Adherence to Sedation Targets With Weight-Based Propofol and Dexmedetomidine in Patients With Morbid Obesity

Evaluation of the Safety of Dexmedetomidine Dosing Utilizing Adjusted Body Weight in Obese Critically Ill Patients: A Retrospective Study

The purpose of this study was to evaluate the safety of dexmedetomidine dosing, utilizing adjusted body weight (AdjBW) in obese, critically ill patients. This was a retrospective cohort study of patients who received dexmedetomidine from March 2020 to April 2021. Participants received dexmedetomidine as the sole agent for sedation for ≥8 hours, were ≥18 years old, had a level of care listed as "critical care," and had an actual body weight (ABW) of at least 120% of their ideal body weight (IBW). A total of 225 participants were included. Results demonstrated that the incidence of hypotension and bradycardia was lower in the AdjBW group compared to the ABW group, but this did not reach statistical significance. Dosing dexmedetomidine based on AdjBW, instead of ABW, resulted in a statistically significant difference in the lowest recorded heart rate, with 61.2 ± 11.8 bpm in the ABW group and 65.2 ± 14.7 bpm in the AdjBW group (p = 0.027). Dosing dexmedetomidine based on AdjBW did not show statistically significant differences in the lowest recorded mean arterial pressure (MAP). Using AdjBW to dose dexmedetomidine appears to be safe in this patient population.

[Translated article] Drug dosing in obese critically ill patients, a literature review

INTRODUCTION

Obesity constitutes a global public health problem, and knowledge about drug dosing in obese patients is limited. Clinical trials in critically ill patients rarely include obese individuals, resulting in a lack of specific dosing information in product data sheets. The aim of this literature review is to provide clinicians with efficient and safe guidelines for this group of patients.

METHODS

A multidisciplinary group composed of pharmacists specialised in hospital pharmacy and physicians specialised in intensive care medicine was formed. The therapeutic groups and, in depth, the most commonly used active ingredients in the intensive care unit were identified and reviewed. The bibliographic review was carried out using terms such as: "obese", "overweight", "critical illness", "drug dosification", and "therapeutic dose monitoring". All the information was evaluated by the working group, which reached a consensus on dosing recommendations for each drug in obese critically ill patients.

RESULTS

Eighty three drugs belonging to the following therapeutic groups were identified: antivirals, antibacterials, antifungals, immunosuppressants, antiepileptics, vasopressors, anticoagulants, neuromuscular blocking agents, and sedatives. A table with the consensus dosing recommendation for each of these was produced after review.

CONCLUSIONS

Drug dosing in obese patients, both in critical and non-critical settings, remains an area with significant uncertainties. This review provides updated and exhaustive information on the dosing of the main therapeutic groups in obese critically ill patients, and is a useful tool for both physicians in critical care units and clinical pharmacists in their practice in this setting.

Pharmacogenomic variation and sedation outcomes during early intensive care unit admission: A pragmatic study

Unpredicted responses to sedatives and analgesics are common in critically ill patients on mechanical ventilation (MV) and may be attributed to genetic variation. Our primary aim was to investigate the association between the pharmacogenomic (PGx) variation and sedation outcomes. The secondary aim was to capture intensive care unit (ICU) participants' perceptions of PGx. This was a prospective, observational PGx association study. Adult ICU patients receiving acute MV and sedatives/analgesics were enrolled. The number of altered PGx phenotypes in genes relevant to fentanyl, propofol, and midazolam (CYP2D6, CYP3A4/5, COMT, OPRM1, and CYP2B6) were tested with logistic regression for association with achieving ≥60% and ≥70% of time within Richmond Agitation-Sedation Scale (RASS) target range (0 to -2) in the first 24 and 48 h of MV. Participants' perceptions of PGx testing and satisfaction with the return of PGx results were collected. Participants (n = 78) had a median of 2 altered PGx phenotypes. Fentanyl and propofol combination was the most frequently administered regimen. There were non-significant associations of worse sedation outcomes with an increasing number of altered PGx phenotypes (i.e., adjusted odds ratio of achieving target RASS range = 0.46 to 0.96 for each altered phenotype increase at both 24 and 48 h). Individuals participating in the post-discharge survey had positive perceptions toward PGx. There were no associations between sedation outcomes and PGx variants in the studied 6 genes. Larger studies are needed to investigate the impact of these genes and to evaluate additional genes. ICU participants had positive attitudes and perceptions toward PGx.

