Acute and Critical Care

Original Article

Cardiology
Diagnostic accuracy of left ventricular outflow tract velocity time integral versus inferior vena cava collapsibility index in predicting post-induction hypotension during general anesthesia: an observational study: Vibhuti Sharma, Arti Sharma, Arvind Sethi, Jyoti Pathania; Acute Crit Care. 2024;39(1):117-126. Published online February 23, 2024; DOI: https://doi.org/10.4266/acc.2023.00913

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Abstract PDF: Background
Point of care ultrasound (POCUS) is being explored for dynamic measurements like inferior vena cava collapsibility index (IVC-CI) and left ventricular outflow tract velocity time integral (LVOT-VTI) to guide anesthesiologists in predicting fluid responsiveness in the preoperative period and in treating post-induction hypotension (PIH) with varying accuracy. Methods: In this prospective, observational study on included 100 adult patients undergoing elective surgery under general anesthesia, the LVOT-VTI and IVC-CI measurements were performed in the preoperative room 15 minutes prior to surgery, and PIH was measured for 20 minutes in the post-induction period. Results: The incidence of PIH was 24%. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the two techniques at 95% confidence interval was 0.613, 30.4%, 93.3%, 58.3%, 81.4%, 73.6% for IVC-CI and 0.853, 83.3%, 80.3%, 57.1%, 93.8%, 77.4% for LVOT-VTI, respectively. In multivariate analysis, the cutoff value for IVC-CI was >51.5 and for LVOT-VTI it was ≤17.45 for predicting PIH with odd ratio [OR] of 8.491 (P=0.025) for IVCCI and OR of 17.427 (P<0.001) for LVOT. LVOT-VTI assessment was possible in all the patients, while 10% of patients were having poor window for IVC measurements. Conclusions: We recommend the use of POCUS using LVOT-VTI or IVC-CI to predict PIH, to decrease the morbidity of patients undergoing surgery. Out of these, we recommend LVOT-VTI measurements as it has showed a better diagnostic accuracy (77.4%) with no failure rate.

Case Reports

Pharmacology
Successful treatment of propofol-related infusion syndrome in critically ill patient receiving low-dose propofol infusion: a case report: Nahyeon Park, Tae Sun Ha; Acute Crit Care. 2023;38(1):144-148. Published online November 26, 2021; DOI: https://doi.org/10.4266/acc.2021.00829

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1 Crossref

Propofol is widely used to sedate agitated patients in intensive care units. However, it can cause a rare but fatal complication, propofol-related infusion syndrome (PRIS). The pathophysiology of PRIS is not clear, and there is no definitive diagnosis and treatment. We report a successfully treated case of PRIS in a critically ill patient receiving low-dose propofol infusion. A 59-year-old male patient complaining of sudden chest pain repeatedly collapsed in an ambulance and the emergency room, and veno-arterial extracorporeal membrane oxygenation was delivered. He was diagnosed with a total occluded left anterior descending coronary artery in coronary angiography. On day 20, he showed arrhythmia, increased creatinine kinase (CK), and increased CK-MB and troponin I, accompanied by unstable hemodynamic status despite high-dose vasopressors. He was administered propofol for 20 days at an average dose of 1.3 mg/kg/hr owing to issues with agitation and ventilator synchrony. We strongly suspected PRIS and immediately discontinued propofol infusion, and he was successfully treated with aggressive supportive care. PRIS can occur in patients administered propofol for a prolonged period at low doses. Thus, clinicians should use propofol with caution for PRIS and change to alternative sedatives for long-term sedation.

Citations

Citations to this article as recorded by

Propofol in ICU Settings: Understanding and Managing Anti-Arrhythmic, Pro-Arrhythmic Effects, and Propofol Infusion Syndrome
Jananthan Paramsothy, Sai Dheeraj Gutlapalli, Vijay Durga Pradeep Ganipineni, Isabelle Mulango, Ikpechukwu J Okorie, Divine Besong Arrey Agbor, Crystal Delp, Hanim Apple, Borislav Kheyson, Jay Nfonoyim, Nidal Isber, Mallikarjuna Yalamanchili
Cureus.2023;[Epub] CrossRef

Pharmacology
Green Urine after Propofol Infusion in the Intensive Care Unit: Min Jeong Lee, Hyun Jeong Lee, Jeong Min Kim, Shin Ok Koh, Eun Ho Kim, Sungwon Na; Korean J Crit Care Med. 2014;29(4):328-330. Published online November 30, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.4.328

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3 Crossref

Abstract PDF

Urine discoloration occurs in the intensive care unit (ICU) due to many causes such as medications, metabolic disorders, and infections. Propofol is advocated as one of the first line sedatives in the ICU, but it is not well known to the intensivists that propofol can induce urine color change. We experienced two cases of green urine after propofol infusion. Propofol should be warranted as the cause of urine discoloration during ICU stay.

