Pub Date : 2014-03-07DOI: 10.2174/1874828701407010001
S. Ley, J. Ammann, C. Herder, T. Dickhaus, M. Hartmann, D. Kindgen-Milles
Introduction: Restoring and maintaining normoglycemia by intensified insulin therapy in critically ill patients is a matter of ongoing debate since the risk of hypoglycemia may outweigh positive effects on morbidity and mortality. In this context, adsorption of insulin to different catheter materials may contribute to instability of glucose control. We studied the adsorption of insulin to different tubing materials in vitro and the effects on glycemic control in vivo. Materials and Methods: In vitro experiments: A syringe pump was filled with 50 IU insulin diluted to 50 ml saline. A flow of 2 ml/h was perfused through polyethylene (PET) or polyurethane (PUR) tubing. Insulin concentrations were measured at the end of the tube for 24 hours using Bradfords protein assay. In vivo study: In a randomized double- blinded cross-over design, 10 intensive care patients received insulin via PET and PUR tubes for 24 hours each, targeting blood glucose levels of 80-150 mg/dl. We measured blood glucose levels, the insulin dose required to maintain target levels, and serum insulin and C-peptide levels. Results: In vitro experiments: After the start of the insulin infusion, only 20% (median, IQR 20-27) (PET) and 22% (IQR 16-27) (PUR) of the prepared insulin concentration were measured at the end of the 2 meter tubing. Using PET, after one hour infusion the concentration increased to 34% (IQR 29-36) and did not increase significantly during the next 24 hours (39% (IQR 39-40)). Using PUR, higher concentrations were detected than for PET at every measurement from 1 hour (82% (IQR 70-86)) to 24 hours (79% (IQR 64-87)). In vivo study: Glycemic control was effective and not different between groups. Significantly higher volumes of insulin solution had to be infused with PET compared to PUR (median PET 70.0 (IQR 56-82) ml vs. PUR 42 (IQR 31-63) ml; p=0.0015). Serum insulin concentrations did not decrease significantly one hour after changing to PET or PUR tubing. Conclusion: Polyurethane tubing systems allow application of insulin with significantly lower adsorption rates than polyethylene tubing systems. As a consequence, less insulin solution has to be infused to patients for effective blood glucose control. Tubing material of the insulin infusion may be crucial for safe and effective glycemic control in critically ill patients.
{"title":"Insulin Adsorption to Catheter Materials Used for Intensive Insulin Therapy in Critically Ill Patients: Polyethylene Versus Polyurethane - Possible Cause of Variation in Glucose Control? §","authors":"S. Ley, J. Ammann, C. Herder, T. Dickhaus, M. Hartmann, D. Kindgen-Milles","doi":"10.2174/1874828701407010001","DOIUrl":"https://doi.org/10.2174/1874828701407010001","url":null,"abstract":"Introduction: Restoring and maintaining normoglycemia by intensified insulin therapy in critically ill patients is a matter of ongoing debate since the risk of hypoglycemia may outweigh positive effects on morbidity and mortality. In this context, adsorption of insulin to different catheter materials may contribute to instability of glucose control. We studied the adsorption of insulin to different tubing materials in vitro and the effects on glycemic control in vivo. Materials and Methods: In vitro experiments: A syringe pump was filled with 50 IU insulin diluted to 50 ml saline. A flow of 2 ml/h was perfused through polyethylene (PET) or polyurethane (PUR) tubing. Insulin concentrations were measured at the end of the tube for 24 hours using Bradfords protein assay. In vivo study: In a randomized double- blinded cross-over design, 10 intensive care patients received insulin via PET and PUR tubes for 24 hours each, targeting blood glucose levels of 80-150 mg/dl. We measured blood glucose levels, the insulin dose required to maintain target levels, and serum insulin and C-peptide levels. Results: In vitro experiments: After the start of the insulin infusion, only 20% (median, IQR 20-27) (PET) and 22% (IQR 16-27) (PUR) of the prepared insulin concentration were measured at the end of the 2 meter tubing. Using PET, after one hour infusion the concentration increased to 34% (IQR 29-36) and did not increase significantly during the next 24 hours (39% (IQR 39-40)). Using PUR, higher concentrations were detected than for PET at every measurement from 1 hour (82% (IQR 70-86)) to 24 hours (79% (IQR 64-87)). In vivo study: Glycemic control was effective and not different between groups. Significantly higher volumes of insulin solution had to be infused with PET compared to PUR (median PET 70.0 (IQR 56-82) ml vs. PUR 42 (IQR 31-63) ml; p=0.0015). Serum insulin concentrations did not decrease significantly one hour after changing to PET or PUR tubing. Conclusion: Polyurethane tubing systems allow application of insulin with significantly lower adsorption rates than polyethylene tubing systems. As a consequence, less insulin solution has to be infused to patients for effective blood glucose control. Tubing material of the insulin infusion may be crucial for safe and effective glycemic control in critically ill patients.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"266 1","pages":"1-6"},"PeriodicalIF":0.0,"publicationDate":"2014-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76508899","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-12-27DOI: 10.2174/1874828701306010040
