alternative to intravenous sedation, and discuss the remaining areas of uncertainty and future perspectives of development.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France.
| | - Ruoyang Zhai
- GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
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14
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Flinspach AN, Zinn S, Zacharowski K, Balaban Ü, Herrmann E, Adam EH. Electroencephalogram-Based Evaluation of Impaired Sedation in Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:jcm11123494. [PMID: 35743572 PMCID: PMC9224742 DOI: 10.3390/jcm11123494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/02/2022] [Accepted: 06/10/2022] [Indexed: 02/01/2023] Open
Abstract
The sedation management of patients with severe COVID-19 is challenging. Processed electroencephalography (pEEG) has already been used for sedation management before COVID-19 in critical care, but its applicability in COVID-19 has not yet been investigated. We performed this prospective observational study to evaluate whether the patient sedation index (PSI) obtained via pEEG may adequately reflect sedation in ventilated COVID-19 patients. Statistical analysis was performed by linear regression analysis with mixed effects. We included data from 49 consecutive patients. None of the patients received neuromuscular blocking agents by the time of the measurement. The mean value of the PSI was 20 (±23). The suppression rate was determined to be 14% (±24%). A deep sedation equivalent to the Richmond Agitation and Sedation Scale of −3 to −4 (correlation expected PSI 25−50) in bedside examination was noted in 79.4% of the recordings. Linear regression analysis revealed a significant correlation between the sedative dosages of propofol, midazolam, clonidine, and sufentanil (p < 0.01) and the sedation index. Our results showed a distinct discrepancy between the RASS and the determined PSI. However, it remains unclear to what extent any discrepancy is due to the electrophysiological effects of neuroinflammation in terms of pEEG alteration, to the misinterpretation of spinal or vegetative reflexes during bedside evaluation, or to other causes.
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Affiliation(s)
- Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
- Correspondence: ; Tel.: +49-69-6301-5868
| | - Sebastian Zinn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
| | - Ümniye Balaban
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (Ü.B.); (E.H.)
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (Ü.B.); (E.H.)
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
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15
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Landoni G, Belloni O, Russo G, Bonaccorso A, Carà G, Jabaudon M. Inhaled Sedation for Invasively Ventilated COVID-19 Patients: A Systematic Review. J Clin Med 2022; 11:jcm11092500. [PMID: 35566625 PMCID: PMC9105857 DOI: 10.3390/jcm11092500] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Volatile anesthetics were used as sedative agents in COVID-19 (Coronavirus Disease 2019) invasively ventilated patients for their potentially beneficial pharmacological effects and due to the temporary shortages of intravenous agents during the pandemic crisis. Methods: Online databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trial) and the “clinicaltrials.gov” website were searched for studies reporting the use of isoflurane, sevoflurane or desflurane. Results: We identified three manuscripts describing the beneficial effects of isoflurane on 41 COVID-19 patients with acute respiratory distress syndrome (ARDS) in Germany (n = 2) and in the USA (n = 1), in terms of reduction in the use of opioids and other sedatives. We also found a case report of two patients with transient nephrogenic diabetes insipidus, which started after 6 and 8 days of sevoflurane sedation. We identified two randomized controlled trials (RCTs; 92 patients overall), two observational studies (238 patients) on the use of volatile anesthetics in COVID-19 patients that were completed but not yet published, and one RCT interrupted for a low recruitment ratio (19 patients) and thus not published. We also identified five ongoing RCTs on the use of inhaled sedation in ARDS, which are also likely to be recruiting COVID-19 patients and which have currently enrolled a total of >1643 patients. Conclusion: Isoflurane was the most frequently used volatile agent in COVID-19 patients and allowed a reduction in the use of other sedative and analgesic drugs. Randomized evidence is building up and will be useful to confirm or challenge these findings.
