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Purpose The aim of this Intensive Care Medicine Rapid Practice Guideline (ICMâRPG) was to formulate evidenceâbased guidance for the use of dexmedetomidine for sedation in invasively mechanically ventilated adults in the intensive care unit (ICU). Methods We adhered to the methodology for trustworthy clinical practice guidelines, including use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and the Evidence-to-Decision framework to generate recommendations. The guideline panel comprised 28 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. Through teleconferences and webâbased discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, feasibility, acceptability, and research priorities. Results The ICMâRPG panel issued one weak recommendation (suggestion) based on overall moderate certainty of evidence: 'In invasively mechanically ventilated adult ICU patients, we suggest using dexmedetomidine over other sedative agents, if the desirable effects including a reduction in delirium are valued over the undesirable effects including an increase in hypotension and bradycardia'. Conclusion This ICM-RPG provides updated evidence-based guidance on the use of dexmedetomidine for sedation in mechanically ventilated adults, and outlines uncertainties and research priorities., Author(s): Morten H. Møller [sup.1], Waleed Alhazzani [sup.2] [sup.3], Kimberley Lewis [sup.2], Emilie Belley-Cote [sup.4], Anders Granholm [sup.1], John Centofanti [sup.5], William B. McIntyre [sup.6] [sup.7], Jessica Spence [sup.3] [sup.8], [...]

Purpose We investigated whether preoperative inflammatory markers, i.e., the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), and platelet distribution width (PDW) can predict the development of postoperative delirium (POD) after esophagectomy. Patients and methods This single-center, retrospective, observational study included 110 patients who underwent an esophagectomy. We assigned the patients with the Intensive Care Delirium Screening Checklist score [greater than or equal to] 4 to the POD group. We performed multivariable logistic regression analyses to determine whether the NLR, PLR, MPV, and PDW can be used to predict the development of POD. Results The POD group had 20 patients; the non-POD group included the other 90 patients. Although only the preoperative NLR in the POD group was significantly higher than in the non-POD group (3.20 [2.52-4.30] vs. 2.05 [1.45-3.02], p = 0.001), multivariable logistic regression analyses showed that the following three parameters were independent predictors of POD: preoperative NLR [greater than or equal to] 2.45 (adjusted odds ratio [aOR]: 8.68, 95%CI 2.33-32.4, p = 0.001), MPV [greater than or equal to] 10.4 (aOR: 3.93, 95%CI: 1.37-11.2, p = 0.011), and PDW [greater than or equal to] 11.8 (aOR: 3.58, 95%CI: 1.22-10.5, p = 0.020). Conclusion Our analysis results demonstrated that preoperative NLR [greater than or equal to] 2.45, MPV [greater than or equal to] 10.4, and PDW [greater than or equal to] 11.8 were significantly associated with a higher risk of POD after adjustment for possible confounding factors. However, as the AUCs of the preoperative MPV and PDW for the prediction of the development of POD in univariable ROC analyses were low, large prospective studies are needed to confirm this result., Author(s): Tasuku Oyama [sup.1], Hirotaka Kinoshita [sup.1], Daiki Takekawa [sup.1], Junichi Saito [sup.1], Tetsuya Kushikata [sup.1], Kazuyoshi Hirota [sup.1] Author Affiliations: (1) grid.257016.7, 0000 0001 0673 6172, Department of Anesthesiology, [...]

Author(s): Naohiro Shioji [sup.1] [sup.2], Tobias Everett [sup.3], Yasuyuki Suzuki [sup.4], Kazuyoshi Aoyama [sup.3] [sup.5] Author Affiliations: (1) grid.17063.33, 0000 0001 2157 2938, Department of Critical Care Medicine, The Hospital [...]

Purpose In this retrospective study, we compared inhaled sedation with isoflurane to intravenous propofol in invasively ventilated COVID-19 patients with ARDS (Acute Respiratory Distress Syndrome). Methods Charts of all 20 patients with COVID-19 ARDS admitted to the ICU of a German University Hospital during the first wave of the pandemic between 22/03/2020 and 21/04/2020 were reviewed. Among screened 333 days, isoflurane was used in 97 days, while in 187 days, propofol was used for 12 h or more. The effect and dose of these two sedatives were compared. Mixed sedation days were excluded. Results Patients' age (median [interquartile range]) was 64 (60-68) years. They were invasively ventilated for 36 [21-50] days. End-tidal isoflurane concentrations were high (0.96 ± 0.41 Vol %); multiple linear regression yielded the ratio (isoflurane infusion rate)/(minute ventilation) as the single best predictor. Infusion rates were decreased under ECMO (3.5 ± 1.4 versus 7.1 ± 3.2 ml*h.sup.-1; p < 0.001). In five patients, the maximum recommended dose of propofol of 4 mg*hour.sup.-1*kg.sup.-1ABW was exceeded on several days. On isoflurane compared to propofol days, neuro-muscular blocking agents (NMBAs) were used less frequently (11% versus 21%; p < 0.05), as were co-sedatives (7% versus 31%, p < 0.001); daily opioid doses were lower (720 [720-960] versus 1080 [720-1620] mg morphine equivalents, p < 0.001); and RASS scores indicated deeper levels of sedation (- 4.0 [- 4.0 to - 3.0] versus - 3.0 [- 3.6 to - 2.5]; p < 0.01). Conclusion Isoflurane provided sufficient sedation with less NMBAs, less polypharmacy and lower opioid doses compared to propofol. High doses of both drugs were needed in severely ill COVID-19 patients., Author(s): Azzeddine Kermad [sup.1], Jacques Speltz [sup.1], Guy Danziger [sup.2], Thilo Mertke [sup.1], Robert Bals [sup.2], Thomas Volk [sup.1], Philipp M. Lepper [sup.2], Andreas Meiser [sup.1] Author Affiliations: (1) grid.411937.9, [...]

