ASA levels of sedation.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"9173",leadTitle:null,fullTitle:"Moving Broadband Mobile Communications Forward - Intelligent Technologies for 5G and Beyond",title:"Moving Broadband Mobile Communications Forward",subtitle:"Intelligent Technologies for 5G and Beyond",reviewType:"peer-reviewed",abstract:"The deployment of 4G/LTE (Long-Term Evolution) mobile networks has solved the major challenge of high capacities to build a real broadband mobile internet. This was possible mainly through a very strong physical layer and flexible network architecture. However, bandwidth-hungry services such as virtual reality (VR) and augmented reality (AR), have been developed in an unprecedented way. Furthermore, mobile networks are facing other new services with extreme demand for greater reliability and almost zero-latency performance, like vehicle communications and the Internet of Vehicles (IoV). Therefore, industries and researchers are investigating new physical layers and softwarization techniques and including more intelligence in 5G and beyond 5G (B5G/6G). This book discusses some of these softwarization techniques, such as fog computing, cloud computing, and artificial intelligence (AI) and machine learning (ML). It also presents use cases showing practical aspects from 5G deployment scenarios, where other communications technologies will co-habit to build the landscape of next-generation mobile networks (NGMNs).",isbn:"978-1-83962-344-8",printIsbn:"978-1-83962-343-1",pdfIsbn:"978-1-83962-345-5",doi:"10.5772/intechopen.83169",price:119,priceEur:129,priceUsd:155,slug:"moving-broadband-mobile-communications-forward-intelligent-technologies-for-5g-and-beyond",numberOfPages:146,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"650198e6e9da2a9a52d8e67b63ccd832",bookSignature:"Abdelfatteh Haidine",publishedDate:"August 18th 2021",coverURL:"https://cdn.intechopen.com/books/images_new/9173.jpg",numberOfDownloads:4717,numberOfWosCitations:0,numberOfCrossrefCitations:4,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:12,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:16,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 25th 2019",dateEndSecondStepPublish:"March 27th 2020",dateEndThirdStepPublish:"May 26th 2020",dateEndFourthStepPublish:"August 14th 2020",dateEndFifthStepPublish:"October 13th 2020",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"187242",title:"Dr.",name:"Abdelfatteh",middleName:null,surname:"Haidine",slug:"abdelfatteh-haidine",fullName:"Abdelfatteh Haidine",profilePictureURL:"https://mts.intechopen.com/storage/users/187242/images/system/187242.jpg",biography:"Dr.Ing. Abdelfatteh Haidine received his Ph.D. in 2008 from the Technische Universität Dresden, Germany, with a focus on the planning and optimization of telecommunications networks. He worked as a consultant and manager for the deployment of smart metering systems and smart grid applications.\n\nCurrently, he is a professor for wireless/mobile communications and intelligent systems with the Laboratory of Information Technologies, National School of Applied Sciences, Morocco. His research interests include different issues related to Machine-to-Machine (M2M) and Internet-of-Things (IoT) communications, networking technologies for smart domains: smart maritime port, smart city and smart grid applications, and so on. This covers LPWA networks and their techno-economical aspects. Dr. Haidine also deals with the application of combinatorial optimization as well as the Game Theory paradigm in network planning/migration and resources allocation in broadband mobile networks. In addition, he investigates artificial intelligence and machine learning in optimization procedures/paradigms.",institutionString:"National School of Applied Sciences",position:null,outsideEditionCount:null,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"2",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"541",title:"Wireless Communication System",slug:"communications-and-security-wireless-communication-system"}],chapters:[{id:"77006",title:"Trends in Cloud Computing Paradigms: Fundamental Issues, Recent Advances, and Research Directions toward 6G Fog