Propofol-related infusion syndrome in intensive care patients

Status Epilepticus: An Update on Pharmacological Management

Status epilepticus (SE) is a neurological emergency that requires timely pharmacological therapy to cease seizure activity. The treatment approach varies based on the time and the treatment stage of SE. Benzodiazepines are considered the first-line therapy during the emergent treatment phase of SE. Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase. These drugs appear to have a similar safety and efficacy profile, and individualized therapy should be chosen based on patient characteristics. Midazolam, propofol, pentobarbital, and ketamine are continuous intravenous infusions of anesthetic medications utilized in the refractory SE (RSE) period. The most efficacious pharmacotherapeutic treatments for RSE and superrefractory status epilepticus are not clearly defined.

The Safety of Continuous Infusion Propofol in Mechanically Ventilated Adults With Coronavirus Disease 2019

BACKGROUND

Propofol is commonly used to achieve ventilator synchrony in critically ill patients with coronavirus disease 2019 (COVID-19), yet its safety in this patient population is unknown.

OBJECTIVE

To evaluate the safety, in particular the incidence of hypertriglyceridemia, of continuous infusion propofol in patients with COVID-19.

METHODS

This was a retrospective study at 1 academic medical center and 1 affiliated teaching hospital in New York City. Adult, critically ill patients with COVID-19 who received continuous infusion propofol were included. Patients who received propofol for <12 hours, were transferred from an outside hospital while on mechanical ventilation, or did not have a triglyceride concentration obtained during the infusion were excluded.

RESULTS

A total of 252 patients were included. Hypertriglyceridemia (serum triglyceride concentration ≥ 400 mg/dL) occurred in 38.9% of patients after a median cumulative dose of 4307 mg (interquartile range [IQR], 2448-9431 mg). The median time to triglyceride elevation was 3.8 days (IQR, 1.9-9.1 days). In the multivariable regression analysis, obese patients had a significantly greater odds of hypertriglyceridemia (odds ratio = 1.87; 95% CI = 1.10, 3.21). There was no occurrence of acute pancreatitis. The incidence of possible propofol-related infusion syndrome was 3.2%.

CONCLUSION AND RELEVANCE

Hypertriglyceridemia occurred frequently in patients with COVID-19 who received propofol but did not lead to acute pancreatitis. Elevated triglyceride concentrations occurred more often and at lower cumulative doses than previously reported in patients without COVID-19. Application of these data may aid in optimal monitoring for serious adverse effects of propofol in patients with COVID-19.

Comparison of Intra and Post-operative Sedation efficacy of Dexmedetomidine-Midazolam and Dexmedetomidine-Propofol for Major Abdominal Surgery

BACKGROUND

The effectiveness and side effects of dexmedetomidine (DEX) in combination with midazolam and propofol have not been comparatively studied in a single clinical trial as sedative agents to general anesthesia before.

OBJECTIVE

The objective of this study is to compare intra and post-operative sedation between DEX-Midazolam and DEX-Propofol in patients who underwent major abdominal surgery on the duration of general anesthesia, hemodynamic and sedation effect.

METHOD

This prospective, randomized, double-blinded clinical trial included 50 patients who were 20 to 60 years of age and admitted for major abdominal surgery. The patients were randomly assigned by a computer-generated random numbers table to sedation with DEX plus midazolam (DM group) (n=25) or DEX plus propofol (DP group) (n=25). In the DM group, patients received a bolus dose of 0.1 mg/kg of midazolam and immediately initiated the intravenous (i.v.) infusion of DEX 1 µg/kg over a 10 min and 0.5 µg/kg/hr by continuous i.v. infusion within operation period. In the DP group, patients received pre-anesthetic i.v. DEX 1 µg/kg over 15 min before anesthesia induction and 0.2-1 µg/kg/hr by continuous i.v. infusion during the operative period. After preoxygenation for at least 2 min, during the surgery, patients received propofol infusion dose of 250 μg/kg/min for 15 min then a basal infusion dose of 50 μg/kg/min. The bispectral index (BIS) value, as well as mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), oxygen saturation (SaO2), percutaneous arterial oxygen saturation (SpO2) and end-tidal carbon dioxide tension (ETCO2) were recorded before anesthesia (T0), during anesthesia (at 15-min intervals throughout the surgical procedure), by a blinded observer. Evidence of apnea, hypotension, hypertension and hypoxemia were recorded during surgery.

