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Levin JH, Wallace MW, Hess TN, Beavers JR, Chang T, Beyene RT. The Effect of Propofol on Peri-Induction Hemodynamics and Resuscitation in Operative Penetrating Trauma. Am Surg 2024; 90:731-738. [PMID: 37209120 DOI: 10.1177/00031348231177932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND Hemorrhaging trauma patients may be disproportionately affected by choice of induction agent during rapid sequence intubation (RSI). Etomidate, ketamine, and propofol are safe in the trauma population-at-large but have not been assessed in patients with ongoing hemorrhage. We hypothesize that in hemorrhaging patients with penetrating injury, propofol deleteriously affects peri-induction hypotension compared to etomidate and ketamine. METHODS Retrospective cohort study. Primary outcome was the effect of induction agent on peri-induction systolic blood pressure. Secondary outcomes were the incidence of peri-induction vasopressor use and quantity of peri-induction blood transfusion requirements. Linear multivariate regression modeling assessed the effect of induction agent on the variables of interest. RESULTS 169 patients were included, 146 received propofol and 23 received etomidate or ketamine. Univariate analysis revealed no difference in peri-induction systolic blood pressure (P = .53), peri-induction vasopressor administration (P = .62), or transfusion requirements within the first hour after induction (PRBC P = .24, FFP P = .19, PLT P = .29). Choice of RSI agent did not independently predict peri-induction systolic blood pressure or blood product administration. Rather, only presenting shock index independently predicted peri-induction hypotension. CONCLUSIONS This is the first study to directly assess the peri-induction effects of anesthetic induction agent choice in penetrating trauma patients undergoing emergent hemorrhage control surgery. Propofol does not appear to worsen peri-induction hypotension regardless of dose. Patient physiology is most predictive of peri-induction hypotension.
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Affiliation(s)
- Jeremy H Levin
- Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | | | - T Noel Hess
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer R Beavers
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tony Chang
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robel T Beyene
- Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Mauro GJ, Armando G, Cabillón LN, Benitez ST, Mogliani S, Roldan A, Vilca M, Rollie R, Martins G. Improvement in intubation success during COVID-19 pandemic with a simple and low-cost intervention: A quasi-experimental study. Med Intensiva 2024; 48:14-22. [PMID: 37455224 DOI: 10.1016/j.medine.2023.06.007] [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] [Accepted: 06/10/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES primary objective: to improve the FPS rates after an educational intervention. SECONDARY OBJECTIVE to describe variables related to FPS in an ED and determine which ones were related to the highest number of attempts. DESIGN it was a prospective quasi-experimental study. SETTING done in an ED in a public Hospital in Argentina. PATIENTS there were patients of all ages with intubation in ED. INTERVENTIONS in the middle of the study, an educational intervention was done to improve FPS. Cognitive aids and pre- intubation Checklists were implemented. MAIN VARIABLES OF INTEREST the operator experience, the number of intubation attempts, intubation judgment, predictors of a difficult airway, Cormack score, assist devices, complications, blood pressure, heart rate, and pulse oximetry before and after intubation All the intubations were done by direct laryngoscopy (DL). RESULTS data from 266 patients were included of which 123 belonged to the basal period and 143 belonged to the post-intervention period. FPS percentage of the pre-intervention group was 69.9% (IC95%: 60.89-77.68) whereas the post-intervention group was 85.3% (IC95%: 78.20-90.48). The difference between these groups was statistically significant (p=0.002). Factors related to the highest number of attempts were low operator experience, Cormack-Lehane 3 score and no training. CONCLUSIONS a low-cost and simple educational intervention in airway management was significantly associated with improvement in FPS, reaching the same rate of FPS than in high income countries.