Purvesh R. Patel, R. Cohen, Seth J. Koenig
Common neurological emergencies include overdose or withdrawal from illegal substance abuse, adverse effects of prescription medications, seizures, metabolic encephalopathy, infections and cerebrovascular accidents. Following a thorough clinical and radiologic assessment, a small group of patients escape definitive diagnosis and autoimmune encephalitides should be considered. Of these, limbic encephalitis (LE) is the most common and may result from paraneoplastic or nonparaneoplastic sources. Common to both is the production of antibodies targeting epitopes in the brain parenchyma thought to be responsible for the clinical manifestations. Paraneoplastic Anti-N-methyl D-aspartate receptor (NMDAR) encephalitis is a common cause of LE and has gained awareness in neurological and psychiatric literature. Paraneoplastic and nonparaneoplastic anti NMDAR encephalitis typically presents in young, previously healthy females with subacute onset of psychiatric symptoms, respiratory insufficiency, orofacial dyskinesias, autonomic instability and seizures. Paraneoplastic LE is induced by antibody production against NMDAR with occult ovarian teratoma being the most common inciting tumor. LE has also been described in association with other tumors and also without tumors. The latter are known as nonparaneoplastic or primary autoimmune disease. Diagnosis requires both clinical suspicion along with prompt serum and cerebrospinal fluid analysis for antibody detection. Immunotherapy to remove and suppress these antibodies along with resection of an identified tumor is the therapy of choice. This article will review the clinical presentation and management of LE in patients who present to the medical intensive care unit.
{"title":"A Typical Neurological Presentations in the ICU: Limbic Encephalitis","authors":"Purvesh R. Patel, R. Cohen, Seth J. Koenig","doi":"10.2174/1874828701306010040","DOIUrl":"https://doi.org/10.2174/1874828701306010040","url":null,"abstract":"Common neurological emergencies include overdose or withdrawal from illegal substance abuse, adverse effects of prescription medications, seizures, metabolic encephalopathy, infections and cerebrovascular accidents. Following a thorough clinical and radiologic assessment, a small group of patients escape definitive diagnosis and autoimmune encephalitides should be considered. Of these, limbic encephalitis (LE) is the most common and may result from paraneoplastic or nonparaneoplastic sources. Common to both is the production of antibodies targeting epitopes in the brain parenchyma thought to be responsible for the clinical manifestations. Paraneoplastic Anti-N-methyl D-aspartate receptor (NMDAR) encephalitis is a common cause of LE and has gained awareness in neurological and psychiatric literature. Paraneoplastic and nonparaneoplastic anti NMDAR encephalitis typically presents in young, previously healthy females with subacute onset of psychiatric symptoms, respiratory insufficiency, orofacial dyskinesias, autonomic instability and seizures. Paraneoplastic LE is induced by antibody production against NMDAR with occult ovarian teratoma being the most common inciting tumor. LE has also been described in association with other tumors and also without tumors. The latter are known as nonparaneoplastic or primary autoimmune disease. Diagnosis requires both clinical suspicion along with prompt serum and cerebrospinal fluid analysis for antibody detection. Immunotherapy to remove and suppress these antibodies along with resection of an identified tumor is the therapy of choice. This article will review the clinical presentation and management of LE in patients who present to the medical intensive care unit.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"9 1","pages":"40-45"},"PeriodicalIF":0.0,"publicationDate":"2013-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87259942","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-12-27DOI: 10.2174/1874828701306010046
G. Zaidi
The optimal blood pressure (BP) management in critically ill patients with neurological emergencies in the intensive care unit poses several challenges. Both over and under correction of the blood pressure are associated with increased morbidity and mortality in this population. Target blood pressures and therapeutic management are based on guidelines including those from the American Stroke Association and the Joint National Committee guidelines. We review these recommendations and the current concepts of blood pressure management in neurological emergencies. A variety of therapeutic agents including nicardipine, labetalol, nitroprusside are used for blood pressure management in patients with ischemic and hemorrhagic strokes. Currently, the role of inducing hypertension remains unclear. Hypertensive crises include hypertensive urgencies where elevated blood pressures are seen without end organ damage and can usually be managed by oral agents, and hypertensive emergencies where end organ damage is present and requires immediate treatment with intravenous drugs.
