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Tracheal intubation is a high-stakes, life-saving procedure commonly performed in intensive care units (ICUs). However, it carries significant risks, especially in critically ill patients who already suffer from physiological derangements like hypoxemia and hypotension. The choice of induction agent can greatly influence patient outcomes. A recent review by Kotani et al. (Crit Care Med., 2025) examines the pharmacological properties, clinical implications, and comparative safety profiles of commonly used induction agents, including propofol, etomidate, ketamine, midazolam, and thiopental. Why induction agent choice matters Critically ill patients are vulnerable to: Hypotension (up to 43% post-intubation) Hypoxemia (9%) Cardiac arrest (3%) Studies show that post-induction hypotension is linked to higher ICU and 28-day mortality. Therefore, minimizing hemodynamic instability is critical. Pharmacological profiles and clinical effects 1. Propofol Mechanism: GABA receptor agonist Effects: Rapid sedation Myocardial depression and vasodilation Risks: High rate of cardiovascular instability Greater blood pressure drops in elderly or hypovolemic patients 2. Etomidate Mechanism: GABA-A receptor agonist Effects: Hemodynamic stability Risks: Adrenal suppression (lasting hours to days) Potential increased mortality 3. Ketamine Mechanism: NMDA receptor antagonist Effects: Sympathetic stimulation (↑HR, ↑BP) Maintains airway reflexes and spontaneous breathing Bronchodilation (beneficial in asthma) Side effects: Hallucinations Hypersalivation 4. Midazolam Mechanism: GABA receptor agonist Effects: Sedation and amnesia Risks: Dose-related hypotension Delirium Use: Often adjunct to other agents 5. Thiopental Mechanism: Barbiturate acting on the GABA receptor Risks: Hypotension, bronchospasm, immunosuppression Status: Rarely used today Combination therapy Fentanyl: Used for pain, may increase hypotension risk. Ketofol (ketamine + propofol): Balances hemodynamic effects Favorable profile in some studies, but lacks standard dosing protocols. Emerging evidence and clinical guidelines Key studies INTUBE study: Propofol linked to cardiovascular instability. Matchett et al. (Intensive Care Med. 2022): Higher 7-day mortality with etomidate vs. ketamine (23% vs. 15%). Meta-analysis: Etomidate is associated with increased mortality risk. Guidelines Difficult Airway […]
June 9, 2025
Chronic lower back pain (CLBP) remains a prevalent and often debilitating condition impacting millions globally. Despite multiple treatment options, many patients continue to struggle with persistent pain, reduced functionality, and heavy reliance on opioids. Lumbar facet joint arthropathy, a major contributor to CLBP, has seen promising therapeutic interventions with radiofrequency ablation (RFA). However, until recently, the optimal temperature for achieving sustained relief with RFA has remained unclear. A new randomized, double-blinded clinical trial led by researchers at the Cleveland Clinic sheds vital light on this issue. By comparing outcomes of RFA performed at 80°C versus 90°C, the study offers compelling evidence that higher temperatures deliver longer-lasting pain relief without additional risks. This discovery could influence the future of spinal interventional medicine. What is lumbar facetogenic back pain? Lumbar facetogenic pain arises from the facet joints, which are small stabilizing joints in the back of the spine. These joints can degenerate over time or due to injury, leading to inflammation, joint dysfunction, and pain. The condition is: Common in adults over 50 Associated with prolonged standing or spinal extension Frequently localized without radiating to the leg Understanding radiofrequency ablation (RFA) RFA is a minimally invasive outpatient procedure targeting pain-carrying nerves. Under fluoroscopic guidance, a radiofrequency probe is inserted to apply controlled thermal energy to the medial branch nerves, disrupting their ability to transmit pain signals. Key goals of RFA: Reduce pain intensity Improve mobility and function Minimize the need for opioids Historically, temperatures for RFA have varied between 70°C and 90°C, with no consensus on the most effective setting. This study fills a critical knowledge gap by directly comparing outcomes at 80°C and 90°C. Study methodology and patient profile The trial enrolled 144 patients with unilateral CLBP due to confirmed lumbar facet joint arthropathy. Inclusion criteria: Adults aged 18 and older […]
June 6, 2025
Surgical procedures in patients with chronic kidney disease (CKD) present unique challenges, particularly concerning anesthetic management. Neuromuscular blocking agents (NMBAs) are essential in modern anesthesia, but their pharmacokinetics can be drastically altered in patients with impaired renal function. A study published in the May 2025 issue of Anesthesia & Analgesia by Georgakis et al. analyzed the comparative safety profiles of two widely used NMBAs, rocuronium and cisatracurium, in patients with CKD. This research is the first large-scale retrospective analysis to explore this topic, offering essential insights for anesthesiologists and perioperative care teams. The role of NMBAs in anesthesia Neuromuscular blocking agents are vital for: Facilitating smooth endotracheal intubation Enhancing mechanical ventilation Ensuring muscle relaxation for optimal surgical conditions There are two main categories of NMBAs: Depolarizing agents (e.g., succinylcholine) Non-depolarizing agents (e.g., rocuronium, cisatracurium) Non-depolarizing NMBAs are preferred due to fewer severe side effects. However, they differ in how the body metabolizes and excretes them, a critical consideration in CKD. Study objectives and design Objective To determine whether rocuronium (with sugammadex) poses a higher risk of acute complications in CKD patients compared to cisatracurium (with neostigmine). Methods Data Source: TriNetX database (over 93 million patients) Study period: April 2004 – April 2024 Study type: Retrospective observational study Population: CKD patients aged 18–80 years Cohorts: Cohort A: Rocuronium + sugammadex Cohort B: Cisatracurium + neostigmine Matching criteria Demographics: Age, sex, ethnicity, race Comorbidities: Atherosclerosis, COPD, pulmonary fibrosis, cardiomyopathy, peripheral vascular disease CKD stages 1–5 and end-stage renal disease (ESRD) Key findings After propensity matching: Each cohort included 10,675 patients Cohort A (rocuronium group) showed significantly higher risks for multiple adverse outcomes: Respiratory failure Acute respiratory distress Hypertensive crisis Heart failure Pleural effusion 30-day mortality Other outcomes, like cardiac arrhythmias and acute kidney injury, did not show significant differences. Pharmacological comparison: rocuronium […]
June 5, 2025