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Affiliation(s)
- Guillermo Jesús Mauro
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina.
| | - Gustavo Armando
- Instituto Nacional de Enfermedades Respiratorias "Dr. Emilio Coni", Argentina
| | - Lorena Natalia Cabillón
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Santiago Tomás Benitez
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Sabrina Mogliani
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Amanda Roldan
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Marisol Vilca
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Ricardo Rollie
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Gustavo Martins
- Servicio de Emergencias, Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
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3
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Arteaga Velásquez J, Rodríguez JJ, Higuita-Gutiérrez LF, Montoya Vergara ME. A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:663-673. [PMID: 36241514 DOI: 10.1016/j.redare.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 05/29/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Rapid sequence intubation is an airway rescue and protection technique in which different sedatives are used to perform orotracheal intubation. Etomidate, due to its pharmacokinetic and pharmacodynamic qualities, particularly hemodynamic stability, is the most widely used sedative in this scenario. However, its superiority over other sedatives is controversial. MATERIALS AND METHODS We performed a meta-analysis using a pre-designed protocol and PRISMA guidelines to evaluate the mean difference between systolic blood pressure before and after administration of the sedative. We also analyzed the relative risks of hypotension. RESULTS Ten studies were included. The incidence of hypotension in patients receiving etomidate ranged from 6.4% to 75.2%, and between 24.0% and 65.9% in patients receiving other sedatives. No significant differences were found in the mean difference in systolic blood pressure during pre-intubation 0.01 mm Hg (95% CI: -0.90; 0.92) or in post-intubation 0.98 mmHg (95% CI: -0.24; 2.20). The relative risk analysis showed that the risk of hypotension is equal to an RR of 1.19 (95% CI: 0.92-1.54) between those who received etomidate and those who received the other sedatives. CONCLUSIONS The risk of hypotension after rapid intubation sequence with etomidate does not differ significantly compared to other sedatives. However, the studies included in this review were heterogeneous.
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Affiliation(s)
- J Arteaga Velásquez
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia.
| | - J J Rodríguez
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia; Servicio de Anestesiología de la Institución Prestadora de Servicios IPS Universitaria, Universidad de Antioquia, Servicio de Anestesiología, Clínica Antioquia, Medellín, Colombia
| | - L F Higuita-Gutiérrez
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia; Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia
| | - M E Montoya Vergara
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia
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4
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Hampton JP, Hommer K, Musselman M, Bilhimer M. Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update. Am J Health Syst Pharm 2022; 80:182-195. [PMID: 36306474 PMCID: PMC9620375 DOI: 10.1093/ajhp/zxac326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.
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Affiliation(s)
- Jeremy P Hampton
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, and University Health Kansas City, Kansas City, MO, USA
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5
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Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, Lascarrou JB, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Pesenti A, Valsecchi MG, Fumagalli R, Foti G, Bellani G, Laffey JG. Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study. Am J Respir Crit Care Med 2022; 206:449-458. [PMID: 35536310 DOI: 10.1164/rccm.202111-2575oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/FiO2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).
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Affiliation(s)
- Vincenzo Russotto
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Antolini
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia e le Neuroscienze, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington & Halton Teaching Hospitals National Health Service Foundation Trust, Warrington, United Kingdom
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesiology, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - John G Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland; and.,Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
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6
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A retrospective data analysis on the induction medications used in trauma rapid sequence intubations and their effects on outcomes. Eur J Trauma Emerg Surg 2022; 48:2275-2286. [PMID: 34357407 PMCID: PMC8343213 DOI: 10.1007/s00068-021-01759-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/27/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents. METHODS This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location. RESULTS Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%). CONCLUSION Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication.
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7
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Freeman J, Alkhouri H, Knipp R, Fogg T, Gillett M. Mapping haemodynamic changes with rapid sequence induction agents in the emergency department. Emerg Med Australas 2021; 34:237-243. [PMID: 34553502 DOI: 10.1111/1742-6723.13867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. METHODS This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability. RESULTS From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. CONCLUSION Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.
