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Baumgartner K, Doering And M, Mullins ME. Dexmedetomidine in the treatment of toxicologic conditions: a systematic review and review of the toxicology investigators consortium database. Clin Toxicol (Phila) 2022; 60:1356-1375. [PMID: 36346349 DOI: 10.1080/15563650.2022.2138761] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Dexmedetomidine is an alpha-2 adrenoceptor agonist which is widely used for sedation. Dexmedetomidine does not suppress the respiratory drive and produces a state of cooperative sedation; it may be associated with beneficial outcomes in the general critical care population. The role of dexmedetomidine in the treatment of toxicologic conditions (excluding alcohol withdrawal) is unclear. OBJECTIVES To critically assess and summarize the literature regarding the use of dexmedetomidine in toxicologic conditions other than alcohol withdrawal. METHODS We performed a systematic review of the medical literature to identify all existing evidence regarding the use of dexmedetomidine for toxicologic conditions. We excluded reviews and commentary, studies reporting exclusively on alcohol withdrawal, and studies reporting the use of dexmedetomidine to treat iatrogenic sedative withdrawal in the intensive care unit. We also performed a review of the Toxicology Investigators Consortium (ToxIC) database for patients treated with dexmedetomidine. RESULTS We identified 98 studies meeting inclusion criteria; 87 of these were case reports or case series, representing 99 unique cases. Eleven articles with other designs were identified, which included 138 patients treated with dexmedetomidine for toxicologic conditions. Ninety-three cases from the ToxIC registry met inclusion criteria. Common indications for dexmedetomidine included stimulant intoxication, sedative withdrawal, serotonin syndrome, antimuscarinic toxidrome, opioid withdrawal, and cannabinoid intoxication. Dexmedetomidine was usually administered by continuous infusion; bolus administration was reported in a minority of cases. Adverse effects were uncommon. The quality of evidence was generally low, given the preponderance of case reports, the rate of missing or poorly reported data, and the near-universal co-administration of other sedatives. TREATMENT OF STIMULANT POISONING Fifty-nine patients with stimulant poisoning were treated with dexmedetomidine. There was reasonably good evidence that dexmedetomidine was helpful in the treatment of stimulant poisoning. TREATMENT OF SEDATIVE WITHDRAWAL Twenty-two patients with sedative withdrawal were treated with dexmedetomidine. Several case reports of very high-quality suggested efficacy of dexmedetomidine for this indication, particularly for baclofen withdrawal. TREATMENT OF SEROTONIN SYNDROME Twenty-six patients with serotonin syndrome were treated with dexmedetomidine. This evidence was of lower quality due to missing clinical details, potential overdiagnosis of serotonin syndrome, and near-universal concomitant treatment with other sedatives. TREATMENT OF ANTIMUSCARINIC POISONING Forty-two patients with antimuscarinic poisoning were treated with dexmedetomidine. This evidence was of low quality and was limited by infrequent use of the preferred antidote, physostigmine. TREATMENT OF OPIOID WITHDRAWAL Forty-four patients with opioid withdrawal were treated with dexmedetomidine. This evidence was of low quality due to missing clinical details and near-universal concomitant treatment with other agents. The one high-quality trial reported the use of dexmedetomidine in ultra-rapid opioid detoxification, which is not indicated in modern practice. TREATMENT OF CANNABINOID INTOXICATION Five patients with cannabinoid intoxication were treated with dexmedetomidine. No definite conclusion can be drawn from the limited available evidence. DISCUSSION It is important to distinguish between the use of dexmedetomidine as a general sedative, which is likely to increase as the overall utilization of dexmedetomidine in critical care settings increases, and the use of dexmedetomidine as a specific pharmacologic treatment for a toxicologic condition. Well-established pharmacologic data from animal and human studies suggest dexmedetomidine counteracts stimulant-induced norepinephrine release. The mechanism by which dexmedetomidine treats sedative withdrawal is unclear. Some animal data show that dexmedetomidine may indirectly suppress serotonin release, which may suggest a role for dexmedetomidine in this condition. CONCLUSIONS There is a small and generally low-quality body of evidence which suggests that dexmedetomidine may be helpful in the treatment of certain toxicologic conditions, particularly stimulant intoxication and sedative withdrawal. Further high-quality research is needed to clarify the role of dexmedetomidine in patients with toxicologic conditions.