RESULTS

The hemodynamic changes, including HR, MAP, BIS, VT, SaO2, and RR had a downward tendency with time, but no significant difference was observed between the groups (P>0.05). However, the two groups showed no significant differences in ETCO2 and SPO2 values in any of the assessed interval (P>0.05). In this study, the two groups showed no significant differences in the incidence of nausea, vomiting, coughing, apnea, hypotension, hypertension, bradycardia and hypoxemia (P>0.05). Respiratory depression and serious adverse events were not reported in either group. Extubation time after surgery was respectively 6.3 ± 1.7 and 5.8 ± 1.4 hr. in the DM and DP groups and the difference was not statistically significant (P= 0.46).

CONCLUSION

Our study showed no significant differences between the groups in hemodynamic and respiratory changes in each of the time intervals. There were also no significant differences between the two groups in the incidence of complication intra and post-operative. Further investigations are required to specify the optimum doses of using drugs which provide safety in cardiovascular and respiratory system without adverse disturbance during surgery.

Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee

Purpose:

Established tonic–clonic status epilepticus (SE) does not stop in one-third of patients when treated with an intravenous (IV) benzodiazepine bolus followed by a loading dose of a second antiseizure medication (ASM). These patients have refractory status epilepticus (RSE) and a high risk of morbidity and death. For patients with convulsive refractory status epilepticus (CRSE), we sought to determine the strength of evidence for 8 parenteral ASMs used as third-line treatment in stopping clinical CRSE.

Methods:

A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was performed to identify original studies on the treatment of CRSE in children and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV), midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids, intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were added to determine the effectiveness in treating hard-to-control seizures in special circumstances. Studies were evaluated by predefined criteria and were classified by strength of evidence in stopping clinical CRSE (either as the last ASM added or compared to another ASM) according to the 2017 American Academy of Neurology process.

Results:

No studies exist on the use of ACTH, corticosteroids, or IVIg for the treatment of CRSE. Small series and case reports exist on the use of these agents in the treatment of RSE of suspected immune etiology, severe epileptic encephalopathies, and rare epilepsy syndromes. For adults with CRSE, insufficient evidence exists on the effectiveness of brivaracetam (level U; 4 class IV studies). For children and adults with CRSE, insufficient evidence exists on the effectiveness of ketamine (level U; 25 class IV studies). For children and adults with CRSE, it is possible that lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV studies). For children with CRSE, insufficient evidence exists that LEV and VPA are equally effective (level U, 1 class III study). For adults with CRSE, insufficient evidence exists to support the effectiveness of LEV (level U; 2 class IV studies). Magnesium sulfate may be effective in the treatment of eclampsia, but there are only case reports of its use for CRSE. For children with CRSE, insufficient evidence exists to support either that MDZ and diazepam infusions are equally effective (level U; 1 class III study) or that MDZ infusion and PTB are equally effective (level U; 1 class III study). For adults with CRSE, insufficient evidence exists to support either that MDZ infusion and PRO are equally effective (level U; 1 class III study) or that low-dose and high-dose MDZ infusions are equally effective (level U; 1 class III study). For children and adults with CRSE, insufficient evidence exists to support that MDZ is effective as the last drug added (level U; 29 class IV studies). For adults with CRSE, insufficient evidence exists to support that PTB and PRO are equally effective (level U; 1 class III study). For adults and children with CRSE, insufficient evidence exists to support that PTB is effective as the last ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence exists to support that PRO is effective as the last ASM used (level U; 26 class IV studies). No pediatric-only studies exist on the use of PRO for CRSE, and many guidelines do not recommend its use in children aged <16 years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be considered in children presenting between birth and age 3 years with refractory seizures and no imaging lesion or other acquired cause of seizures. For children with CRSE, insufficient evidence exists that VPA and diazepam infusion are equally effective (level U, 1 class III study). No class I to III studies have been reported in adults treated with VPA for CRSE. In comparison, for children and adults with established convulsive SE (ie, not RSE), after an initial benzodiazepine, it is likely that loading doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are equally effective at stopping SE (level B, 1 class I study).

Conclusions:

Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO either as the last ASM or compared to others of these drugs. Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and pyridoxine have been used in special situations but have not been studied for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV, VPA, and fosphenytoin are likely equally effective, but whether this is also true for CRSE is unknown. Triple-masked, randomized controlled trials are needed to compare the effectiveness of parenteral anesthetizing and nonanesthetizing ASMs in the treatment of CRSE.

Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.