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Affiliation(s)
- Jessica Freeman
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Robert Knipp
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Gillett
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
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8
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Hawkins WA, Kim JY, Smith SE, Sikora Newsome A, Hall RG. Effects of Propofol on Hemodynamic Profile in Adults Receiving Targeted Temperature Management. Hosp Pharm 2021; 57:329-335. [DOI: 10.1177/00185787211032359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Propofol is a key component for the management of sedation and shivering during targeted temperature management (TTM) following cardiac arrest. The cardiac depressant effects of propofol have not been described during TTM and may be especially relevant given the stress to the myocardium following cardiac arrest. The purpose of this study is to describe hemodynamic changes associated with propofol administration during TTM. Methods: This single center, retrospective cohort study evaluated adult patients who received a propofol infusion for at least 30 minutes during TTM. The primary outcome was the change in cardiovascular Sequential Organ Failure Assessment (cvSOFA) score 30 minutes after propofol initiation. Secondary outcomes included change in systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), and vasopressor requirements (VR) expressed as norepinephrine equivalents at 30, 60, 120, 180, and 240 minutes after propofol initiation. A multivariate regression was performed to assess the influence of propofol and body temperature on MAP, while controlling for vasopressor dose and cardiac arrest hospital prognosis (CAHP) score. Results: The cohort included 40 patients with a median CAHP score of 197. The goal temperature of 33°C was achieved for all patients. The median cvSOFA score was 1 at baseline and 0.5 at 30 minutes, with a non-significant change after propofol initiation ( P = .96). SBP and MAP reductions were the greatest at 60 minutes (17 and 8 mmHg; P < .05 for both). The median change in HR at 120 minutes was −9 beats/minute from baseline. This reduction was sustained through 240 minutes ( P < .05). No change in VR were seen at any time point. In multivariate regression, body temperature was the only characteristic independently associated with changes in MAP (coefficient 4.95, 95% CI 1.6-8.3). Conclusion: Administration of propofol during TTM did not affect cvSOFA score. The reductions in SBP, MAP, and HR did not have a corresponding change in vasopressor requirements and are likely not clinically meaningful. Propofol appears to be a safe choice for sedation in patients receiving targeted temperature management after cardiac arrest.
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Affiliation(s)
- W. Anthony Hawkins
- University of Georgia College of Pharmacy, Albany, GA, USA
- Medical College of Georgia at Augusta University, Augusta, GA, USA
| | | | - Susan E. Smith
- University of Georgia College of Pharmacy, Athens, GA, USA
| | - Andrea Sikora Newsome
- University of Georgia College of Pharmacy, Augusta, GA, USA
- Augusta University Medical Center, Augusta, GA, USA
| | - Ronald G. Hall
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Dose Optimization and Outcomes Research Program, Dallas, TX, USA
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9
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Leede E, Kempema J, Wilson C, Rios Tovar AJ, Cook A, Fox E, Regner J, Richmond R, Carrick M, Brown CVR. A multicenter investigation of the hemodynamic effects of induction agents for trauma rapid sequence intubation. J Trauma Acute Care Surg 2021; 90:1009-1013. [PMID: 33657073 DOI: 10.1097/ta.0000000000003132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several options exist for induction agents during rapid sequence intubation (RSI) in trauma patients, including etomidate, ketamine, and propofol. These drugs have reported variable hemodynamic effects (hypotension with propofol and sympathomimetic effects with ketamine) that could affect trauma resuscitations. The purpose of this study was to compare the hemodynamic effects of these three induction agents during emergency department RSI in adult trauma. We hypothesized that these drugs would display a differing hemodynamic profile during RSI. METHODS We