Networks",doi:"10.5772/intechopen.98315",slug:"trends-in-cloud-computing-paradigms-fundamental-issues-recent-advances-and-research-directions-towar",totalDownloads:320,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"There has been significant research interest in various computing-based paradigms such as cloud computing, Internet of Things, fog computing, and edge computing, due to their various associated advantages. In this chapter, we present a comprehensive review of these architectures and their associated concepts. Moreover, we consider different enable technologies that facilitate computing paradigm evolution. In this context, we focus mainly on fog computing considering its related fundamental issues and recent advances. Besides, we present further research directions toward the sixth generation fog computing paradigm.",signatures:"Isiaka A. Alimi, Romil K. Patel, Aziza Zaouga, Nelson J. Muga, Qin Xin, Armando N. Pinto and Paulo P. Monteiro",downloadPdfUrl:"/chapter/pdf-download/77006",previewPdfUrl:"/chapter/pdf-preview/77006",authors:[{id:"208236",title:"Dr.",name:"Isiaka",surname:"Alimi",slug:"isiaka-alimi",fullName:"Isiaka Alimi"},{id:"419218",title:"Dr.",name:"Romil K.",surname:"Patel",slug:"romil-k.-patel",fullName:"Romil K. Patel"},{id:"419219",title:"Dr.",name:"Aziza",surname:"Zaouga",slug:"aziza-zaouga",fullName:"Aziza Zaouga"},{id:"419220",title:"Dr.",name:"Nelson J.",surname:"Muga",slug:"nelson-j.-muga",fullName:"Nelson J. Muga"},{id:"419221",title:"Dr.",name:"Qin",surname:"Xin",slug:"qin-xin",fullName:"Qin Xin"},{id:"419222",title:"Dr.",name:"Armando N.",surname:"Pinto",slug:"armando-n.-pinto",fullName:"Armando N. Pinto"},{id:"419223",title:"Dr.",name:"Paulo P.",surname:"Monteiro",slug:"paulo-p.-monteiro",fullName:"Paulo P. Monteiro"}],corrections:null},{id:"71376",title:"Low-Latency Strategies for Service Migration in Fog Computing Enabled Cellular Networks",doi:"10.5772/intechopen.91439",slug:"low-latency-strategies-for-service-migration-in-fog-computing-enabled-cellular-networks",totalDownloads:585,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"This chapter presents a fog computing enabled cellular network (FeCN), in which the high user-mobility feature brings critical challenges for service continuity under stringent service requirements. Service migration is promising to fulfill the service continuity during mobility. However, service migration cannot be completed immediately and may lead to situations where the user-experience degrades. For this, a quality-of-service aware service migration strategy is proposed. The method is based on existing handover procedures with newly introduced distributed fog computing resource management scheme to minimize the potential negative effects induced by service migration. The performance of the proposed schemes is evaluated by a case study, where realistic vehicular mobility pattern in the metropolitan network of Luxembourg is used. Results show that low end-to-end latency for vehicular communication can be achieved. During service migration, both the traffic generated by migration and the other traffic (e.g., control information, video) are transmitted via mobile backhaul networks. To balance the performance of the two kinds of traffic, a delay-aware bandwidth slicing scheme is proposed. Simulation results show that, with the proposed method, migration data can be transmitted successfully within a required time threshold, while the latency and jitter for nonmigration traffic with different priorities can be reduced significantly.",signatures:"Jun Li, Xiaoman Shen, Lei Chen and Jiajia Chen",downloadPdfUrl:"/chapter/pdf-download/71376",previewPdfUrl:"/chapter/pdf-preview/71376",authors:[{id:"313110",title:"Dr.",name:"Lei",surname:"Chen",slug:"lei-chen",fullName:"Lei Chen"},{id:"313111",title:"Prof.",name:"Jiajia",surname:"Chen",slug:"jiajia-chen",fullName:"Jiajia Chen"},{id:"313112",title:"Dr.",name:"Jun",surname:"Li",slug:"jun-li",fullName:"Jun Li"},{id:"316559",title:"Dr.",name:"Xiaoman",surname:"Shen",slug:"xiaoman-shen",fullName:"Xiaoman Shen"}],corrections:null},{id:"77411",title:"Artificial Intelligence and Machine Learning in 5G and beyond: A Survey and Perspectives",doi:"10.5772/intechopen.98517",slug:"artificial-intelligence-and-machine-learning-in-5g-and-beyond-a-survey-and-perspectives",totalDownloads:589,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The