Collaborative Management Strategies for Drug Shortages in Neurocritical Care

Drug shortages have become all too familiar in the health care environment, with over 200 drugs currently on shortage. In the wake of Hurricane Maria in September 2017, hospitals across the USA had to quickly and creatively adjust medication preparation and administration techniques in light of decreased availability of intravenous (IV) bags used for compounding a vast amount of medications. Amino acid preparations, essential for compounding parenteral nutrition, were also directly impacted by the hurricane. Upon realization of the impending drug shortages, hospitals resorted to alternative methods of drug administration, such as IV push routes, formulary substitutions, or alternative drug therapies in hopes of preserving the small supply of IV bags available and prioritizing them for them most critical needs. In some cases, alternative drug therapies were required, which increased the risk of medication errors due to the use of less-familiar treatment options. Clinical pharmacists rounding with medical teams provided essential, patient-specific drug regimen alternatives to help preserve a dwindling supply while ensuring use in the most critical cases. Drug shortages also frequently occur in the setting of manufacturing delays or discontinuation and drug recalls, with potential to negatively impact patient care. The seriousness of the drug shortage crisis reached public attention by December 2017, when political and pharmacy organizations called for response to the national drug shortage crisis. In this article, we review institutional mitigation strategies in response to drug shortages and discuss downstream effects of these shortages, focusing on medications commonly prescribed in neurocritical care patients.

Survey of Pharmacists Regarding the Use of Propofol Infusions in the PICUs in North America

OBJECTIVE

The objective of this survey was to assess the current use of continuous infusion propofol in PICUs across the United States and Canada.

METHODS

A list of institutions with PICU beds/units was identified through the residency directories available on the American Society of Health-Systems Pharmacists (ASHP) and Canadian Society of Hospital Pharmacists (CHSP) Web sites. A REDCap questionnaire was sent to each identified institution's program director via email. An initial reminder email was sent out 2 weeks later and a second reminder email was sent 4 weeks after the initial request. The survey was closed at 6 weeks.

RESULTS

A total of 514 emails were sent to residency program directors, and 50 pharmacists responded to the survey. Of the pharmacists that did respond, 27 (54%) reported using propofol while 23 (46%) did not. Of those that did not, 43.5% reported the FDA boxed warning as the primary reason. Thirty-seven percent of respondents using propofol felt comfortable using a maximum infusion rate of 200 mcg/kg/min. Twenty-nine percent, 25%, and 33% of those who responded as using propofol felt comfortable using this agent for a maximum duration of 24, 48, and 72 hours, respectively. The majority of respondents using propofol did not have a case of propofol-related infusion syndrome.

CONCLUSIONS

Despite the FDA warning, propofol is used as a continuous infusion (with variable limitations) by a majority of pharmacists in North America. Self-reported incidence of propofol-related infusion syndrome (PRIS) remains low.

Propofol-induced acute pancreatitis

WHAT IS KNOWN AND OBJECTIVE

Drug-induced acute pancreatitis comprises only 0.5%-2% of all cases of acute pancreatitis. Propofol is a potentially dangerous drug that can cause acute pancreatitis, but this complication is extremely rare.

CASE SUMMARY

A 57-year-old patient developed acute pancreatitis after a planned thyroidectomy. As the common causes of acute pancreatitis were excluded, we believe that the pancreatitis was drug-induced, in this case by a single dose of propofol administered to the patient during the surgery.

WHAT IS NEW AND CONCLUSION

We present a rare case of propofol-induced acute necrotising pancreatitis, which is to the best of our knowledge the first fatal case reported in an adult patient.

Optimizing sedation in patients with acute brain injury

Daily interruption of sedative therapy and limitation of deep sedation have been shown in several randomized trials to reduce the duration of mechanical ventilation and hospital length of stay, and to improve the outcome of critically ill patients. However, patients with severe acute brain injury (ABI; including subjects with coma after traumatic brain injury, ischaemic/haemorrhagic stroke, cardiac arrest, status epilepticus) were excluded from these studies. Therefore, whether the new paradigm of minimal sedation can be translated to the neuro-ICU (NICU) is unclear. In patients with ABI, sedation has ‘general’ indications (control of anxiety, pain, discomfort, agitation, facilitation of mechanical ventilation) and ‘neuro-specific’ indications (reduction of cerebral metabolic demand, improved brain tolerance to ischaemia). Sedation also is an essential therapeutic component of intracranial pressure therapy, targeted temperature management and seizure control. Given the lack of large trials which have evaluated clinically relevant endpoints, sedative selection depends on the effect of each agent on cerebral and systemic haemodynamics. Titration and withdrawal of sedation in the NICU setting has to be balanced between the risk that interrupting sedation might exacerbate brain injury (e.g. intracranial pressure elevation) and the potential benefits of enhanced neurological function and reduced complications. In this review, we provide a concise summary of cerebral physiologic effects of sedatives and analgesics, the advantages/disadvantages of each agent, the comparative effects of standard sedatives (propofol and midazolam) and the emerging role of alternative drugs (ketamine). We suggest a pragmatic approach for the use of sedation-analgesia in the NICU, focusing on some practical aspects, including optimal titration and management of sedation withdrawal according to ABI severity.

