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Ozel ES, Kaya C, Turunc E, Ustun YB, Cebeci H, Dost B. Analgesic efficacy of the external oblique intercostal fascial plane block on postoperative acute pain in laparoscopic sleeve gastrectomy: a randomized controlled trial. Korean J Anesthesiol 2025; 78:159-170. [PMID: 39834021 PMCID: PMC12013990 DOI: 10.4097/kja.24569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Revised: 11/17/2024] [Accepted: 11/17/2024] [Indexed: 01/22/2025] Open
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) causes significant postoperative pain, necessitating effective multimodal analgesia strategies. This study evaluated the efficacy of the external oblique intercostal block (EOIB) in this context. METHODS This prospective, randomized, controlled, single-blind study conducted between April and December 2023 included 60 patients who underwent LSG. Patients were divided into the EOIB (30 ml 0.25% bupivacaine/side) and control (no block) groups. The primary outcome was the cumulative intravenous morphine milligram equivalent (MME) consumption in the first 24 h postoperatively. Secondary outcomes included 12-h MME consumption, pain scores, intraoperative remifentanil use, rescue analgesia requirements, time to first analgesic request, nausea/vomiting scores, antiemetic use, and American Pain Society Patient Outcome Questionnaire-Revised Turkish Version (APS-POQ-R-TR) scores. RESULTS The control group had significantly higher median opioid consumption than the EOIB group at 12 (14.4 vs. 5.8 mg; P < 0.001) and 24 h (25.9 vs. 10.6 mg; P < 0.001) postoperatively. The need for rescue analgesics did not differ significantly (43.3 vs. 23.3%; P = 0.1). The EOIB group exhibited significantly higher patient satisfaction (APS-POQ-R-TR score 2.91 vs. 4.42; P < 0.001) and consistently lower pain scores across all time points (P < 0.001). The EOIB group had lower nausea/vomiting scores (P < 0.001), fewer patients requiring antiemetics (16.7% vs. 40%; P = 0.045), longer time to first morphine request (57.5 vs. 25 min; P < 0.001), and lower remifentanil use (850 vs. 1050 μg; P < 0.001). CONCLUSIONS The preoperative EOIB, as a part of multimodal analgesia, provides effective analgesia for acute pain in patients undergoing LSG.
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Affiliation(s)
- Elif Sarikaya Ozel
- Department of Anesthesiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Cengiz Kaya
- Department of Anesthesiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Esra Turunc
- Department of Anesthesiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Yasemin B. Ustun
- Department of Anesthesiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Halil Cebeci
- Department of Anesthesiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Burhan Dost
- Department of Anesthesiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
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2
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Castro-Balado A, Varela-Rey I, Mejuto B, Mondelo-García C, Zarra-Ferro I, Rodríguez-Jato T, Fernández-Ferreiro A. Updated antimicrobial dosing recommendations for obese patients. Antimicrob Agents Chemother 2024; 68:e0171923. [PMID: 38526051 PMCID: PMC11064535 DOI: 10.1128/aac.01719-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
The prevalence of obesity has increased considerably in the last few decades. Pathophysiological changes in obese patients lead to pharmacokinetic (PK) and pharmacodynamic (PD) alterations that can condition the correct exposure to antimicrobials if standard dosages are used. Inadequate dosing in obese patients can lead to toxicity or therapeutic failure. In recent years, additional antimicrobial PK/PD data, extended infusion strategies, and studies in critically ill patients have made it possible to obtain data to provide a better dosage in obese patients. Despite this, it is usually difficult to find information on drug dosing in this population, which is sometimes contradictory. This is a comprehensive review of the dosing of different types of antimicrobials (antibiotics, antifungals, antivirals, and antituberculosis drugs) in obese patients, where the literature on PK and possible dosing strategies in obese adults was critically assessed.
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Affiliation(s)
- Ana Castro-Balado
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Iria Varela-Rey
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Beatriz Mejuto
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
| | - Cristina Mondelo-García
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Irene Zarra-Ferro
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Teresa Rodríguez-Jato
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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3
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Crow J, Lindsley J, Cho SM, Wang J, Lantry JH, Kim BS, Tahsili-Fahadan P. Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J 2022; 68:1419-1427. [PMID: 35593878 PMCID: PMC9675878 DOI: 10.1097/mat.0000000000001758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly utilized intervention for cardiopulmonary failure. Analgosedation during ECMO support is essential to ensure adequate pain and agitation control and ventilator synchrony, optimize ECMO support, facilitate patient assessment, and minimize adverse events. Although the principles of analgosedation are likely similar for all critically ill patients, ECMO circuitry alters medication pharmacodynamics and pharmacokinetics. The lack of clinical guidelines for analgosedation during ECMO, especially at times of medication shortage, can affect patient management. Here, we review pharmacological considerations, protocols, and special considerations for analgosedation in critically ill adults receiving ECMO support.