{"title":"Blood Pressure Control in Neurological ICU Patients: What is Too High and What is Too Low?","authors":"G. Zaidi","doi":"10.2174/1874828701306010046","DOIUrl":"https://doi.org/10.2174/1874828701306010046","url":null,"abstract":"The optimal blood pressure (BP) management in critically ill patients with neurological emergencies in the intensive care unit poses several challenges. Both over and under correction of the blood pressure are associated with increased morbidity and mortality in this population. Target blood pressures and therapeutic management are based on guidelines including those from the American Stroke Association and the Joint National Committee guidelines. We review these recommendations and the current concepts of blood pressure management in neurological emergencies. A variety of therapeutic agents including nicardipine, labetalol, nitroprusside are used for blood pressure management in patients with ischemic and hemorrhagic strokes. Currently, the role of inducing hypertension remains unclear. Hypertensive crises include hypertensive urgencies where elevated blood pressures are seen without end organ damage and can usually be managed by oral agents, and hypertensive emergencies where end organ damage is present and requires immediate treatment with intravenous drugs.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"16 1","pages":"46-55"},"PeriodicalIF":0.0,"publicationDate":"2013-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81876532","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-12-27DOI: 10.2174/1874828701306010080
Janice Wang, H. Greenberg
Disturbed sleep is common in critical illness, not only during early phases of treatment in an intensive care unit (ICU) but also during later stages of recovery after ICU discharge. While sleep quality during critical illness is usually not a primary concern of intensivists, disrupted sleep can impede recovery and has been associated with immune system dysfunction, impaired wound healing, and adverse neurological and psychological outcomes (1). The noise and lighting of the ICU environment, frequent patient-provider interactions, and critical care procedures all profoundly impact sleep quality and continuity in critically ill patients. Various sedative medications and various modes of mechanical ventilation can also affect sleep. This article will review (1) sleep disruption and its clinical manifestations in the ICU patient, (2) the effects of the ICU environment and routine critical care on sleep disturbances, (3) the biological consequences of critical illness on sleep and circadian rhythms, and how sleep deprivation (SD) affects the immune system, (4) iatrogenic disturbances of sleep in the ICU patient (e.g. commonly used sedatives, mechanical ventilation), and (5) sleep during recovery after critical illness.
{"title":"Sleep and the ICU","authors":"Janice Wang, H. Greenberg","doi":"10.2174/1874828701306010080","DOIUrl":"https://doi.org/10.2174/1874828701306010080","url":null,"abstract":"Disturbed sleep is common in critical illness, not only during early phases of treatment in an intensive care unit (ICU) but also during later stages of recovery after ICU discharge. While sleep quality during critical illness is usually not a primary concern of intensivists, disrupted sleep can impede recovery and has been associated with immune system dysfunction, impaired wound healing, and adverse neurological and psychological outcomes (1). The noise and lighting of the ICU environment, frequent patient-provider interactions, and critical care procedures all profoundly impact sleep quality and continuity in critically ill patients. Various sedative medications and various modes of mechanical ventilation can also affect sleep. This article will review (1) sleep disruption and its clinical manifestations in the ICU patient, (2) the effects of the ICU environment and routine critical care on sleep disturbances, (3) the biological consequences of critical illness on sleep and circadian rhythms, and how sleep deprivation (SD) affects the immune system, (4) iatrogenic disturbances of sleep in the ICU patient (e.g. commonly used sedatives, mechanical ventilation), and (5) sleep during recovery after critical illness.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"27 1","pages":"80-87"},"PeriodicalIF":0.0,"publicationDate":"2013-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76385708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-12-27DOI: 10.2174/1874828701306010066
A. Iakovou, K. W. Lama, Adey Tsegaye
Recognition and treatment of pain, agitation and anxiety is a challenge in the care of Intensive Care Unit (ICU) patients. Management of pain, agitation and anxiety is necessary for patient comfort, and reduces long term psychological sequelae of ICU admission, time on mechanical ventilation, and length of stay in both the ICU and hospital. ICU providers must be very familiar with the pharmacologic agents available and their appropriate use. Objective, easy to use, reliable and reproducible scales to assess pain and level of sedation are necessary to provide adequate treatment and to avoid untoward effects. Lighter sedation is presently the accepted goal and newer sedatives with safer side effect profiles are being used. Neuromuscular blocking agents continue to be recommended in certain clinical situations and for as short a time period as possible. Delirium is a common problem that must be prevented with early mobilization and promotion of sleep by creating an optimal environment. The use of dexmedetomidine in at-risk mechanically ventilated patients and atypical antipsychotics may be beneficial and reduce the duration of delirium.