Comparison of dexmedetomidine versus propofol for sedation in mechanically ventilated patients after cardiovascular surgery

Many cardiovascular surgeries are fast-tracked to extubation and require short-term sedation. Dexmedetomidine and propofol have very different mechanisms of action and pharmacokinetic profiles that make them attractive sedative agents in this patient population. Recently, there has been increased use of dexmedetomidine in the intensive care unit (ICU), but few studies exist or have been published directly comparing both agents in this setting. We conducted a retrospective cohort study with patients admitted to the ICU after cardiovascular surgery from January through June 2011. Adult patients who underwent coronary artery bypass and/or cardiac valve surgery received either dexmedetomidine or propofol continuous infusion for short-term sedation after cardiovascular surgery. The primary end point was time (hours) on mechanical ventilation after surgery. Secondary end points included ICU length of stay (LOS), hospital LOS, incidence of delirium, and requirement of a second sedative agent. A total of 352 patients met study inclusion criteria, with 33 enrolled in the dexmedetomidine group and 319 in the propofol group. Time on mechanical ventilation was shorter in the dexmedetomidine group (7.4 hours vs. 12.9 hours, P = .042). No difference was seen in ICU or hospital LOS. The need for a second sedative agent to achieve optimal sedation (24% vs. 27%, P = .737) and incidence of delirium (9% vs. 7.5%, P = .747) were similar between both groups. Sedation with dexmedetomidine resulted in a significant reduction in time on mechanical ventilation. However, no difference was seen in ICU or hospital LOS, incidence of delirium, or mortality.

PRIS may be diagnosed before ICU period for patients undergoing cardiopulmonary bypass

There are many published articles on the clinical manifestations of propofol-related infusion syndrome (PRIS), but they are not the same in each case.(1)Moreover, PRIS is only encountered infrequently and, therefore, it may create a diagnostic challenge. Nearly all of the published articles on PRIS are related to the use of long-term (> 48 hour) propofol infusion with a dose range of at least 4-5 mg/kg/h. In this case, not only a short duration, but also a low-dose propofol administration seems to induce PRIS. A 73-year-old male patient under cardiopulmonary bypass (CPB) suffered from some clinical symptoms of PRIS, such as hyperlactatemia and persistent low metabolic acidosis which promptly resolved on the discontinuation of propofol. Therefore, we suggest that any propofol administration (bolus or infusion) may result in such clinical symptoms, which may be the earliest indicators of PRIS. When those symptoms are observed on propofol administration during cardiopulmonary bypass (CPB), the perfusionist must alert both the anaesthesiologist and the surgeon to stop the propofol in order to prevent the patient from further adverse effects of PRIS.

Therapeutic plasma exchange as treatment for propofol infusion syndrome

Propofol infusion syndrome (PRIS), a rare complication of propofol sedation, is associated with high mortality. There is no specific therapy. A 16-year-old with head injury and status epilepticus is described. Three days after seizure resolution, whilst receiving propofol, he developed severe lactic acidosis, rhabdomyolysis, and hemodynamic instability. Suspected PRIS was treated with a single session of therapeutic plasma exchange (TPE). This was associated with immediate improvement in hemodynamic status, resolution of lactic acidosis within 24 h, normalization of CPK over 10 days, and a subsequent full recovery. TPE is suggested as a novel therapy for PRIS.

Propofol and survival: a meta-analysis of randomized clinical trials

BACKGROUND

One of the most commonly used hypnotics is propofol. Several studies performed in cardiac surgery suggested an increased mortality in patients receiving a propofol-based total intravenous anaesthesia. Furthermore, the possibility of infections and the 'propofol syndrome' have suggested that propofol might be dangerous. Nonetheless, propofol is widely used in different settings because of its characteristics: fast induction, rapid elimination, short duration of action, smooth recovery from anaesthesia, few adverse effects, no teratogenic effects, characteristics that have undoubtedly contributed to its popularity. The effect of propofol on survival is unknown. We decided to carry out a meta-analysis of all randomized controlled studies ever performed on propofol vs. any comparator in any clinical setting.