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Affiliation(s)
- Jessica Crow
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - John Lindsley
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jing Wang
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - James H Lantry
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - Bo S. Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pouya Tahsili-Fahadan
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
- Department of Medical Education, University of Virginia, Inova Fairfax Medical Campus, Falls Church, VA
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4
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Xu KY, Li D, Hu ZJ, Zhao CC, Bai J, Du WL. Vancomycin dosing in an obese patient with acute renal failure: A case report and review of literature. World J Clin Cases 2022; 10:6218-6226. [PMID: 35949852 PMCID: PMC9254177 DOI: 10.12998/wjcc.v10.i18.6218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/19/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vancomycin is the most commonly used drug for methicillin-resistant Staphylococcus aureus. The empirical clinical doses of vancomycin based on non-obese patients may not be optimal for obese ones.
CASE SUMMARY This study reports a case of vancomycin dosing adjustment in an obese patient (body mass index 78.4 kg/m2) with necrotizing fasciitis of the scrotum and left lower extremity accompanied with acute renal failure. Dosing adjustment was performed based on literature review and factors that influence pharmacokinetic parameters are analyzed. The results of the blood drug concentration monitoring confirmed the successful application of our dosing adjustment strategy in this obese patient. Total body weight is an important consideration for vancomycin administration in obese patients, which affects the volume of distribution and clearance of vancomycin. The alterations of pharmacokinetic parameters dictate that vancomycin should be dose-adjusted when applied to obese patients. At the same time, the pathophysiological status of patients, such as renal function, which also affects the dose adjustment of the patient, should be considered.
CONCLUSION Monitoring vancomycin blood levels in obese patients is critical to help adjust the dosing regimen to ensure that vancomycin concentrations are within the effective therapeutic range and to reduce the incidence of renal injury.
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Affiliation(s)
- Kun-Yan Xu
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Dan Li
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Cong-Cong Zhao
- Department of Intensive Care Unit, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Jing Bai
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Wen-Li Du
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
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5
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Seyni-Boureima R, Zhang Z, Antoine MMLK, Antoine-Frank CD. A review on the anesthetic management of obese patients undergoing surgery. BMC Anesthesiol 2022; 22:98. [PMID: 35382771 PMCID: PMC8985303 DOI: 10.1186/s12871-022-01579-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/27/2022] [Indexed: 12/01/2022] Open
Abstract
There has been an observed increase in theprevalence of obesity over the past few decades. The prevalence of anesthesiology related complications is also observed more frequently in obese patients as compared to patients that are not obese. Due to the increased complications that accompany obesity, obese patients are now more often requiring surgical interventions. Therefore, it is important that anesthesiologists be aware of this development and is equipped to manage these patients effectively and appropriately. As a result, this review highlights the effective management of obese patients undergoing surgery focusing on the preoperative, perioperative and postoperative care of these patients.
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Affiliation(s)
- Rimanatou Seyni-Boureima
- Department of Anaesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China
| | - Zongze Zhang
- Department of Anaesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China.