Drug dosing in obese critically ill patients, a literature review

INTRODUCTION

The prevalence of obesity represents a significant global public health challenge, and the available evidence concerning the appropriate dosing of pharmaceutical in patients with obesity is limited. It is uncommon for clinical trials in critically ill patients to include obese individuals, which results in a lack of specific dosing information in product data sheets. The objective of this literature review is to provide clinicians with efficacious and secure guidelines for this cohort of patients.

METHODS

A multidisciplinary team comprising pharmacists specialized in hospital pharmacy and physicians with expertise in intensive care medicine was established. The therapeutic groups and, in particular, the most commonly used active ingredients within the Intensive Care Unit were identified and subjected to detailed analysis. The following terms were included in the search: "obese", "overweight", "critical illness", "drug dosification", and "therapeutic dose monitoring". All the information was then evaluated by the working group, which reached a consensus on the dosing recommendations for each drug in obese critically ill patients.

RESULTS

A total of 83 drugs belonging to the following therapeutic groups were identified: antivirals, antibacterials, antifungals, immunosuppressants, antiepileptics, vasopressors, anticoagulants, neuromuscular blocking agents and sedatives. A table was produced containing the consensus dosing recommendations for each of the aforementioned drugs following a review of the available evidence.

CONCLUSIONS

Drug dosing in obese patients, both in critical and noncritical settings, remains an area with significant uncertainty. This review provides comprehensive and up-to-date information on the dosing of the main therapeutic groups in obese critically ill patients, offering a valuable resource physicians in critical care units and clinical pharmacists in their practice in this setting.

Remimazolam Tosylate Combined with Low-Dose Propofol Improves Sedation and Safety in Hysteroscopy

Background

Propofol is widely used for sedation of hysteroscopy. It can cause injection pain, respiratory depression, and hypotension. Remimazolam is a novel ultra-short-acting benzodiazepine. Clinical practice has found that the use of remimazolam alone often leads to body movement during hysteroscopy, which decreases the safety and comfort. Here this study is to investigate whether remimazolam combined with low-dose propofol can improve the sedation effect and safety of hysteroscopy.

Patients and Methods

In this prospective, randomized, parallel-controlled trial, women (18 to 60 years) undergoing hysteroscopy were randomly assigned to receive propofol (Group P), remimazolam tosylate (Group R), or remimazolam tosylate plus propofol (Group RP). Intraoperative sedation depth was kept at the bispectral index (BIS) value of 40-60. 6 μg/kg alfentanil was used for analgesic before sedation. Intraoperative low pulse oxygen saturation (SpO2), body movement, injection pain, mean arterial pressure (MAP), heart rate (HR), and postoperative recovery time, dizziness, nausea and vomiting were recorded and compared.

Results

From February to July 2022, 193 patients were recruited and randomly assigned to group P (n=64), group R (n=64), or group RP (n=65). There was no significant inter-group difference of the intraoperative BIS values. The incidence of low SpO2, injection pain, hypotension, and postoperative dizziness in group RP were less than that in group P, and had no significant difference from group R. The incidence of body movement in group RP was less than that in group R, and had no significant difference from group P. Postoperative recovery time of group RP was shorter than that of the other two groups. No significant inter-group difference in bradycardia, nausea and vomiting was observed.

Conclusion

Remimazolam tosylate combined with low dose of propofol improved sedation and safety in hysteroscopy, and may be a more ideal sedative method for hysteroscopy.