{"title":"Update on Sedation in the Critical Care Unit","authors":"A. Iakovou, K. W. Lama, Adey Tsegaye","doi":"10.2174/1874828701306010066","DOIUrl":"https://doi.org/10.2174/1874828701306010066","url":null,"abstract":"Recognition and treatment of pain, agitation and anxiety is a challenge in the care of Intensive Care Unit (ICU) patients. Management of pain, agitation and anxiety is necessary for patient comfort, and reduces long term psychological sequelae of ICU admission, time on mechanical ventilation, and length of stay in both the ICU and hospital. ICU providers must be very familiar with the pharmacologic agents available and their appropriate use. Objective, easy to use, reliable and reproducible scales to assess pain and level of sedation are necessary to provide adequate treatment and to avoid untoward effects. Lighter sedation is presently the accepted goal and newer sedatives with safer side effect profiles are being used. Neuromuscular blocking agents continue to be recommended in certain clinical situations and for as short a time period as possible. Delirium is a common problem that must be prevented with early mobilization and promotion of sleep by creating an optimal environment. The use of dexmedetomidine in at-risk mechanically ventilated patients and atypical antipsychotics may be beneficial and reduce the duration of delirium.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"359 1","pages":"66-79"},"PeriodicalIF":0.0,"publicationDate":"2013-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76404572","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-12-27DOI: 10.2174/1874828701306010056
A. Sadoughi, I. Rybinnik, R. Cohen
Increased intracranial pressure (ICP) is a serious complication of a variety of neurologic injuries and is a major challenge in intensive care units. The most common causes of increased ICP are: traumatic brain injury (TBI), stroke, neoplasms, hydrocephalus, hepatic encephalopathy, CNS venous return impairment, encephalitis, and abscesses. Prompt diagnosis and intensive monitoring and therapy of this condition are essential for successful management of this potentially devastating condition. Recent technical innovations in neuromonitoring may allow for improvement in morbidity and mortality rates attributable to elevated ICP. Normal ICP ranges from 3-15 mmHg. In routine intensive care unit (ICU) practice, the goal of ICP management is to maintain levels below 20 mmHg. Noninvasive and metabolic monitoring of ICP including imaging-clinical examination has been studied and suggested to be as efficient as the care based on invasive ICP monitoring; however its application in clinical practice is to be established. Raised intracranial pressure correlates with decreased survival and is often the only remediable element of brain pathology. While elimination of the cause of elevated ICP remains the definitive approach, there are maneuvers that should be used to decrease ICP urgently. Surgical decompression of mass effect may rapidly improve ICP elevation. Osmolar therapy, maintenance of euvolemia, cerebral metabolic suppression, and temperature control are part of the advanced management of elevated ICP.