| | - Malyn M L K Antoine
- Department of Endocrinology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China
| | - Chrystal D Antoine-Frank
- Department of Anatomical Sciences, St. George's University, True Blue,Grand Anse, West Indies, St. George, Grenada
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Management of Neuromuscular Blockade in the Elderly and Morbidly Obese Patient: What Does the Data Show? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00375-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Hussain Z, Gadd K, Curtain C, Mirkazemi C, Peterson GM, R Zaidi ST. Anaesthetists' drug dosing practices in class III obese surgical patients: A bi-national survey. Anaesth Intensive Care 2019; 47:516-521. [PMID: 31752498 DOI: 10.1177/0310057x19886596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Class III obese (body mass index ≥ 40 kg/m2) patients, now regularly encountered clinically, have increased perioperative risks, including potentially from suboptimal drug dosing. However, current dosing guidelines are based on low-level evidence and may not be widely accepted. This study aimed to investigate anaesthetists’ dosing practices for class III obese surgical patients, explore if they had experienced an increased incidence of adverse events potentially related to drug dosing with these patients and assess which resources they consulted for dosing advice in this population. An electronic survey was emailed to 1000 randomly selected members of the Australian and New Zealand College of Anaesthetists. Data were summarised and the Pearson’s χ2 test was used to compare respondents’ genders, geographic locations and seniority designations with the greater Australian and New Zealand College of Anaesthetists’ membership. There were 230 completed responses (response rate 23%). A large proportion (46%–76%) of respondents indicated they dose class III obese patients in keeping with current recommendations; however, substantial heterogeneity in dosing practices was found. Lean body weight was the most frequently used regimen for dosing propofol, non-depolarising muscle relaxants, sugammadex and opioids, whereas total body weight was most frequently used for suxamethonium. Nearly 70% of respondents reported using at least one resource to assist their dosing practices in obesity. Importantly, increased incidences of adverse events in class III obese patients related to drug dosing were commonly experienced by respondents. Until higher-level evidence is available for dosing class III obese patients, anaesthetists should consider current recommendations and exercise increased attention to dosing. Further clinician education may assist in optimising dosing in this patient group.
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Affiliation(s)
- Zahid Hussain
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia.,Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Karl Gadd
- Department of Anaesthesia, Launceston General Hospital, Tasmania, Australia.,Anaesthesia Discipline Lead, Launceston Clinical School, University of Tasmania, Tasmania, Australia
| | - Colin Curtain
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia
| | - Corinne Mirkazemi
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia
| | - Gregory M Peterson
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia.,Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Syed Tabish R Zaidi
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia.,School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,National Institute for Health Research Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
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8
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Verkerk BS, Dzierba AL, Muir J, Der-Nigoghossian C, Brodie D, Bacchetta M, Rietdijk W, Bakker J. Opioid and Benzodiazepine Requirements in Obese Adult Patients Receiving Extracorporeal Membrane Oxygenation. Ann Pharmacother 2019; 54:144-150. [DOI: 10.1177/1060028019872940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The use of extracorporeal membrane oxygenation (ECMO) sometimes requires deep levels of sedation (Richmond Agitation Sedation Scale [RASS] −5) in patients with acute respiratory distress syndrome (ARDS). The role of obesity in opioid and sedative requirements remains unclear in patients receiving ECMO. Objective: This study sought to determine whether obesity increases midazolam and opioid requirements in patients receiving venovenous (vv)-ECMO up to the first 7 days after initiation. Methods: This was a retrospective cohort study of adult patients with ARDS managed with vv-ECMO. Results: The obese (n = 38) and nonobese (n = 43) groups had similar baseline characteristics. Fentanyl equivalents were significantly higher on day 3 in the obese group ( P = 0.02) despite similar RASS scores with no differences in midazolam requirements. There were no differences in duration of ECMO, length of stay, or mortality. Conclusion and Relevance: Daily midazolam requirements were not significantly different, and opioid requirements were only significantly higher in the obese group on day 3 despite similar levels of sedation. The impact of obesity with the addition of ECMO and how to adapt doses of medications remains elusive.