The usefulness and safety of continuous glucose monitoring (CGM) systems in adult patients with severe coronavirus disease (COVID-19) have been reported. Using CGM might reduce the exposure patients and healthcare workers to COVID-19 and limit the use of personal protective equipment during the pandemic. CGM devices measure glucose in the subcutaneous interstitial fluid, but the accuracy of this technique has not been established in critically ill patients. The artificial pancreas, STG-55 (Nikkiso, Tokyo), is a closed-loop device that conducts continuous blood glucose monitoring using a peripheral vein. We used the STG-55 for glucose control in a 60-year-old woman with severe COVID-19 admitted to the intensive care unit. Due to severe respiratory failure, the patient was intubated, and extracorporeal membrane oxygenation was introduced. Because she had hyperglycemia despite high-dose intravenous insulin therapy, we decided to use STG-55 for glucose control. The STG-55 safely titrated the insulin infusion and monitored glucose levels. Fifty-six hours after adopting the STG-55, it was removed because the blood sampling failed. No episodes of hypoglycemia were observed despite deep sedation during this period. In conclusion, this case demonstrates the potential utility of an artificial pancreas in patients with severe COVID-19., Author(s): Takuya Hinoue [sup.1], Tomoaki Yatabe [sup.2], Himuro Fujiwara [sup.1], Osamu Nishida [sup.1] Author Affiliations: (1) grid.256115.4, 0000 0004 1761 798X, Department of Anesthesiology and Critical Care Medicine, Fujita Health [...]

Background Several anesthetic agents are used in cesarean sections for both regional and general anesthesia purposes. However, there are no data comparing the in vivo effects of propofol, sevoflurane, and dexmedetomidine on the contraction of the myometrium in pregnant rats. The aim of this study was to investigate the effect of these anesthetic agents on myometrial contraction and elucidate the underlying mechanisms. Methods Contraction force and frequency changes in response to propofol, dexmedetomidine, or sevoflurane were evaluated in vivo and in vitro. To test the effect of arachidonic acid on myometrial contraction enhanced by dexmedetomidine, changes in myometrial contraction with dexmedetomidine after administration of indomethacin were evaluated. The amount of phosphorylated myosin phosphatase target subunit 1 (MYPT1) in the membrane fraction was expressed as a percentage of the total fraction by Western blot analysis. Results This study demonstrated that dexmedetomidine enhances oxytocin-induced contraction in the myometrium of pregnant rats, whereas propofol and sevoflurane attenuate these contractions. The dexmedetomidine-induced enhancement of myometrial contraction force was abolished by the administration of indomethacin. Propofol did not affect oxytocin-induced MYPT1 phosphorylation, whereas sevoflurane attenuated oxytocin-induced MYPT1 phosphorylation. Conclusions Inhibition of myofilament calcium sensitivity may underlie the inhibition of myometrial contraction induced by sevoflurane. Arachidonic acid may play an important role in the enhancement of myometrial contraction induced by dexmedetomidine by increasing myofilament calcium sensitivity. Dexmedetomidine may be used as a sedative agent to promote uterine muscle contraction and suppress bleeding after fetal delivery., Author(s): Motonobu Kimizuka [sup.1], Yasuyuki Tokinaga [sup.1], Ryu Azumaguchi [sup.1], Kosuke Hamada [sup.1], Satoshi Kazuma [sup.1], Michiaki Yamakage [sup.1] Author Affiliations: (1) grid.263171.0, 0000 0001 0691 0855, Department of Anesthesiology, [...]