performed a retrospective (2014-2019), multicenter trial of adult (≥18 years) trauma patients admitted to eight ACS-verified Level I trauma centers who underwent emergency department RSI. Variables collected included systolic blood pressure (SBP) and pulse before and after RSI. The primary outcomes were change in heart rate and SBP before and after RSI. RESULTS There were 2,092 patients who met criteria, 85% received etomidate (E), 8% ketamine (K), and 7% propofol (P). Before RSI, the ketamine group had a lower SBP (E, 135 vs. K, 125 vs. P, 135 mm Hg, p = 0.04) but there was no difference in pulse (E, 104 vs. K, 107 vs. P, 105 bpm, p = 0.45). After RSI, there were no differences in SBP (E, 135 vs. K, 130 vs. P, 133 mm Hg, p = 0.34) or pulse (E, 106 vs. K, 110 vs. P, 104 bpm, p = 0.08). There was no difference in the average change of SBP (E, 0.2 vs. K, 5.2 vs. P, -1.8 mm Hg, p = 0.4) or pulse (E, 1.7 vs. K, 3.5 bpm vs. P, -0.96, p = 0.24) during RSI. CONCLUSION Contrary to our hypothesis, there was no difference in the hemodynamic effect for etomidate versus ketamine versus propofol during RSI in trauma patients. LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Emily Leede
- From the Department of Surgery and Perioperative Care (E.L., J.K., C.V.R.B., F.B.), Dell Medical School at the University of Texas at Austin, Austin; Division of Trauma and Acute Care Surgery 3 (C.W., A.K.), Ben Taub Hospital, Houston; Department of Surgery (A.J.R.T.), University Medical Center of El Paso, El Paso; Department of Surgery (A.C., L.A.), University of Texas Health Science Center at Tyler, Tyler; Department of Surgery (E.F., V.E.H.), University of Texas Health Science Center at Houston, Houston; Division of Acute Care Surgery (J.R.), Baylor Scott&White Medical Center-Temple, Temple; Department of Surgery (R.R., N.T.), University Medical Center, Lubbock; Department of Surgery (M.C.), Medical City Plano, Plano, Texas
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10
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Propofol, Ketamine, and Etomidate as Induction Agents for Intubation and Outcomes in Critically Ill Patients: A Retrospective Cohort Study. Crit Care Explor 2021; 3:e0435. [PMID: 34046636 PMCID: PMC8148417 DOI: 10.1097/cce.0000000000000435] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Propofol, ketamine, and etomidate are common anesthetic agents for induction of anesthesia in the ICU. The choice between these agents is complex and may not depend solely upon severity of illness. OBJECTIVES To evaluate the association between the administration of propofol, ketamine, and etomidate and ICU, hospital mortality, and length of stay. DESIGN SETTING AND PARTICIPANTS Retrospective single-center cohort study. ICUs in a tertiary medical center, between January 01, 2012, and December 31, 2017. Critically ill adult patients given a single IV anesthetic for intubation. MAIN OUTCOME AND MEASURES Primary outcomes were ICU and hospital mortality. Secondary outcomes were ICU- and hospital-free days through 28 days. An inverse probability of treatment weighed approach was used. The propensity score was estimated using a generalized logit model as a function of patient characteristics, admission source, ICU type, readmission status, length of ICU stays prior to intubation, and acute physiology score. Mortality outcomes were assessed with weighted logistic regression and -free days assessed by weighted linear regression with Bonferroni correction for pairwise comparisons. RESULTS Of 2,673 patients, 36% received propofol, 30% ketamine and 34% etomidate. Overall ICU and hospital mortality were 19% and 29%, respectively. Patients given ketamine had higher odds of ICU mortality (1.45; [95% CI, 1.07-1.94]; p = 0.015) and patients given etomidate had higher odds of ICU mortality (1.87; 1.40-2.49; p < 0.001), hospital mortality (1.43; 1.09-1.86; p = 0.009), and less ICU-free days (-2.10; -3.21 to -1.00; p < 0.001) than those given propofol. Patients given ketamine and etomidate had similar odds of hospital mortality (1.06; 0.80-1.42; p = 0.761) and similar hospital-free days (0.30; -0.81 to 1.40; p = 0.600). CONCLUSIONS AND RELEVANCE Compared with ketamine and etomidate, propofol was associated with better outcome in critically ill patients undergoing anesthesia for intubation. Even after adjusting for severity of illness prior to intubation, residual confounders cannot be excluded.