METHODS

Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, Clinicaltrial.gov, and Cochrane Central Register of Clinical Trials by expert investigators. The following inclusion criteria were used: random allocation to treatment, comparison between propofol and any comparator in any clinical setting.

RESULTS

One hundred thirty-three studies randomizing 14,516 patients were included. No differences in mortality between patients receiving propofol [349/6957 (5.0%)] vs. any comparator [340/7559 (4.5%)] were observed in the overall population [risk ratio = 1.05, 95% confidence interval (0.93 to 1.18), P = 0.5] and in several sub-analyses.

CONCLUSION

Inspite of theoretical concerns, propofol has no detrimental effect on survival according to the largest meta-analysis of randomized trials ever performed on hypnotic drug.

Is propofol a friend or a foe of the pediatric intensivist? Description of propofol use in a PICU*

OBJECTIVE

The primary objective is to describe the practice patterns of nonprocedural propofol use in a single-center referral PICU. The secondary objective is to describe the rate of concordance of propofol use with the PICU local practice of a maximum mean rate of 4 mg/kg/hr and a maximum duration of 24 hours and to assess for signs and symptoms of propofol infusion syndrome.

DESIGN

Retrospective descriptive cohort study.

SETTING

PICU of a tertiary care teaching hospital and referral hospital for the Western Canada.

PATIENTS

Children 1 month to 17 years old who received a nonprocedural propofol infusion between January 1, 2009, and December 31, 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred twenty-three infusions (representing 210 unique patients) were included in the study. The median average infusion rate (interquartile range) including boluses was 2.7 mg/kg/hr (1.9-3.6 mg/kg/hr), and the mean infusion duration (SD) was 10.3 hours (6.7 hr). Eighty-seven percent and 98% of infusions were concordant with PICU intensivists self-reported practice maximum rate and duration, respectively. No cases of propofol-related infusion syndrome or deaths associated with propofol infusions were identified.

CONCLUSIONS

The use of propofol infusions was in concordance with PICU local practice, and propofol infusion syndrome did not developed in patients. In agreement with previous recommendations, propofol infusions in the PICU appear to be safe when limiting doses to 4 mg/kg/hr and for less than 24 hours; however, appropriate monitoring of adverse effects is still warranted due to absence of robust evidence.

Propofol infusion syndrome resuscitation with extracorporeal life support: a case report and review of the literature

We report a case of propofol infusion syndrome (PRIS) in a young female treated for status epilepticus. In this case, PRIS rapidly evolved to full cardiovascular collapse despite aggressive supportive care in the intensive care unit, as well as prompt discontinuation of the offending agent. She progressed to refractory cardiac arrest requiring emergent initiation of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR). She regained a perfusing rhythm after prolonged (>8 hours) asystole, was weaned off ECMO and eventually all life support, and was discharged to home. We also present a review of the available literature on the use of ECMO for PRIS.

Therapeutic drug monitoring in the neurocritical care unit

PURPOSE OF REVIEW

Various antiepileptics, sedative and anesthetic agents are used in the neurocritical care setting and therapeutic drug monitoring (TDM) has been proposed as a means to individualize dosing to ensure efficacy, avoid toxicity, and to account for drug-drug interactions. The purpose of this review is to highlight key articles relating to TDM published in the last 5 years with a focus on drug therapy for seizures, status epilepticus, and traumatic brain injury.

RECENT FINDINGS

Current evidence supports TDM of first-generation antiepileptics, and free-level monitoring for phenytoin and valproic acid is recommended in the neurocritical care population. There are insufficient data to recommend routine TDM of second-generation antiepileptics at this time. In traumatic brain injury, routine TDM of barbiturate infusions appears to be of little value in guiding or evaluating patient response to therapy except to differentiate between drug-induced coma and brain death. Although TDM of sedative agents has been studied, the use of clinical sedation scales is preferred over TDM in evaluating a patient's level of sedation.

SUMMARY

Therapeutic drug monitoring plays an important role in the care of patients in the neurocritical care setting but is applicable only to a limited number of drugs.