{"title":"Measurement and Management of Increased Intracranial Pressure","authors":"A. Sadoughi, I. Rybinnik, R. Cohen","doi":"10.2174/1874828701306010056","DOIUrl":"https://doi.org/10.2174/1874828701306010056","url":null,"abstract":"Increased intracranial pressure (ICP) is a serious complication of a variety of neurologic injuries and is a major challenge in intensive care units. The most common causes of increased ICP are: traumatic brain injury (TBI), stroke, neoplasms, hydrocephalus, hepatic encephalopathy, CNS venous return impairment, encephalitis, and abscesses. Prompt diagnosis and intensive monitoring and therapy of this condition are essential for successful management of this potentially devastating condition. Recent technical innovations in neuromonitoring may allow for improvement in morbidity and mortality rates attributable to elevated ICP. Normal ICP ranges from 3-15 mmHg. In routine intensive care unit (ICU) practice, the goal of ICP management is to maintain levels below 20 mmHg. Noninvasive and metabolic monitoring of ICP including imaging-clinical examination has been studied and suggested to be as efficient as the care based on invasive ICP monitoring; however its application in clinical practice is to be established. Raised intracranial pressure correlates with decreased survival and is often the only remediable element of brain pathology. While elimination of the cause of elevated ICP remains the definitive approach, there are maneuvers that should be used to decrease ICP urgently. Surgical decompression of mass effect may rapidly improve ICP elevation. Osmolar therapy, maintenance of euvolemia, cerebral metabolic suppression, and temperature control are part of the advanced management of elevated ICP.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"1 1","pages":"56-65"},"PeriodicalIF":0.0,"publicationDate":"2013-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89986545","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-12-27DOI: 10.2174/1874828701306010039
R. Cohen
Following a period of dormancy during the 1960s and 1970s, neurological intensive care slowly evolved into its own specialty with the recognition of the unique physiology and sensitivity to injury that affects the central nervous system (CNS) and the realization of the role the CNS plays in critical illness [1,2]. In spite of this, many hospitals do not provide dedicated neurological intensive care and patients are cared for in non-specialized critical care units. Moreover, the outlook for many neurological disorders had previously been one of nihilism. However, fundamental understanding of pathophysiology and translation of research from bench to bedside combined with data from large randomized clinical trials are beginning to turn this nihilistic tide. Therefore, there is a great need to communicate scientific findings in neurological intensive care to the larger critical care community who may not be familiar with this rapidly evolving field. The purpose of this issue is to provide guidance to medical intensivists in the care of several neurological conditions. We review causes and treatments of increased intracerebral pressure and its brain-focused management. The management of blood pressure in critical care neurology especially following cerebro-vascular accidents remains controversial, however recent randomized trial have clarified some of the issues and these are discussed in another article in this review [3].
{"title":"Care of the Neurological Patient in the Medical ICU","authors":"R. Cohen","doi":"10.2174/1874828701306010039","DOIUrl":"https://doi.org/10.2174/1874828701306010039","url":null,"abstract":"Following a period of dormancy during the 1960s and 1970s, neurological intensive care slowly evolved into its own specialty with the recognition of the unique physiology and sensitivity to injury that affects the central nervous system (CNS) and the realization of the role the CNS plays in critical illness [1,2]. In spite of this, many hospitals do not provide dedicated neurological intensive care and patients are cared for in non-specialized critical care units. Moreover, the outlook for many neurological disorders had previously been one of nihilism. However, fundamental understanding of pathophysiology and translation of research from bench to bedside combined with data from large randomized clinical trials are beginning to turn this nihilistic tide. Therefore, there is a great need to communicate scientific findings in neurological intensive care to the larger critical care community who may not be familiar with this rapidly evolving field. The purpose of this issue is to provide guidance to medical intensivists in the care of several neurological conditions. We review causes and treatments of increased intracerebral pressure and its brain-focused management. The management of blood pressure in critical care neurology especially following cerebro-vascular accidents remains controversial, however recent randomized trial have clarified some of the issues and these are discussed in another article in this review [3].","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"133 1","pages":"39-39"},"PeriodicalIF":0.0,"publicationDate":"2013-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90611055","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-10-04DOI: 10.2174/1874828701306010031
F. C. Bagna, S. Pitoni, Peter J D Andrews
Background: Therapeutic hypothermia may alter both the pharmacokinetic (PK) and dynamics (PD) of the commonly used drugs in critical care. To achieve maximum benefit, medication dosage and schedules should be optimized. Objective: To review the existing scientific evidence showing the effect of therapeutic hypothermia on the pharmacokinetics of drugs commonly used in the care of patients after Trauma Brain Injury (TBI); particularly including sedatives, anticonvulsants and antibiotics. Data Sources: Computerized searches of OVID MEDLINE, OVID EMBASE, Cochrane Clinical Trials Register to August 2013 and hand searching of references of retrieved articles and proceedings of meetings; associated reference lists; and articles identified by experts in the field. Study Selection: Inclusion criteria were as follows: a) population- humans or animals undergoing therapeutic hypothermia b) design-prospective, randomized controlled trial, c) intervention-hypothermia; measurement of PD and PK of different drugs. Data Extraction: A data extraction form was used and authors (CB & SP) reviewed all trials. Data Synthesis: We reviewed 30 trials that documented changes in PD and PK of sedatives (propofol and midazolam), opioids (fentanyl, remifentanil, alfentil and morphine), anticonvulsants (phenytoin) and antibiotics (aminoglycosides) conducted in human or animal models undergoing therapeutic hypothermia. Conclusion: Data show that therapeutic hypothermia significantly alters the pharmacokinetics of commonly used agents. Particular care should be taken to reduce sedatives once target temperature is reached. Further clinical studies are required to clarify the effect of hypothermia on the PD and PK of therapeutic agents to optimize the benefits of therapeutic hypothermia in the treatment of TBI patients.