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Emerling AD, Bianchi W, Krzyzaniak M, Deaton T, Via D, Archer B, Sutherland J, Shannon K, Dye JL, Clouser M, Auten JD. Rapid Sequence Induction Strategies Among Critically Injured U.S. Military During the Afghanistan and Iraq Conflicts. Mil Med 2021; 186:316-323. [PMID: 33499492 DOI: 10.1093/milmed/usaa356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/29/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Rapid sequence intubation of patients experiencing traumatic hemorrhage represents a precarious phase of care, which can be marked by hemodynamic instability and pulseless arrest. Military combat trauma guidelines recommend reduced induction dose and early blood product resuscitation. Few studies have evaluated the role of induction dose and preintubation transfusion on hemodynamic outcomes. We compared rates of postintubation systolic blood pressure (SBP) of < 70 mm Hg, > 30% drop in SBP, pulseless arrest, and mortality at 24 hours and 30 days among patients who did and did not receive blood products before intubation and then examined if induction agent and dose influenced the same outcomes. MATERIALS AND METHODS A retrospective analysis was performed of battle-injured personnel presenting to surgical care facilities in Iraq and Afghanistan between 2004 and 2018. Those who received blood transfusions, underwent intubation, and had an Injury Severity Score of ≥15 were included. Intubation for primary head, facial, or neck injury, burns, operative room intubations, or those with cardiopulmonary resuscitation in progress were excluded. Multivariable logistic regression was performed with unadjusted and adjusted odds ratios for the five study outcomes among patients who did and did not receive preintubation blood products. The same analysis was performed for patients who received full or excessive versus partial induction agent dose. RESULTS A total of 153 patients had a mean age of 24.9 (SD 4.5), Injury Severity Score 29.7 (SD 11.2), heart rate 122.8 (SD 24), SBP 108.2 (SD 26.6). Eighty-one (53%) patients received preintubation blood products and had similar characteristics to those who did not receive transfusions. Adjusted multivariate analysis found odds ratios as follows: 30% SBP decrease 9.4 (95% CI 2.3-38.0), SBP < 70 13.0 (95% CI 3.3-51.6), pulseless arrest 18.5 (95% CI 1.2-279.3), 24-hour mortality 3.8 (95% CI 0.7-21.5), and 30-day mortality 1.3 (0.4-4.7). In analysis of induction agent choice and comparison of induction agent dose, no statistically significant benefit was seen. CONCLUSION Within the context of this historical cohort, the early use of blood products conferred a statistically significant benefit in reducing postintubation hypotension and pulseless arrest among combat trauma victims exposed to traumatic hemorrhage. Induction agent choice and dose did not significantly influence the hemodynamic or mortality outcomes.
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Affiliation(s)
- Alec D Emerling
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - William Bianchi
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Michael Krzyzaniak
- Department of General Surgery, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Travis Deaton
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Darin Via
- Director, Medical Systems Integration and Combat Survivability, N44, Chief of Naval Operations, 2000 Navy Pentagon, Room 2E274, Washington DC 20350, USA
| | - Benjamin Archer
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Jared Sutherland
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Kaeley Shannon
- Department of Operational Readiness, Naval Health Research Center, Bldg. 329, Ryne Rd, San Diego, CA, 92152, USA
| | - Judy L Dye
- Department of Operational Readiness, Naval Health Research Center, Bldg. 329, Ryne Rd, San Diego, CA, 92152, USA
| | - Mary Clouser
- Department of Operational Readiness, Naval Health Research Center, Bldg. 329, Ryne Rd, San Diego, CA, 92152, USA
| | - Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
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Abstract
Management of acute neurologic disorders in the emergency department is multimodal and may require the use of medications to decrease morbidity and mortality secondary to neurologic injury. Clinicians should form an individualized treatment approach with regard to various patient specific factors. This review article focuses on the pharmacotherapy for common neurologic emergencies that present to the emergency department, including traumatic brain injury, central nervous system infections, status epilepticus, hypertensive emergencies, spinal cord injury, and neurogenic shock.