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Affiliation(s)
- Kevin Baumgartner
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michelle Doering And
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
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- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Martini ML, Neifert SN, Yaeger KA, Hardigan T, Ladner TR, Nistal DA, Lamb C, Kellner CP, Macdonald RL, Mocco J, Oermann EK. Increased Risk of Transient Cerebral Ischemia After Subarachnoid Hemorrhage in Patients with Premorbid Opioid Use Disorders: A Nationwide Analysis of Outcomes. World Neurosurg 2020; 141:e195-e203. [DOI: 10.1016/j.wneu.2020.05.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 12/15/2022]
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Gallego-Ligorit L, Vives M, Vallés-Torres J, Sanjuán-Villarreal TA, Pajares A, Iglesias M. Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia. J Cardiothorac Vasc Anesth 2017; 32:1426-1438. [PMID: 29325842 DOI: 10.1053/j.jvca.2017.11.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Indexed: 12/16/2022]
Abstract
Dexmedetomidine is a highly selective α2-adrenergic agonist with analgesic and sedative properties. In the United States, the Food and Drug Administration approved the use of the drug for short-lasting sedation (24 h) in intensive care units (ICUs) in patients undergoing mechanical ventilation and endotracheal intubation. In October 2008, the Food and Drug Administration extended use of the drug for the sedation of nonintubated patients before and during surgical and nonsurgical procedures. In the European Union, the European Medicine Agency approved the use of dexmedetomidine in September 2011 with a single recognized indication: ICU adult patients requiring mild sedation and awakening in response to verbal stimulus. At present, the use of dexmedetomidine for sedation outside the ICU remains an off-label indication. The benefits of dexmedetomidine in critically ill patients and in cardiac, electrophysiology-related, vascular, and thoracic procedures are discussed.
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Affiliation(s)
- Lucía Gallego-Ligorit
- Department of Anesthesiology and Critical Care Medicine, Cardiovascular and Thoracic Anesthesia Section,Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - Marc Vives
- Department of Anesthesiology and Critical Care Medicine, Hospital de Bellvitge, Barcelona, Spain
| | - Jorge Vallés-Torres
- Department of Anesthesiology and Critical Care Medicine, Cardiovascular and Thoracic Anesthesia Section,Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - T Alberto Sanjuán-Villarreal
- Department of Anesthesiology and Critical Care Medicine, Cardiovascular and Thoracic Anesthesia Section,Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Azucena Pajares
- Department of Anesthesiology and Critical Care Medicine, Cardiovascular and Thoracic Anesthesia Section,Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Mario Iglesias
- Department of Anesthesiology and Reanimation, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
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Seyit M, Erdur B, Kortunay S, Yuksel A, Yilmaz A, Ozen M, Uyanik A, Tomruk O, Ergin A. A Comparison of Dexmedetomidine, Moxonidine and Alpha-Methyldopa Effects on Acute, Lethal Cocaine Toxicity. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e18780. [PMID: 26290748 PMCID: PMC4537789 DOI: 10.5812/ircmj.17(5)2015.18780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 06/02/2014] [Accepted: 01/18/2015] [Indexed: 02/02/2023]
Abstract
Background: The treatment of cocaine toxicity is an important subject for emergency physicians. We investigated the effects of dexmedetomidine, moxonidine and alpha-methyldopa on acute cocaine toxicity in mice. Objectives: The aim of this study was to evaluate the effects of dexmedetomidine, moxonidine and alpha-methyldopa in a mouse model of acute cocaine toxicity. Materials and Methods: We performed an experiment consisting of four groups (n = 25 each). The first group received normal saline solution, the second group received 40 µg/kg of dexmedetomidine, the third group received 0.1 mg/kg of moxonidine and the fourth group received 200 mg/kg of alpha-methyldopa, all of which were intraperitoneally administered 10 minutes before cocaine hydrochloride (105 mg/kg). All animals were observed for seizures (popcorn jumping, tonic-clonic activity, or a loss of the righting reflex) and lethality over the 30 minutes following cocaine treatment. Results: The ratio of animals with convulsions was lower in all treated groups when compared to the control (P < 0.001). Furthermore, 68% (n = 17) of animals in the dexmedetomidine group, 84% (n = 21) of the alpha-methyldopa group, 92% (n = 23) of the moxonidine group and 100% (n = 25) of the control group showed evidence of seizure activity (P = 0.009). Cocaine-induced lethality was observed in 12% (n = 3) of the dexmedetomidine group, 48% (n = 12) of the alpha-methyldopa group, 52% (n = 13) of the moxonidine group, and 72% (n = 18) of the control group (P < 0.001). All treatments prolonged the time to seizure, which was longest in the dexmedetomidine group (P > 0.05). In addition, the time to lethality was also longer in the same group (P < 0.001). Conclusions: The present study provides the first experimental evidence in support of dexmedetomidine treatment for cocaine-induced seizures. Premedication with dexmedetomidine reduces seizure activity in a mouse model of acute cocaine toxicity. In addition, while dexmedetomidine may be effective, moxonidine and alpha-methyldopa did not effectively prevent cocaine-induced lethality.