Even though several studies have demonstrated the effectiveness of opioid free anesthesia (OFA) strategies in pediatric patients, OFA has not been studied in pediatric renal surgery. We, therefore, conducted a prospective observational pilot study on a total of 26 children to assess the feasibility and efficacy of using a single injection ultrasound-guided paravertebral block (PVB) at T10 level with 0.4 mL/kg bupivacaine 0.25% in combination with sevoflurane as an OFA technique in elective open renal surgery. A successful PVB (defined in terms of both hemodynamic change after the skin incision and the use of rescue analgesia) was observed in 25 children (96%). The interval between PVB and skin incision was 21 min [IQR (18-25)]. End tidal sevoflurane concentration was 2.1% [IQR (1.8-2.4)]. The median time between extubation and waking was 2.5 min [IQR (1-4)]. The median Face, Legs, Activity, cry, Consolability score in post-anesthesia care unit was 1.00 [IQR (0-2)]. Blood pressure falls were not significant at different measurement times. None of the patients had complications related to PVB, and only one patient had post-operative vomiting. PVB is an attractive method that can procure an effective OFA in combination with sevoflurane in pediatric renal surgery., Author(s): Abdelghafour Elkoundi [sup.1], Aziza Bentalha [sup.1], Yasser Asmai [sup.1], Alae El koraichi [sup.1] Author Affiliations: (1) grid.31143.34, 0000 0001 2168 4024, Pediatric Anesthesia and Critical Care Department, Children Hospital [...]

Purpose We assessed the prevalence and variables associated with haloperidol use for delirium in ICU patients and explored any associations of haloperidol use with 90-day mortality. Methods All acutely admitted, adult ICU patients were screened during a 2-week inception period. We followed the patient throughout their ICU stay and assessed 90-day mortality. We assessed patients and their variables in the first 24 and 72 h in ICU and studied their association together with that of ICU characteristics with haloperidol use. Results We included 1260 patients from 99 ICUs in 13 countries. Delirium occurred in 314/1260 patients [25% (95% confidence interval 23-27)] of whom 145 received haloperidol [46% (41-52)]. Other interventions for delirium were benzodiazepines in 36% (31-42), dexmedetomidine in 21% (17-26), quetiapine in 19% (14-23) and olanzapine in 9% (6-12) of the patients with delirium. In the first 24 h in the ICU, all subtypes of delirium [hyperactive, adjusted odds ratio (aOR) 29.7 (12.9-74.5); mixed 10.0 (5.0-20.2); hypoactive 3.0 (1.2-6.7)] and circulatory support 2.7 (1.7-4.3) were associated with haloperidol use. At 72 h after ICU admission, circulatory support remained associated with subsequent use of haloperidol, aOR 2.6 (1.1-6.9). Haloperidol use within 0-24 h and within 0-72 h of ICU admission was not associated with 90-day mortality [aOR 1.2 (0.5-2.5); p = 0.66] and [aOR 1.9 (1.0-3.9); p = 0.07], respectively. Conclusions In our study, haloperidol was the main pharmacological agent used for delirium in adult patients regardless of delirium subtype. Benzodiazepines, other anti-psychotics and dexmedetomidine were other frequently used agents. Haloperidol use was not statistically significantly associated with increased 90-day mortality., Author(s): Marie O. Collet [sup.1] [sup.2], Jesús Caballero [sup.3], Romain Sonneville [sup.4] [sup.5], Fernando A. Bozza [sup.6], Peter Nydahl [sup.7] [sup.8], Anna Schandl [sup.9], Hilden Wøien [sup.10], Giuseppe Citerio [sup.11], [...]

Byline: Rajeev. Chauhan, Ankur. Luthra, Sameer. Sethi, Nidhi. Panda, Shyam. Meena, Vikas. Bhatia, Summit. Bloria Aim: Sodium tetradecyl sulfate (STS) sclerotherapy in pediatric patients is usually undertaken under sedation inside [...]

Author(s): Jonas P. DeMuro [sup.1], David G. Botros [sup.1], Ela Wirkowski [sup.2], Adel F. Hanna [sup.1] Author Affiliations: (1) grid.281603.e, 000000010228085X, Division of Trauma and Critical Care, Department of Surgery, [...], Alcohol withdrawal syndrome (AWS) continues to be a challenge to manage in the ICU setting, and the ideal pharmacological treatment continues to evolve. Dexmedetomidine is a newer agent approved for short-term sedation in the ICU, but its use in the treatment of AWS has been limited. We report a retrospective case series of ten patients who were identified as receiving dexmedetomidine for AWS as designated by electronic pharmacy records. All subjects were male, with a mean age of 53.6 years, and a mean ICU length of stay of 9.3 days. They were all diagnosed with AWS by DSM-IV criteria. All the study patients received dexmedetomidine during their hospital course as a treatment for AWS. Studied variables included demographic data, dose and duration of dexmedetomidine, other pharmaceutical agents, and hemodynamics. Dexmedetomidine was safe to use in all patients, although mechanical ventilation was still required in three patients. With dexmedetomidine, the autonomic hyperactivity was blunted, with a mean 12.8 % reduction in rate pressure product observed. Consideration should be given to the combined use of dexmedetomidine with benzodiazepines in the treatment of AWS.