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Affiliation(s)
- Kyle M DeWitt
- Emergency Medicine, Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA.
| | - Blake A Porter
- Emergency Medicine, Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA. https://twitter.com/RxEmergency
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Shriki J, Galvagno SM. Sedation for Rapid Sequence Induction and Intubation of Neurologically Injured Patients. Emerg Med Clin North Am 2020; 39:203-216. [PMID: 33218658 DOI: 10.1016/j.emc.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.
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Affiliation(s)
- Jesse Shriki
- Surgical Critical Care, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Samuel M Galvagno
- Multi Trauma Critical Care Unit, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
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Wang H, Zhao L, Wu J, Hong J, Wang S. Propofol induces ROS-mediated intrinsic apoptosis and migration in triple-negative breast cancer cells. Oncol Lett 2020; 20:810-816. [PMID: 32566008 PMCID: PMC7285815 DOI: 10.3892/ol.2020.11608] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 04/03/2020] [Indexed: 11/05/2022] Open
Abstract
Propofol is widely applied in general anesthesia owing to its short effect and rapid recovery. Apart from its anesthetic advantages, propofol has also been observed to inhibit the growth of several types of cancer cells. Breast cancer is the most diagnosed cancer in females worldwide and triple negative breast cancer (TNBC) constitutes 15-20% of all breast cancer cases. TNBC is characterized by a high recurrence rate, which is associated with its high mortality rate. The present study aimed to evaluate apoptosis in MDA-MB-468 cells treated with propofol. The Cell Counting Kit-8 assay was used to assess proliferation in cells treated with different concentrations of propofol. In addition, Annexin V-FITC was used to detect apoptosis. Furthermore, the generation of reactive oxygen species (ROS) was examined. The relative expression of proteins in the intrinsic apoptosis pathway, such as Bak, Bax, Bcl-2, Cytochrome c, apoptotic peptidase-activating factor 1 (Apaf-1), Caspase 3 and Caspase 9, were calculated relative to GAPDH with western blot analysis. A wound healing assay was performed to examine the effect of propofol on MDA-MB-468 cell migration. The present study revealed that propofol inhibited the proliferation and increased the level of ROS in MDA-MB-468 cells. The expression levels of Cytochrome c, Apaf-1, Bax, Bak and cleaved Caspase 3/9 were upregulated compared with GAPDH. The level of Bcl-2 protein was upregulated by propofol at a concentration of 5 µM and downregulated at concentrations of 10 and 20 µM. In the wound-healing assay, propofol reduced the scratch distance and area. Taken together, the results of the present study suggested that propofol may induce ROS-mediated intrinsic apoptosis and promote migration in TNBC cells.
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Affiliation(s)
- Hao Wang
- Department of Traditional Chinese Medicine, The General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, P.R. China.,Department of Pneumology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, Jiangsu 224003, P.R. China
| | - Lidong Zhao
- Department of Internal and Emergency Medicine, The General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, P.R. China
| | - Jing Wu
- School of Pharmacy, Shanghai Jiaotong University, Shanghai 200080, P.R. China
| | - Jiang Hong
- Department of Internal and Emergency Medicine, The General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, P.R. China
| | - Songpo Wang
- Department of Traditional Chinese Medicine, The General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, P.R. China
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15
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Comparison of drugs used for intubation of pediatric trauma patients. J Pediatr Surg 2020; 55:926-929. [PMID: 32067810 DOI: 10.1016/j.jpedsurg.2020.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. METHODS A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. RESULTS Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. CONCLUSION Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. TYPE OF STUDY Retrospective. LEVEL OF EVIDENCE IV.
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Glahn A, Proskynitopoulos PJ, Bleich S, Hillemacher T. Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients. Expert Opin Pharmacother 2020; 21:1083-1092. [PMID: 32281894 DOI: 10.1080/14656566.2020.1746271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts. AREAS COVERED The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EXPERT OPINION For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.
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Affiliation(s)
- A Glahn
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - P J Proskynitopoulos
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - S Bleich
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - T Hillemacher
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany.,Department of Psychiatry and Psychotherapy, Paracelcus Medical University , Nuremberg, Germany
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