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Affiliation(s)
| | | | - Justin Muir
- NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Daniel Brodie
- NewYork-Presbyterian Hospital, New York, NY, USA
- Columbia College of Physicians and Surgeons, New York, NY, USA
| | | | - Wim Rietdijk
- University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jan Bakker
- Columbia College of Physicians and Surgeons, New York, NY, USA
- University Medical Center Rotterdam, Rotterdam, Netherlands
- NYU Langone Department of Pulmonology and Critical Care, USA
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9
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Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients: A Systematic Review of Clinical Studies. Clin Drug Investig 2018; 38:673-693. [DOI: 10.1007/s40261-018-0662-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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10
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Araújo AM, Machado HS, Falcão AC, Soares-da-Silva P. Reliability of body-weight scalars on the assessment of propofol induction dose in obese patients. Acta Anaesthesiol Scand 2018; 62:464-473. [PMID: 29159892 DOI: 10.1111/aas.13039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Obese patients require specific perioperative care when compared with non-obese patients. The present study aimed to analyse the ability of size descriptors to estimate propofol induction dose in class II and III obese patients. METHODS A cross-sectional study on adult patients with body mass index (BMI) equal to or greater than 35 kg/m2 and on adult patients with BMI lower than 35 kg/m2 was carried out. General anaesthesia was induced with remifentanil, propofol and rocuronium. Propofol infusion was started at 2000 mg/h until loss of consciousness. Bioelectrical impedance analysis and Brice modified interview was completed during pre- and post-operative evaluation, respectively. Measurements of propofol plasma concentration were performed using gas chromatography/ion trap-mass spectrometry. RESULTS Forty patients were enrolled in the study. The median values of fat free mass (FFM) in BMI < 35 kg/m2 and BMI ≥ 35 kg/m2 groups were 70% and 55% of total body weight, respectively. Our results did not demonstrate a strong correlation level between the studied size descriptors and propofol induction dose in both groups. Nevertheless, when propofol doses were normalized by FFM, an apparent convergence of the empirical cumulative distribution functions was observed. CONCLUSION None of the size descriptors was seen to be an effective predictor of the propofol induction dose in class II and III obese patients when a fixed infusion rate was used. Due to the observed variability between patients, guiding propofol induction dose against a clinical endpoint of unconsciousness appears more appropriate in order to avoid side effects related both with under or overdosing of propofol.
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Affiliation(s)
- A. M. Araújo
- Department of Anesthesiology, Intensive Care and Emergency; Centro Hospitalar do Porto; Porto Portugal
| | - H. S. Machado
- Department of Anesthesiology, Intensive Care and Emergency; Centro Hospitalar do Porto; Porto Portugal
- Instituto de Ciências Biomédicas Abel Salazar; University of Porto; Porto Portugal
| | - A. C. Falcão
- Laboratory of Pharmacology; Faculty of Pharmacy; University of Coimbra; Coimbra Portugal
| | - P. Soares-da-Silva
- Department of Biomedicine; Unit of Pharmacology and Therapeutics; Faculty of Medicine; University of Porto; Porto Portugal
- MedInUP; Center for Drug Discovery and Innovative Medicines; University of Porto; Porto Portugal
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11
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Chidambaran V, Tewari A, Mahmoud M. Anesthetic and pharmacologic considerations in perioperative care of obese children. J Clin Anesth 2018; 45:39-50. [DOI: 10.1016/j.jclinane.2017.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
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12
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Meng L, Mui E, Holubar MK, Deresinski SC. Comprehensive Guidance for Antibiotic Dosing in Obese Adults. Pharmacotherapy 2017; 37:1415-1431. [DOI: 10.1002/phar.2023] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lina Meng
- Department of Pharmacy; Stanford Health Care; Stanford California
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
| | - Emily Mui
- Department of Pharmacy; Stanford Health Care; Stanford California
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
| | - Marisa K. Holubar
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
- Division of Infectious Diseases and Geographic Medicine; Stanford University School of Medicine; Stanford California
| | - Stan C. Deresinski
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
- Division of Infectious Diseases and Geographic Medicine; Stanford University School of Medicine; Stanford California
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13
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Clinical pharmacology of anti-angiogenic drugs in oncology. Crit Rev Oncol Hematol 2017; 119:75-93. [PMID: 28916378 DOI: 10.1016/j.critrevonc.2017.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/23/2017] [Accepted: 08/29/2017] [Indexed: 12/14/2022] Open
Abstract
Abnormal vasculature proliferation is one of the so-called hallmarks of cancer. Angiogenesis inhibitor therapies are one of the major breakthroughs in cancer treatment in the last two decades. Two types of anti-angiogenics have been approved: monoclonal antibodies and derivatives, which are injected and target the extracellular part of a receptor, and protein kinase inhibitors, which are orally taken small molecules targeting the intra-cellular Adenosine Triphosphate -pocket of different kinases. They have become an important part of some tumors' treatment, both in monotherapy or in combination. In this review, we discuss the key pharmacological concepts and the major pitfalls of anti-angiogenic prescriptions. We also review the pharmacokinetic and pharmacodynamics profile of all approved anti-angiogenic protein kinase inhibitors and the potential role of surrogate markers and of therapeutic drug monitoring.