{"title":"Therapeutic Mild Hypothermia and the Pharmacokinetics of Drugs in Trauma Brain Injury (TBI) Patients with a Focus on Sedation, Anticonvulsant and Antibiotic Therapy","authors":"F. C. Bagna, S. Pitoni, Peter J D Andrews","doi":"10.2174/1874828701306010031","DOIUrl":"https://doi.org/10.2174/1874828701306010031","url":null,"abstract":"Background: Therapeutic hypothermia may alter both the pharmacokinetic (PK) and dynamics (PD) of the commonly used drugs in critical care. To achieve maximum benefit, medication dosage and schedules should be optimized. Objective: To review the existing scientific evidence showing the effect of therapeutic hypothermia on the pharmacokinetics of drugs commonly used in the care of patients after Trauma Brain Injury (TBI); particularly including sedatives, anticonvulsants and antibiotics. Data Sources: Computerized searches of OVID MEDLINE, OVID EMBASE, Cochrane Clinical Trials Register to August 2013 and hand searching of references of retrieved articles and proceedings of meetings; associated reference lists; and articles identified by experts in the field. Study Selection: Inclusion criteria were as follows: a) population- humans or animals undergoing therapeutic hypothermia b) design-prospective, randomized controlled trial, c) intervention-hypothermia; measurement of PD and PK of different drugs. Data Extraction: A data extraction form was used and authors (CB & SP) reviewed all trials. Data Synthesis: We reviewed 30 trials that documented changes in PD and PK of sedatives (propofol and midazolam), opioids (fentanyl, remifentanil, alfentil and morphine), anticonvulsants (phenytoin) and antibiotics (aminoglycosides) conducted in human or animal models undergoing therapeutic hypothermia. Conclusion: Data show that therapeutic hypothermia significantly alters the pharmacokinetics of commonly used agents. Particular care should be taken to reduce sedatives once target temperature is reached. Further clinical studies are required to clarify the effect of hypothermia on the PD and PK of therapeutic agents to optimize the benefits of therapeutic hypothermia in the treatment of TBI patients.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"56 1","pages":"31-38"},"PeriodicalIF":0.0,"publicationDate":"2013-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85572642","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-09-10DOI: 10.2174/1874828720130909001
J. Bracht
Background: Multimodality brain monitoring includes intracranial temperature (ICT) measurements. Different ICT readings have been reported from Licox ® and Hemedex ® systems used in the same patient with the Hummingbird ® "SynergyDuo Ventricular" introducer. Methods: To investigate the differences we report an analysis of causes for different ICT readings. In keeping with the radial brain ICT gradient model model we calculated ICTs according to the sensors' penetration depths and compared the results to clinical data from six patients. Results: The ICT accuracy is ±0.2°C for Licox ® and ±0.3°C for Hemedex ® so any ICT difference � ±0.5°C between the systems is not significant. The Hemedex ® -ICT sensor is placed 15.5mm deeper than the Licox ® -ICT sensor with the Hummingbird ® . The calculatedICT from the model range from -0.7°C to -1.0°C for a 37.5°C arterial temperature, and a 22°C ambient temperature. TheICT (ICTLicox ® - ICTHemedex ® ) in six patients were -0.6°C, SD = 0.7°C, median = -0.6°C, max = 0.4°C, min = -5.7°C, range 6.1°C. 41.1% of recorded data lie within the accuracy range of ±0.5°C. 53.8% lie within a range between -0.5°C and -1.5°C, and represent the differences which can be explained by different sensor insertion depths and the model. Only 5% were outliers withICT < -1.5°C. Conclusions: This study shows that the discrepancy in ICT measurements using different sensors can be explained by (a) the ICT measurement accuracies/specifications, and (b) different insertion depths. Other causes may include (c) environmental conditions and (d) unknown factors secondary to body - and/or brain physiology.