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Affiliation(s)
- Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Correspondence:
| | - Olivia Belloni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Giada Russo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Alessandra Bonaccorso
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Gianmarco Carà
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France;
- GReD, Université Clermont Auvergne, CNRS, INSERM, F-63000 Clermont-Ferrand, France
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16
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Olsby JH, Dihle A, Hofsø K, Steindal SA. Intensive care nurses' experiences using volatile anaesthetics in the intensive care unit: An exploratory study. Intensive Crit Care Nurs 2022; 70:103220. [PMID: 35216899 DOI: 10.1016/j.iccn.2022.103220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 01/16/2022] [Accepted: 02/09/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To explore the experiences intensive care nurses have with volatile anaesthetics in the intensive care unit. RESEARCH METHODOLOGY AND DESIGN A qualitative exploratory and descriptive design was used. Data were collected in 2019 from individual interviews with nine intensive care nurses, who were recruited using purposive sampling. Data were analysed using systematic text condensation. SETTING The study was undertaken in two general intensive care units from different university hospitals in Norway where volatile anaesthetics were utilised. FINDINGS Three categories emerged from the data analysis: experiencing the benefits of volatile anaesthetics; coping with unfamiliarity in handling volatile anaesthetics; and meeting challenges related to volatile anaesthetics in practice. CONCLUSION The intensive care nurses had positive experiences related to administering volatile anaesthetics in the intensive care unit and responded positively to the prospect of using it more often. Because volatile anaesthetics were rarely used in their units, the participants felt uncertain regarding its use due to unfamiliarity. Collegial support and guidelines were perceived as pivotal in helping them cope with this uncertainty. The participants also experienced several challenges in using volatile anaesthetics in the intensive care unit, with ambient pollution being regarded as the main challenge.
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Affiliation(s)
- Jim Harald Olsby
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Postoperative and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Ullevål sykehus, Postboks 4956 Nydalen, 0424 Oslo, Norway.
| | - Alfhild Dihle
- Faculty of Health Science, OsloMet - Oslo Metropolitan University, Oslo, Norway.
| | - Kristin Hofsø
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Faculty of Health Studies, VID Specialized University, Oslo, Norway.
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17
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Cuninghame S, Gorsky K, Francoeur C, Withington D, Burry L, Jerath A, Slessarev M. Effect of sedation with inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults: a systematic review protocol. BMJ Open 2022; 12:e052893. [PMID: 35131825 PMCID: PMC8822506 DOI: 10.1136/bmjopen-2021-052893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has renewed interest in the use of inhaled anaesthetics for sedation of ventilated critically ill patients. Preliminary data show that inhaled anaesthetics reduce lung inflammation, time to extubation and intensive care unit length of stay compared with intravenous sedatives. However, the impact of inhaled anaesthetics on cognitive and psychiatric outcomes is not well described in this setting. Randomised controlled trials are underway to establish if inhaled anaesthetics affect these and other patient and health system outcomes. Our aim is to summarise the known effects of inhaled sedatives on cognitive and psychiatric outcomes. METHODS AND ANALYSIS In this systematic review, we will use MEDLINE, EMBASE, and PsycINFO to identify studies from 1970 to 2021 that assessed cognitive and psychiatric outcomes in critically ill adult patients sedated with inhaled anaesthetics. We will include case series, observational and cohort studies and randomised controlled trials. We will exclude case studies due to the heterogeneity of reporting in these studies. For randomised controlled trials comparing inhaled to intravenous sedation, we will report cognitive and psychiatric outcomes for both study arms. Studies will be selected based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Data will be extracted using a standardised data extraction tool by two independent reviewers. Studies will be assessed for bias using the Cochrane risk of bias tool for randomised controlled trials, or the Newcastle-Ottawa Scale for cohort and case-control studies. Findings will be reported according to outcome and descriptive statistics will be used to illustrate findings in a narrative fashion. ETHICS AND DISSEMINATION The systematic review uses published data and therefore does not require ethics approval. Results will be disseminated via publication in peer-reviewed journals and presentation at conferences related to the field. PROSPERO REGISTRATION NUMBER CRD42021236455.
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Affiliation(s)
- Sean Cuninghame
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Kevin Gorsky
- Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Conall Francoeur
- Department of Pediatrics, Laval University, Quebec, Quebec, Canada
| | - Davinia Withington
- Department of Anesthesiology, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Mangement and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, Ontario, Canada
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18
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Editorial: cardiovascular anaesthesiology. Curr Opin Anaesthesiol 2022; 35:1-4. [PMID: 34932519 DOI: 10.1097/aco.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:jcm11030588. [PMID: 35160040 PMCID: PMC8837042 DOI: 10.3390/jcm11030588] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.
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Bellgardt M, Özcelik D, Breuer-Kaiser AFC, Steinfort C, Breuer TGK, Weber TP, Herzog-Niescery J. Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome. World J Crit Care Med 2021; 10:323-333. [PMID: 34888158 PMCID: PMC8613718 DOI: 10.5492/wjccm.v10.i6.323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/24/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is a severe complication of infection with severe acute respiratory syndrome coronavirus 2, and the primary cause of death in the current pandemic. Critically ill patients often undergo extracorporeal membrane oxygenation (ECMO) therapy as the last resort over an extended period. ECMO therapy requires sedation of the patient, which is usually achieved by intravenous administration of sedatives. The shortage of intravenous sedative drugs due to the ongoing pandemic, and attempts to improve treatment outcome for COVID-19 patients, drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy. Administration of volatile anesthetics requires an appropriate delivery. Commercially available ones are the anesthetic gas reflection systems AnaConDa® and MIRUSTM, and each should be combined with a gas scavenging system. In this review, we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS. We focus particularly on the technical details of administration of volatile anesthetics. Furthermore, we describe the advantages of inhaled sedation and volatile anesthetics, and we discuss the limitations as well as the requirements for safe application in the clinical setting.