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Affiliation(s)
- Murat Seyit
- Department of Emergency Medicine, Medical Faculty, Pamukkale University, Denizli, Turkey
| | - Bulent Erdur
- Department of Emergency Medicine, Medical Faculty, Pamukkale University, Denizli, Turkey
- Corresponding Author: Bulent Erdur, Department of Emergency Medicine, Medical Faculty, Pamukkale University, Denizli, Turkey. Tel: +90-2582134812, E-mail:
| | - Selim Kortunay
- Department of Pharmacology, Medical Faculty, Pamukkale University, Denizli, Turkey
| | - Aykut Yuksel
- Department of Emergency Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Atakan Yilmaz
- Department of Emergency Medicine, Medical Faculty, Pamukkale University, Denizli, Turkey
| | - Mert Ozen
- Department of Emergency Medicine, Medical Faculty, Suleyman Demirel University, Isparta, Turkey
| | - Aykut Uyanik
- Department of Emergency Medicine, Medical Faculty, Pamukkale University, Denizli, Turkey
| | - Onder Tomruk
- Department of Emergency Medicine, Medical Faculty, Suleyman Demirel University, Isparta, Turkey
| | - Ahmet Ergin
- Department of Public Health, Medical Faculty, Pamukkale University, Denizli, Turkey
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Salgado DR, Silva E, Vincent JL. Control of hypertension in the critically ill: a pathophysiological approach. Ann Intensive Care 2013; 3:17. [PMID: 23806076 PMCID: PMC3704960 DOI: 10.1186/2110-5820-3-17] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 05/14/2013] [Indexed: 01/21/2023] Open
Abstract
Severe acute arterial hypertension can be associated with significant morbidity and mortality. After excluding a reversible etiology, choice of therapeutic intervention should be based on evaluation of a number of factors, such as age, comorbidities, and other ongoing therapies. A rational pathophysiological approach should then be applied that integrates the effects of the drug on blood volume, vascular tone, and other determinants of cardiac output. Vasodilators, calcium channel blockers, and beta-blocking agents can all decrease arterial pressure but by totally different modes of action, which may be appropriate or contraindicated in individual patients. There is no preferred agent for all situations, although some drugs may have a more attractive profile than others, with rapid onset action, short half-life, and fewer adverse reactions. In this review, we focus on the main mechanisms underlying severe hypertension in the critically ill and how using a pathophysiological approach can help the intensivist decide on treatment options.
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Affiliation(s)
- Diamantino Ribeiro Salgado
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, Brussels 1070, Belgium
- Dept of Internal Medicine, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255 Sala 4A, Rio de Janeiro 12-21941-913, Brazil
| | - Eliezer Silva
- Intensive Care Unit, Albert Einstein Hospital, Sao Paulo, Brazil
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, Brussels 1070, Belgium
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Wong GTC, Irwin MG. Poisoning with illicit substances: toxicology for the anaesthetist. Anaesthesia 2013; 68 Suppl 1:117-24. [PMID: 23210561 DOI: 10.1111/anae.12053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The consumption of illicit substances represents a considerable threat to the health and wellbeing of particular sectors of our communities. Hospitalisation is sometimes required for the treatment of the direct toxic effects of the drugs as well as for injuries sustained while under their influence. Although poisoning with 'traditional' substances of abuse such as opioids, cocaine and cannabis still predominate in terms of numbers, the availability and use of new psychoactive substances are on the rise. These latter agents, some of which began life as failed pharmaceutical products, have enjoyed renewed status as recreational stimulants, entactogens or hallucinogens, properties that originally precluded them from legitimate use. These drugs may act by enhancing endogenous release of neurotransmitters, inhibiting their reuptake back into neurons or having direct effects on receptors, and may involve adrenergic, dopaminergic or serotonergic systems. The use of intravenous lipid emulsion for the symptomatic treatment of drug overdose has become a fertile ground for research and may hold promise as a non-specific treatment for poisoning with illicit substances. Dexmedetomidine, an α(2)-receptor agonist with a central sympatholytic effect, may be able to counteract the cardiovascular and central nervous system overstimulation that may accompany stimulant toxicity.
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Affiliation(s)
- G T C Wong
- Department of Anaesthesiology, University of Hong Kong, Hong Kong.