{"title":"Differences in Intracranial Temperature Measurements - A Systematic Analysis Between the Licox ® and Hemedex ® Systems","authors":"J. Bracht","doi":"10.2174/1874828720130909001","DOIUrl":"https://doi.org/10.2174/1874828720130909001","url":null,"abstract":"Background: Multimodality brain monitoring includes intracranial temperature (ICT) measurements. Different ICT readings have been reported from Licox ® and Hemedex ® systems used in the same patient with the Hummingbird ® \"SynergyDuo Ventricular\" introducer. Methods: To investigate the differences we report an analysis of causes for different ICT readings. In keeping with the radial brain ICT gradient model model we calculated ICTs according to the sensors' penetration depths and compared the results to clinical data from six patients. Results: The ICT accuracy is ±0.2°C for Licox ® and ±0.3°C for Hemedex ® so any ICT difference � ±0.5°C between the systems is not significant. The Hemedex ® -ICT sensor is placed 15.5mm deeper than the Licox ® -ICT sensor with the Hummingbird ® . The calculatedICT from the model range from -0.7°C to -1.0°C for a 37.5°C arterial temperature, and a 22°C ambient temperature. TheICT (ICTLicox ® - ICTHemedex ® ) in six patients were -0.6°C, SD = 0.7°C, median = -0.6°C, max = 0.4°C, min = -5.7°C, range 6.1°C. 41.1% of recorded data lie within the accuracy range of ±0.5°C. 53.8% lie within a range between -0.5°C and -1.5°C, and represent the differences which can be explained by different sensor insertion depths and the model. Only 5% were outliers withICT < -1.5°C. Conclusions: This study shows that the discrepancy in ICT measurements using different sensors can be explained by (a) the ICT measurement accuracies/specifications, and (b) different insertion depths. Other causes may include (c) environmental conditions and (d) unknown factors secondary to body - and/or brain physiology.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"3 1","pages":"0-0"},"PeriodicalIF":0.0,"publicationDate":"2013-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89266628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2013-05-17DOI: 10.2174/1874828701306010001
E. Lang, M. Jaeger
This review has been compiled to assess publications related to the clinical application of direct cerebral tissue oxygenation (pbtO2) monitoring published in international, peer-reviewed scientific journals, or major meeting reports published as journal supplements. Its goal was to extract relevant, i.e. positive and negative, information on indications, clinical application, safety issues and impact on clinical situations, as well as treatment strategies in neurosurgery, neurosurgical anaesthesiology, neurosurgical intensive care, neurology, and related specialties. For completeness' sake it also presents related basic science research and case reports. This review is an update of its previous edition published elsewhere in 2007. This review reflects publications from 2004 to 2012. Only relevant publications prior to 2004, which explicitly addressed or systematically examined the above issues, are included in this review and are listed in the reference section. Based on 349 citations it is the most comprehensive review available on direct cerebral oxygen monitoring to this date.
{"title":"Systematic and Comprehensive Literature Review of Publications on Direct Cerebral Oxygenation Monitoring","authors":"E. Lang, M. Jaeger","doi":"10.2174/1874828701306010001","DOIUrl":"https://doi.org/10.2174/1874828701306010001","url":null,"abstract":"This review has been compiled to assess publications related to the clinical application of direct cerebral tissue oxygenation (pbtO2) monitoring published in international, peer-reviewed scientific journals, or major meeting reports published as journal supplements. Its goal was to extract relevant, i.e. positive and negative, information on indications, clinical application, safety issues and impact on clinical situations, as well as treatment strategies in neurosurgery, neurosurgical anaesthesiology, neurosurgical intensive care, neurology, and related specialties. For completeness' sake it also presents related basic science research and case reports. This review is an update of its previous edition published elsewhere in 2007. This review reflects publications from 2004 to 2012. Only relevant publications prior to 2004, which explicitly addressed or systematically examined the above issues, are included in this review and are listed in the reference section. Based on 349 citations it is the most comprehensive review available on direct cerebral oxygen monitoring to this date.","PeriodicalId":88750,"journal":{"name":"The open critical care medicine journal","volume":"74 1","pages":"0-0"},"PeriodicalIF":0.0,"publicationDate":"2013-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79173275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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