Anesthesia with propofol induces insulin resistance systemically in skeletal and cardiac muscles and liver of rats

Hyperglycemia together with hepatic and muscle insulin resistance are common features in critically ill patients, and these changes are associated with enhanced inflammatory response, increased susceptibility to infection, muscle wasting, and worsened prognosis. Tight blood glucose control by intensive insulin treatment may reduce the morbidity and mortality in intensive care units. Although some anesthetics have been shown to cause insulin resistance, it remains unknown how and in which tissues insulin resistance is induced by anesthetics. Moreover, the effects of propofol, a clinically relevant intravenous anesthetic, also used in the intensive care unit for sedation, on insulin sensitivity have not yet been investigated. Euglycemic hyperinsulinemic clamp study was performed in rats anesthetized with propofol and conscious unrestrained rats. To evaluate glucose uptake in tissues and hepatic glucose output [(3)H]glucose and 2-deoxy[(14)C]glucose were infused during the clamp study. Anesthesia with propofol induced a marked whole-body insulin resistance compared with conscious rats, as reflected by significantly decreased glucose infusion rate to maintain euglycemia. Insulin-stimulated tissue glucose uptake was decreased in skeletal muscle and heart, and hepatic glucose output was increased in propofol anesthetized rats. Anesthesia with propofol induces systemic insulin resistance along with decreases in insulin-stimulated glucose uptake in skeletal and heart muscle and attenuation of the insulin-mediated suppression of hepatic glucose output in rats.

Analgosedation: A Paradigm Shift in Intensive Care Unit Sedation Practice

Objective:

To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients.

Data Sources:

Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed.

Study Selection and Data Extraction:

All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included.

Data Synthesis:

Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-in dependent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens.

Conclusions:

Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics.

The use of propofol sedation in a paediatric intensive care unit

BACKGROUND

The aim of this study was to prospectively evaluate and report the experience of the use of continuous intravenous propofol sedation in a paediatric intensive care unit (PICU).

METHODS

All children younger than 16 years who were admitted to the PICU at a University Hospital for slightly more than a year and received propofol infusion were included prospectively and data were recorded before and within 6 h after completion of the propofol infusion.

RESULTS

A total of 174 out of 955 children (18·2%) received propofol infusion for sedation. The median age was 2 years 10 months (range: 2 months to 16 years), duration of propofol infusion 13 h (range: 1·6-179 h) and dose of propofol 2·9 mg/kg/h (range: 0·3-6·5 mg/kg/h). No one developed signs of the propofol infusion syndrome (PRIS). Neither dose >3 mg/kg/h, duration of infusion >48 h nor both were found to be related to adverse metabolic derangements or circulatory failure. Eight children increased their lactate concentration ≥1·8 mmol/L during propofol infusion. All had a favourable outcome. One child who had received propofol infusion for 10 h died, but this occurred 14 h after the infusion ceased and was without doubt attributed to a multiple organ failure not related to the propofol infusion.

CONCLUSION

Propofol infusion was used in this population at low risk of PRIS with no metabolic or circulatory adverse effects. These findings indicate that the occurrence of adverse effects may not be directly related to dose or duration of infusion, but emphasizes the risk that sporadic factors may be involved, such as genetic mutations. Guidelines are presented.

Altering intensive care sedation paradigms to improve patient outcomes

Providing sedation and comfort for intensive care patients has evolved in the last 30 years but remains difficult for clinicians. As research has focused on this challenging area, the authors have identified ways to improve practice, including providing analgesia before sedation, strategies to help recognize dangerous adverse effects associated with the medications that are used, and better ways to monitor pain and delirium in patients. Dexmedetomidine and propofol have become the preferred sedatives for many ICU situations, and creative ways to administer them, such as linking awakening and breathing trials, are emerging. Finally, screening survivors for cognitive impairments may allow clinicians to refer them for the focused rehabilitation they require.