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Panzer O, Moitra V, Sladen RN. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral Mu antagonists. Anesthesiol Clin 2011; 29:587-vii. [PMID: 22078911 DOI: 10.1016/j.anclin.2011.09.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this article, the authors discuss the pharmacology of sedative-analgesic agents like dexmedetomidine, remifentanil, ketamine, and volatile anesthetics. Dexmedetomidine is a highly selective alpha-2 agonist that provides anxiolysis and cooperative sedation without respiratory depression. It has organ protective effects against ischemic and hypoxic injury, including cardioprotection, neuroprotection, and renoprotection. Remifentanil is an ultra-short-acting opioid that acts as a mu-receptor agonist. Ketamine is a nonbarbiturate phencyclidine derivative and provides analgesia and apparent anesthesia with relative hemodynamic stability. Volatile anesthetics such as isoflurane, sevoflurane, and desflurane are in daily use in the operating room in the delivery of general anesthesia. A major advantage of these halogenated ethers is their quick onset, quick offset, and ease of titration in rendering the patient unconscious, immobile, and amnestic.
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Affiliation(s)
- Oliver Panzer
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA
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Anand KJS, Willson DF, Berger J, Harrison R, Meert KL, Zimmerman J, Carcillo J, Newth CJL, Prodhan P, Dean JM, Nicholson C. Tolerance and withdrawal from prolonged opioid use in critically ill children. Pediatrics 2010; 125:e1208-25. [PMID: 20403936 PMCID: PMC3275643 DOI: 10.1542/peds.2009-0489] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE After prolonged opioid exposure, children develop opioid-induced hyperalgesia, tolerance, and withdrawal. Strategies for prevention and management should be based on the mechanisms of opioid tolerance and withdrawal. PATIENTS AND METHODS Relevant manuscripts published in the English language were searched in Medline by using search terms "opioid," "opiate," "sedation," "analgesia," "child," "infant-newborn," "tolerance," "dependency," "withdrawal," "analgesic," "receptor," and "individual opioid drugs." Clinical and preclinical studies were reviewed for data synthesis. RESULTS Mechanisms of opioid-induced hyperalgesia and tolerance suggest important drug- and patient-related risk factors that lead to tolerance and withdrawal. Opioid tolerance occurs earlier in the younger age groups, develops commonly during critical illness, and results more frequently from prolonged intravenous infusions of short-acting opioids. Treatment options include slowly tapering opioid doses, switching to longer-acting opioids, or specifically treating the symptoms of opioid withdrawal. Novel therapies may also include blocking the mechanisms of opioid tolerance, which would enhance the safety and effectiveness of opioid analgesia. CONCLUSIONS Opioid tolerance and withdrawal occur frequently in critically ill children. Novel insights into opioid receptor physiology and cellular biochemical changes will inform scientific approaches for the use of opioid analgesia and the prevention of opioid tolerance and withdrawal.
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Affiliation(s)
- Kanwaljeet J. S. Anand
- Department of Pediatrics, Le Bonheur Children’s Hospital and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas F. Willson
- Department of Pediatrics & Anesthesiology, University of Virginia Children’s Hospital, Charlottesville, Virginia
| | - John Berger
- Department of Pediatrics, Children’s National Medical Center, Washington, DC
| | - Rick Harrison
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, California
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, Michigan
| | - Jerry Zimmerman
- Department of Pediatrics, Children’s Hospital and Medical Center, Seattle, Washington
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Parthak Prodhan
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - J. Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Carol Nicholson
- Pediatric Critical Care and Rehabilitation Program, National Center for Medical Rehabilitation Research (NCMRR), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Marik PE, Varon J. Perioperative hypertension: a review of current and emerging therapeutic agents. J Clin Anesth 2009; 21:220-9. [PMID: 19464619 DOI: 10.1016/j.jclinane.2008.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Revised: 09/07/2008] [Accepted: 09/19/2008] [Indexed: 01/05/2023]
Abstract
Perioperative hypertension is a common problem encountered by anesthesiologists, surgeons, internists, and intensivists. Surprisingly, no randomized, placebo-controlled studies exist that show that the treatment of perioperative hypertension reduces morbidity or mortality. Nevertheless, perioperative hypertension requires careful management. While sodium nitroprusside and nitroglycerin are commonly used to treat these conditions, these agents are less than ideal. Intravenous beta blockers and calcium channel blockers have particular appeal in this setting.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Pharmacology of Sedative-Analgesic Agents: Dexmedetomidine, Remifentanil, Ketamine, Volatile Anesthetics, and the Role of Peripheral Mu Antagonists. Crit Care Clin 2009; 25:451-69, vii. [PMID: 19576524 DOI: 10.1016/j.ccc.2009.04.004] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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