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Affiliation(s)
- Martin Bellgardt
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Dennis Özcelik
- Chemistry | Biology | Pharmacy Information Center, ETH Zürich, Zürich 8093, Switzerland
| | | | - Claudia Steinfort
- General and Visceral Surgery, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Thomas Georg Karl Breuer
- Internal Medicine/Intensive Care, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Thomas Peter Weber
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Jennifer Herzog-Niescery
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
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Meiser A, Volk T, Wallenborn J, Guenther U, Becher T, Bracht H, Schwarzkopf K, Knafelj R, Faltlhauser A, Thal SC, Soukup J, Kellner P, Drüner M, Vogelsang H, Bellgardt M, Sackey P. Inhaled isoflurane via the anaesthetic conserving device versus propofol for sedation of invasively ventilated patients in intensive care units in Germany and Slovenia: an open-label, phase 3, randomised controlled, non-inferiority trial. THE LANCET RESPIRATORY MEDICINE 2021; 9:1231-1240. [PMID: 34454654 DOI: 10.1016/s2213-2600(21)00323-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies indicate that isoflurane could be useful for the sedation of patients in the intensive care unit (ICU), but prospective studies evaluating isoflurane's efficacy have been small. The aim of this study was to test whether the sedation with isoflurane was non-inferior to sedation with propofol. METHODS This phase 3, randomised, controlled, open-label non-inferiority trial evaluated the efficacy and safety of up to 54 h of isoflurane compared with propofol in adults (aged ≥18 years) who were invasively ventilated in ICUs in Germany (21 sites) and Slovenia (three sites). Patients were randomly assigned (1:1) to isoflurane inhalation via the Sedaconda anaesthetic conserving device (ACD; Sedana Medical AB, Danderyd, Sweden; ACD-L [dead space 100 mL] or ACD-S [dead space 50 mL]) or intravenous propofol infusion (20 mg/mL) for 48 h (range 42-54) using permuted block randomisation with a centralised electronic randomisation system. The primary endpoint was percentage of time in Richmond Agitation-Sedation Scale (RASS) range -1 to -4, assessed in eligible participants with at least 12 h sedation (the per-protocol population), five or more RASS measurements, and no major protocol violations, with a non-inferiority margin of 15%. Key secondary endpoints were opioid requirements, spontaneous breathing, time to wake-up and extubation, and adverse events. Safety was assessed in all patients who received at least one dose. The trial is complete and registered with EudraCT, 2016-004551-67. FINDINGS Between July 2, 2017, and Jan 12, 2020, 338 patients were enrolled and 301 (89%) were randomly assigned to isoflurane (n=150) or propofol (n=151). 146 patients (97%) in each group completed the 24-h follow-up. 146 (97%) patients in the isoflurane group and 148 (98%) of patients in the propofol group were included in the per-protocol analysis of the primary endpoint. Least-squares mean percentage of time in RASS target range was 90·7% (95% CI 86·8-94·6) for isoflurane and 91·1% (87·2-95·1) for propofol. With isoflurane sedation, opioid dose intensity was 29% lower than with propofol for the overall sedation period (0·22 [0·12-0·34] vs 0·32 [0·21-0·42] mg/kg per h morphine equivalent dose, p=0·0036) and spontaneous breathing was more frequent on day 1 (odds ratio [OR] 1·72 [1·12-2·64], generalised mixed linear model p=0·013, with estimated rates of 50% of observations with isoflurane vs 37% with propofol). Extubation times were short and median wake-up was significantly faster after isoflurane on day 2 (20 min [IQR 10-30] vs 30 min [11-120]; Cox regression p=0·0011). The most common adverse events by treatment group (isoflurane vs propofol) were: hypertension (ten [7%] of 150 vs two [1%] of 151), delirium (eight [5%] vs seven [5%]), oliguria (seven [5%] vs six [4%]), and atrial fibrillation (five [3%] vs four [3%]). INTERPRETATION These results support the use of isoflurane in invasively ventilated patients who have a clinical need for sedation. FUNDING Sedana Medical AB.