Attenuating sevoflurane-induced cellular injury of human peripheral lymphocytes by propofol in a concentration-dependent manner

Sevoflurane, one of the most commonly used inhalation anesthetics, induces apoptosis and oxidative stress in lymphocytes. Propofol, an intravenous anesthetic, exhibits antiapoptotic and antioxidative activities. Therefore, the present study aimed to investigate whether propofol attenuates sevoflurane-induced cellular injury in human peripheral lymphocytes. Lymphocytes harvested from healthy volunteers were assigned to treatments with different concentrations of propofol, or 8% sevoflurane, or their combination. Propofol at concentrations of 5, 10 or 25 μg/mL had little effect, but 50 μg/mL propofol or 8% sevoflurane significantly reduced cell viability and mitochondrial membrane potential (ΔΦm), and increased cell apoptosis, activation of caspase-3 and the production of intracellular reactive oxygen species, compared with untreated cells. Five and ten μg/mL propofol attenuated the impact of sevoflurane on cell viability, apoptosis and ΔΦm, and 5, 10 and 25 μg/mL propofol inhibited the production of intracellular reactive oxygen species stimulated by sevoflurane. However, a combination of 50 μg/mL propofol and 8% sevoflurane led to more severe cellular injury than sevoflurane alone. The results suggest that propofol can attenuate sevoflurane-induced cellular injury of human peripheral lymphocytes in a concentration-dependent manner, providing a rational for the clinical use of sevoflurane combined with appropriate doses of propofol.

Molecular approaches to improving general anesthetics

Over the last several decades, the average age of patients has steadily increased, whereas the use of general anesthesia and deep sedation has grown largely outside the operating room environment. Currently available general anesthetics and delivery models represent limitations in addressing these trends. At the same time, research has tremendously expanded the knowledge of how general anesthetics produce their beneficial effects and also revealed evidence of previously unappreciated general anesthetic toxicities. The goal of this review is to highlight these important developments and describe translational research on new general anesthetics with the potential to improve and reshape clinical care.

Evaluation of dexmedetomidine versus propofol-based sedation therapy in mechanically ventilated cardiac surgery patients at a tertiary academic medical center

Management of pain and sedation therapy is a vital component of optimizing patient outcomes; however, the ideal pharmacotherapy regimen has not been identified in the postoperative cardiac surgery population. We sought to evaluate efficacy and safety outcomes between postoperative mechanically ventilated cardiac surgery patients receiving dexmedetomidine versus propofol therapy upon arrival to the intensive care unit (ICU). We conducted a single center, descriptive study of clinical practice at a 20-bed cardiac surgery ICU in a tertiary academic medical center. Adult mechanically ventilated postcardiac surgery patients who received either dexmedetomidine or propofol for sedation therapy upon admission to the ICU between October 20, 2006 and December 15, 2006 were evaluated. A pharmacy database was used to identify patients receiving dexmedetomidine or propofol therapy for perioperative sedation during cardiac surgery. Patients were matched according to surgical procedure type. Fifty-six patients who received either dexmedetomidine (n = 28) or propofol (n = 28) were included in the analysis. No differences in the ICU length of stay (58.67 ± 32.61 vs. 61 ± 33.1 hours; P = 0.79) and duration of mechanical ventilation (16.21 ± 6.05 vs. 13.97 ± 4.62 hours; P = 0.13) were seen between the propofol and dexmedetomidine groups, respectively. Hypotension (17 [61%] vs. 9 [32%]; P = 0.04), morphine use (11 [39.3%] vs. 1 [3.6%]; P = 0.002), and nonsteroidal anti-inflammatory use (7 [25%] vs. 1 [3.6%]; P = 0.05) occurred more during dexmedetomidine therapy versus propofol. Dexmedetomidine therapy resulted in a higher incidence of hypotension and analgesic consumption compared with propofol-based sedation therapy. Further evaluation is needed to assess differences in clinical outcomes of propofol and dexmedetomidine-based therapy in mechanically ventilated cardiac surgery patients.

Alcohol withdrawal syndromes in the intensive care unit

This article reviews the pathophysiology, diagnosis, and treatment of alcohol withdrawal syndromes in the intensive care unit as well as the literature on the optimal pharmacologic strategies for treatment of alcohol withdrawal syndromes in the critically ill. Treatment of alcohol withdrawal in the intensive care unit mirrors that of the general acute care wards and detoxification centers. In addition to adequate supportive care, benzodiazepines administered in a symptom-triggered fashion, guided by the Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar), still seem to be the optimal strategy in the intensive care unit. In cases of benzodiazepine resistance, numerous options are available, including high individual doses of benzodiazepines, barbiturates, and propofol. Intensivists should be familiar with the diagnosis and treatment strategies for alcohol withdrawal syndromes in the intensive care unit.

Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit

As critically ill patients frequently receive analgesics, sedatives, and antipsychotics to optimize patient comfort and facilitate mechanical ventilation, adverse events associated with the use of these agents can affect all organ systems and result in substantial morbidity and mortality. Although many of these adverse effects are common pharmacologic manifestations of the agent, and therefore frequently reversible, others are idiosyncratic and thus unexpected. The critically ill are more susceptible to adverse drug events than nonintensive care unit patients due to the high doses and long periods for which each of these agents are often administered, the frequent use of intravenous formulations that contain adjuvants that may lead to toxicity in some instances, and the high prevalence of end-organ dysfunction that affects the pharmacokinetic and pharmacodynamic response to therapy. This paper will review the most common and serious adverse drug events reported to occur with the use of sedatives, analgesics, and antipsychotics in the intensive care unit; highlight the pharmacokinetic, pharmacodynamic, and pharmacogenetic factors that can influence analgesic, sedative, and antipsychotic response and safety in the critically ill; and identify strategies that can be used to minimize toxicity with these agents.

Status epilepticus

Status epilepticus (SE) is one of the most commonly occurring neurologic emergencies. About 40% of SE cases occur in people with epilepsy. Convulsive SE is easily recognized, but nonconvulsive SE is not and requires both a high index of suspicion and EEG confirmation. SE has a high mortality risk and requires rapid effective treatment for optimal response to therapy and outcome. The goal of treatment is to stop all clinical and electrographic seizures while maintaining vital functions. If seizures continue after initial treatment with a benzodiazepine, additional antiepileptic therapy should be administered. When SE is refractory to these treatments, continuous IV infusion with midazolam, propofol, or a barbiturate suppresses seizure activity. Standard treatment protocols are useful in promoting rapid intervention with appropriate medications.

[Sedation in neurointensive care unit]

The objectives for using sedation in neurointensive care unit (neuroICU) are somewhat different from those used for patients without severe brain injuries. One goal is to clinically reassess the neurological function following the initial brain insult in order to define subsequent strategies for diagnosis and treatment. Another goal is to prevent severely injured brain from additional aggravation of cerebral blood perfusion and intracranial pressure. Depending on these situations is the choice of sedatives and analgesics: short-term agents, e.g., remifentanil, if a timely neurological reassessment is required, long-term agents, e.g., midazolam and sufentanil, as part of the treatment for elevated intracranial pressure. In that situation, a multimodal monitoring is needed to overcome the lack of clinical monitoring, including repeated measurements of intracranial pressure, blood flow velocities (transcranial Doppler), cerebral oxygenation (brain tissue oxygen tension), and brain imaging. The ultimate stop of neurosedation can distinguish between no consciousness and an alteration of arousing in brain-injured patients. During this period, an elevation of intracranial pressure is usual, and should not always result in reintroducing the neurosedation.

Altering intensive care sedation paradigms to improve patient outcomes

Providing sedation and comfort for intensive care patients has evolved in the last few years. New approaches to improving outcomes for intensive care unit (ICU) patients include providing analgesia before adding sedation and recognizing dangerous adverse effects associated with sedative medications, such as prolonged effects of midazolam, propylene glycol toxicity with lorazepam, propofol infusion syndrome, the deliriogenic effects of benzodiazepines and propofol, and bradycardia with dexmedetomidine. There are now reliable and valid ways to monitor pain and delirium in ICU patients. Dexmedetomidine reduces the incidence of delirium, reduces the duration of mechanical ventilation, and appears to be cost effective.

RESUSCITATION AND CRITICAL CARE OF POOR-GRADE SUBARACHNOID HEMORRHAGE

AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.

Sedation management in the mechanically ventilated critically ill patient

Sedation management in the mechanically ventilated critically ill patient is a topic of continuing interest in the critical care literature. The wide variety of clinical practices described in the literature with regard to sedation management has limited the implementation of evidence-based practice guidelines. Common themes for a coherent sedation management strategy include articulation of indications for sedation, initial and daily evaluation of sedation goals, sedation-level assessment, appropriate sedative selection, effective sedation management strategy, and efficient sedation weaning strategy. We provide a summary of the literature on key aspects of sedation in clinical practice. Evidence-based recommendations are provided for clinicians involved in the management of sedation in mechanically ventilated patients.

Propofol infusion syndrome

Propofol (Diprivan) is an intravenous sedative hypnotic that is used in the induction and maintenance of anesthesia and sedation. High-dose infusions have been associated with several serious adverse effects and, when combined, they are known as propofol infusion syndrome (PRIS). Although PRIS is rare, it is frequently fatal if not identified early. The purpose of this article is to raise practitioner awareness to this syndrome, with recommendations for early identification, prevention, and treatment of PRIS.