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14
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Abstract
Propofol is an intravenous agent used commonly for the induction and maintenance of anesthesia, procedural, and critical care sedation in children. The mechanisms of action on the central nervous system involve interactions at various neurotransmitter receptors, especially the gamma-aminobutyric acid A receptor. Approved for use in the USA by the Food and Drug Administration in 1989, its use for induction of anesthesia in children less than 3 years of age still remains off-label. Despite its wide use in pediatric anesthesia, there is conflicting literature about its safety and serious adverse effects in particular subsets of children. Particularly as children are not "little adults", in this review, we emphasize the maturational aspects of propofol pharmacokinetics. Despite the myriad of propofol pharmacokinetic-pharmacodynamic studies and the ability to use allometrical scaling to smooth out differences due to size and age, there is no optimal model that can be used in target controlled infusion pumps for providing closed loop total intravenous anesthesia in children. As the commercial formulation of propofol is a nutrient-rich emulsion, the risk for bacterial contamination exists despite the Food and Drug Administration mandating addition of antimicrobial preservative, calling for manufacturers' directions to discard open vials after 6 h. While propofol has advantages over inhalation anesthesia such as less postoperative nausea and emergence delirium in children, pain on injection remains a problem even with newer formulations. Propofol is known to depress mitochondrial function by its action as an uncoupling agent in oxidative phosphorylation. This has implications for children with mitochondrial diseases and the occurrence of propofol-related infusion syndrome, a rare but seriously life-threatening complication of propofol. At the time of this review, there is no direct evidence in humans for propofol-induced neurotoxicity to the infant brain; however, current concerns of neuroapoptosis in developing brains induced by propofol persist and continue to be a focus of research.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH, 45229, USA,
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15
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Friesen JHP. Lean Body Weight Is Not a Weight Scalar for Estimating Drug Doses in Morbid Obesity. Obes Surg 2015; 25:1496-7. [DOI: 10.1007/s11695-015-1758-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Joshi SB, Upadhyaya KV, Manjuladevi M. Comparison of neostigmine induced reversal of vecuronium in normal weight, overweight and obese female patients. Indian J Anaesth 2015; 59:165-70. [PMID: 25838588 PMCID: PMC4378077 DOI: 10.4103/0019-5049.153038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Obese patients are more vulnerable to residual neuromuscular block (NMB) and its associated complications in the post-operative period. This study was carried out to compare neostigmine induced reversal of vecuronium in normal weight, overweight and obese female patients, objectively using neuromuscular (NM) monitoring. Methods: Twenty female patients each belonging to normal weight, overweight and obese, based on body mass index, requiring general anaesthesia were recruited for this prospective cross sectional study. NMB was induced with vecuronium (0.1 mg/kg) dose based on patient's real body weight (RBW) and monitored using acceleromyographic train of four (TOF). All patients received neostigmine 40 μg/kg and glycopyrrolate 10 μg/kg at 25% of spontaneous recovery of first twitch height (T1) of TOF (DUR 25%) and were allowed to recover to TOF ratio of 0.9. Statistical analysis was done using analysis of variance test. Results: Recovery of TOF ratio to 0.5 was comparable in all three groups. Recovery of TOF ratio to 0.7 was delayed in obese (9.82 ± 3.21 min) compared with normal weight group (7.50 ± 2.52 min). Recovery of TOF to 0.9 was significantly delayed in both overweight (12.18 ± 4.29 min) and obese patients (13.78 ± 4.30 min). DUR 25% was significantly longer in overweight (mean, standard deviation [range]; 30.10 [19–40 min]) and obese (28.8 [12–45 min]) compared with normal weight patients (22.75 [16–30 min]). Conclusion: In overweight and obese patients, when vecuronium induction dose is based on RBW, neostigmine induced recovery of NMB is delayed in late phases (TOF 0.7-0.9), which may result in vulnerability for associated complications of incomplete recovery. Ensuring safe recovery thus requires objective NM monitoring.
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Affiliation(s)
- Shilpa Bhimasen Joshi
- Department of Anaesthesiology and Critical Care, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Ks Vasudeva Upadhyaya
- Department of Anaesthesiology and Critical Care, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - M Manjuladevi
- Department of Anaesthesiology and Critical Care, St John's Medical College and Hospital, Bengaluru, Karnataka, India
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Lean-scaled weight can be used to estimate blood volume for obese patients. Can J Anaesth 2014; 61:1059-60. [PMID: 25091297 DOI: 10.1007/s12630-014-0218-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 07/18/2014] [Indexed: 10/24/2022] Open
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