Citations

Citations to this article as recorded by

An unusual instance of propofol-triggered green urine in anesthesia management: A case report
Madhusoodan M Gonenavar, Sudhanshu Shukla, Tejashree Sridhar, Rashmi Prasad, Rudresh Tabali
MGM Journal of Medical Sciences.2024; 11(1): 165. CrossRef
Propofol-Associated Urine Discoloration: Systematic Literature Review
Ana Lasica, Cinzia Cortesi, Gregorio P. Milani, Mario G. Bianchetti, Federica M. Schera, Pietro Camozzi, Sebastiano A.G. Lava
Pharmacology.2023; 108(5): 415. CrossRef
Green urine after general anesthesia with propofol: different responses in the same patient -A case report-
Go Eun Kim, Dae Yoon Kim, Doek Kyu Yoo, Jong-Hwan Lee, Sangmin Maria Lee, Jeong Jin Min
Anesthesia and Pain Medicine.2017; 12(1): 32. CrossRef

Propofol-Related Infusion Syndrome in an Adult Patient Using Propofol Coma Therapy to Control Intracranial Pressure: Sang Youn Park, Eu Gene Kim, Hee Pyoung Park; Korean J Crit Care Med. 2013;28(3):234-238.; DOI: https://doi.org/10.4266/kjccm.2013.28.3.234

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Abstract PDF

Propofol-related infusion syndrome (PRIS) is a rare but fatal complication. Unexplained metabolic acidosis, rhabdomyolysis, hyperkalemia, myocardial dysfunction, cardiovascular collapse and acute kidney injury are the main characteristics of PRIS. Herein, we report a case of PRIS in a neurosurgical adult patient, who had received high-dose propofol continuous infusion in order to control intracranial pressure in an intensive care unit. She manifested severe metabolic acidosis, rhabdomyolysis, acute kidney injury and myocardial dysfunction. As soon as PRIS was diagnosed, propofol infusion was stopped. Conservative treatments, such as vasopressors and inotropics, continuous renal replacement therapy and extracorporeal membrane oxygenation were used to treat PRIS. However, she finally expired. This case report suggests that a great caution to PRIS is needed in a situation with high-dose propofol continuous infusion.

Citations

Citations to this article as recorded by

Successful treatment of propofol-related infusion syndrome in critically ill patient receiving low-dose propofol infusion: a case report
Nahyeon Park, Tae Sun Ha
Acute and Critical Care.2023; 38(1): 144. CrossRef

Anesthetic Management of Whole-Lung Lavage Using Propofol-Remifentanil in a Patient with Pulmonary Alveolar Proteinosis: Ji Hyeon Lee, Chan Jong Chung, Ji Na Oh, Byung Ju Ko, So Ron Choi; Korean J Crit Care Med. 2012;27(3):173-178.; DOI: https://doi.org/10.4266/kjccm.2012.27.3.173

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Abstract PDF

Pulmonary alveolar proteinosis (PAP) is characterized by the progressive accumulation of phospholipids and proteins within the alveolar sacs without producing an inflammatory response. Whole-lung lavage (WLL) is performed as the standard therapy for this disease because it serves to wash out the proteinaceous material from the alveoli. In this case, we performed sequential WLL using propofol-remifentanil, which is not related to hypoxic pulmonary vasoconstriction during one-lung ventilation. The patient's symptoms and radiologic findings showed improvement without the occurrence of any specific complications. Therefore, we report a case of anesthetic management of WLL performed repeatedly for a patient with recurrent PAP.

Citations

Citations to this article as recorded by

Whole lung lavage using a rapid infusion system to treat a patient with pulmonary alveolar proteinosis
Seung Won Ra, Soon Eun Park, Hyung Kwan Lee, Il Sang Han, Se Hun Park
Yeungnam University Journal of Medicine.2020; 37(1): 67. CrossRef

Randomized Controlled Trial

The Analgesic Effect of Remifentanil on Propofol Injection Pain: Younghoon Jeon, Min Je Choi, Choon Hak Lim; Korean J Crit Care Med. 2011;26(4):212-216.; DOI: https://doi.org/10.4266/kjccm.2011.26.4.212