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Affiliation(s)
- Andreas Meiser
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Jan Wallenborn
- Department of Anesthesiology and Intensive Care Medicine, Helios Klinikum Aue, Aue, Germany
| | - Ulf Guenther
- University Clinic of Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, Klinikum Oldenburg, Oldenburg, Germany
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Hendrik Bracht
- Department of Emergency Medicine, and Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Rihard Knafelj
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Serge C Thal
- Helios University Hospital Wuppertal, University of Witten-Herdecke, Department of Anesthesiology, Wuppertal, Germany; University Medical Center of the Johannes Gutenberg-University Mainz, Department of Anesthesiology, Mainz, Germany
| | - Jens Soukup
- Department of Anaesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care, University of Lübeck, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Matthias Drüner
- Department of Anaesthesiology and Intensive Care Medicine, Emden Hospital, Emden, Germany
| | - Heike Vogelsang
- St Josef-Hospital Bochum, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Martin Bellgardt
- St Josef-Hospital Bochum, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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22
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Kashav RC, Kohli JK, Magoon R. TIVA versus Inhalational Agents for Pediatric Cardiac Intensive Care. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1732834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractThe field of pediatric intensive care has come a long way, especially with the recognition that adequate sedation and analgesia form an imperative cornerstone of patient management. With various drugs available for the same, the debate continues as to which is the better: total intravenous anesthesia (TIVA) or inhalational agents. While each have their own advantages and disadvantages, in the present era of balance toward the IV agents, we should not forget the edge our volatile agents (VAs) might have in special scenarios. And ultimately as anesthesiologists, let us not forget that be it knob and dial, or syringe and plunger, our aim is to put pain to sleep and awaken a new faith to breathe.
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Affiliation(s)
- Ramesh Chand Kashav
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Jasvinder Kaur Kohli
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
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Flinspach AN, Booke H, Zacharowski K, Balaban Ü, Herrmann E, Adam EH. High sedation needs of critically ill COVID-19 ARDS patients-A monocentric observational study. PLoS One 2021; 16:e0253778. [PMID: 34314422 PMCID: PMC8315516 DOI: 10.1371/journal.pone.0253778] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). METHODS We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. RESULTS In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. CONCLUSION The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.
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Affiliation(s)
- Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
| | - Hendrik Booke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
| | - Ümniye Balaban
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Hessen, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Hessen, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
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Hirota K, Lambert DG. Anaesthesia-related drugs and SARS-CoV-2 infection. Br J Anaesth 2021; 127:e32-e34. [PMID: 33934887 PMCID: PMC8020093 DOI: 10.1016/j.bja.2021.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - David G Lambert
- University Department of Cardiovascular Sciences, Anaesthesia, Critical Care and Pain Management, Leicester Royal Infirmary, Leicester, UK
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Standard Sedation and Sedation With Isoflurane in Mechanically Ventilated Patients With Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0370. [PMID: 33786446 PMCID: PMC7994032 DOI: 10.1097/cce.0000000000000370] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives: To describe sedative and analgesic drug utilization in a cohort of critically ill patients with coronavirus disease 2019 and compare standard sedation with an alternative approach using inhaled isoflurane. Design: This was a retrospective cohort study designed to compare doses of sedatives between ICU patients receiving standard IV sedation and patients receiving mixed sedation including inhaled isoflurane. Data were obtained from electronic medical records. Setting: ICU at large academic medical center where mechanical ventilation was delivered with Draeger Apollo (Draeger Medical, Telford, PA) anesthesia machines. Patients: Consecutive adult patients (≥ 18 yr) with confirmed coronavirus disease 2019 admitted to ICU between April 2, 2020, and May 4, 2020. Interventions: None. Measurements and Main Results: Thirty-five mechanically ventilated patients were included in the study, with a mean (sd) age of 59.4 (12.8) years. Twenty-three patients (65.7%) were men. Seventeen patients (48.6%) received standard IV sedation, whereas 18 (51.4%) also received isoflurane. The mean duration of mechanical ventilation (sd) was 23.3 (11.6) days in the standard sedation group and 23.8 (12.5) days in the isoflurane group. Mean (sd) duration of isoflurane exposure was 5.61 (2.99) days, representing 29.1% of total sedation time (sd, 20.4). Cumulative opioid exposure did not differ between the standard sedation and isoflurane sedation groups (mean morphine milligram equivalent 6668 [sd, 1,346] vs 6678 [sd, 2,000] mg). However, the initiation of isoflurane in patients was associated with decreased utilization of propofol (mean daily amount 3,656 [sd, 1,635] before vs 950 [sd, 1,804] mg during isoflurane) and hydromorphone (mean daily amount 48 [sd, 30] before vs 23 [sd, 27] mg). Conclusions: In the subjects that received isoflurane, its use was associated with significant decreases in propofol and hydromorphone infusions.
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