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Abstract PDF: BACKGROUND
Pain is a common side-effect of propofol injection. A remifentanil pretreatment has been reported to decrease the incidence and intensity of pain during a propofol injection and has been suggested to act through a central or peripheral effect. This trial was designed to explore the action site of remifentanil on reducing propofol injection pain, using the venous occlusion technique and a time interval between the applications of remifentanil and propofol.
METHODS
This randomized, double-blind study was designed to explore the action site of remifentanil on reducing propofol injection pain in 200 patients scheduled for elective surgery. The peripheral properties were examined using the venous occlusion technique for 30 s while a 1 min time interval between remifentanil and propofol injections was allowed for the central effect. Before the propofol injection, group A was pretreated with remifentanil (0.5 microg/ kg) with a venous occlusion, group B with remifentanil and a 1 min interval, and group C with remifentanil with a venous occlusion and a 1 min interval. Pain severity was assessed using a four-point scale.
RESULTS
40 patients (80%) complained of pain in the placebo group compared with 35 (70%) in group A, 20 (40%) in group B (p < 0.05) and 17 (34%) in group C (p < 0.05). The incidence and severity of propofol injection pain were lower in groups B and C than in group A (p < 0.05). However, there was no significant difference between groups B and C.
CONCLUSIONS
The remifentanil mediated analgesic effect occurs mainly through the central effect.

Original Articles

The Effect of Sevoflurane and Propofol on Expression of Inducible Nitric Oxide Synthase in Endotoxemic Rats: Cheul Hong Kim, Joo Hyeuk Park, Seung Hoon Baek, Seong Wan Baik; Korean J Crit Care Med. 2004;19(2):106-114.

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Abstract PDF: BACKGROUND
It is a well-known phenomenon that alveolar and peritoneal macrophages exposed to bacterial lipopolysaccharide (LPS) induce a large output of nitric oxide (NO) and an inducible nitric oxide synthase (iNOS) mRNA expression. The purpose of this study is actually how much NO production and iNOS mRAN expression are effected by anesthetics (sevoflurane and propofol) on endotoxemic rats.
METHODS
To examine the production of NO in peritoneal macrophages, NO concentration were measured from the rats following 2 hours exposure to LPS and 2 hours administration of sevoflurane and propofol, respectively. Culture supernatants were collected 24 hours after exposure to LPS and anesthetics and assayed by ELISA (Enzyme Linked Immunosorbent Assay) for production of NO. The iNOS mRNA expression was measured using PCR (Polymerase Chain Reaction) techniques and autoradiography. RESULTS: In the control group, the NO concentration was measured at 2 hours after infusion of LPS to rats, and showed 12 4micrometer. After insufflations of anesthetics to experimental animals, NO concentration increased in the sevoflurane and propofol groups, 37 13 (p<0.05) and 29 12micrometer (p<0.05) respectively. The size and brightness of the iNOS mRAN bands were distinct in sevoflurane and propofol in order.
CONCLUSIONS
There were no different in regard of NO production and hemodynamic changes but iNOS mRNA expression between sevoflurane and propofol group in endotoxemic rats. The mechanism is not clear, but it is related to the strong stimulating effects on the respiratory tract of inhalation anesthetics.

The Effects of Propofol on Blood-Brain Barrier Disruption with Mannitol Infusion in Cervical Sympathetic Nerve Blocked Rats: Jin Young Lee, Soo Han Yoon, Jae Hyung Kim, Yun Jeong Chae, Young Joo Lee, Jin Soo Kim, Bong Ki Moon; Korean J Crit Care Med. 2002;17(2):95-99.

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Abstract PDF: BACKGROUND
Blood brain barrier disruption (BBBD)increases therapeutic agents delivery to brain diseases.Increasing the delivery of therapeutic drugs to the brainimproves out come f or patients with brain tumors.Cervical sympathetic chain block can increase the degree of mannitol induced blood brain barrier disruption in rats.Anesthetic agents may modify hyperosmolar blood brain barrier disruption.Therefore we evaluated the effecfs of pentobarbital and propofol on mannitol induced blood brain barrier disruption(BBBD)in cervical sympathetic nerve blocked rats.
METHODS
14 male Sprague-Dawley rats were divided into 2 groups.Intravenous pentobarbital (group 1,n=7)and propofol (group 2,n=7)were administrated.Rats was blocked with 0.5% bupivacaine on right cervical sympathetic chain.All rats received 37degrees C,25%mannitol (1.75 g/kg) via right carotid artery.BBBD was estimated by Evans blue staining in cerebral hemisphere.
RESULTS
Both groups showed BBBD in right side hemisphere and there was no significant difference between group 1 and group 2 in right side hemisphere.
CONCLUSIONS
The results suggest that propofol could be used to be anesthetics for BBBD in cervical sympathetic blocked rats.

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