deployment of 4G/LTE (Long Term Evolution) mobile network has solved the major challenge of high capacities, to build real broadband mobile Internet. This was possible mainly through very strong physical layer and flexible network architecture. However, the bandwidth hungry services have been developed in unprecedented way, such as virtual reality (VR), augmented reality (AR), etc. Furthermore, mobile networks are facing other new services with extremely demand of higher reliability and almost zero-latency performance, like vehicle communications or Internet-of-Vehicles (IoV). Using new radio interface based on massive MIMO, 5G has overcame some of these challenges. In addition, the adoption of software defend networks (SDN) and network function virtualization (NFV) has added a higher degree of flexibility allowing the operators to support very demanding services from different vertical markets. However, network operators are forced to consider a higher level of intelligence in their networks, in order to deeply and accurately learn the operating environment and users behaviors and needs. It is also important to forecast their evolution to build a pro-actively and efficiently (self-) updatable network. In this chapter, we describe the role of artificial intelligence and machine learning in 5G and beyond, to build cost-effective and adaptable performing next generation mobile network. Some practical use cases of AI/ML in network life cycle are discussed.",signatures:"Abdelfatteh Haidine, Fatima Zahra Salmam, Abdelhak Aqqal and Aziz Dahbi",downloadPdfUrl:"/chapter/pdf-download/77411",previewPdfUrl:"/chapter/pdf-preview/77411",authors:[{id:"187242",title:"Dr.",name:"Abdelfatteh",surname:"Haidine",slug:"abdelfatteh-haidine",fullName:"Abdelfatteh Haidine"},{id:"209714",title:"Dr.",name:"Abdelhak",surname:"Aqqal",slug:"abdelhak-aqqal",fullName:"Abdelhak Aqqal"},{id:"346723",title:"Dr.",name:"Salmam",surname:"Fatima Zahra",slug:"salmam-fatima-zahra",fullName:"Salmam Fatima Zahra"},{id:"346724",title:"Dr.",name:"Aziz",surname:"Dahbi",slug:"aziz-dahbi",fullName:"Aziz Dahbi"}],corrections:null},{id:"71476",title:"A Brief Overview of CRC Implementation for 5G NR",doi:"10.5772/intechopen.91790",slug:"a-brief-overview-of-crc-implementation-for-5g-nr",totalDownloads:764,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"In fifth generation (5G) new radio (NR), the medium access control (MAC) layer organizes the data into the transport block and transmits it to the physical layer. The transport block consists of up to million bits. When the transport block size exceeds a threshold, the transport block is divided into multiple equal size code blocks. The code block consists of up to 8448 bits. Both the transport block and the code block have a cyclic redundancy check (CRC) attached. Due to the difference in the size of the transport block and the code block, the CRC processing scheme suitable for the transport block and that suitable for the code block are different. This chapter gives an overview of the CRC implementation in 5G NR.",signatures:"Hao Wu",downloadPdfUrl:"/chapter/pdf-download/71476",previewPdfUrl:"/chapter/pdf-preview/71476",authors:[{id:"312541",title:"Mr.",name:"Hao",surname:"Wu",slug:"hao-wu",fullName:"Hao Wu"}],corrections:null},{id:"70821",title:"Prospects of 5G Satellite Networks Development",doi:"10.5772/intechopen.90943",slug:"prospects-of-5g-satellite-networks-development",totalDownloads:1482,totalCrossrefCites:4,totalDimensionsCites:6,hasAltmetrics:1,abstract:"In the future, 5G networks will represent the global telecommunication infrastructure of the digital economy, which should cover the whole world including inaccessible areas not covered by 5G terrestrial networks. Given this, the satellite segment of 5G networks becomes one of the pressing issues of development and standardization at the second stage of 5G networks development in the period 2020–2025. The requirements for 5G satellite network will be determined primarily by combination of key services supported by 5G networks, which are combined by three basic business models of 5G terrestrial networks: enhanced Mobile Broadband Access (eMBB), Massive Internet of Things connections (mIoT), and Ultra-reliable low-latency communication (uRLLC). 3GPP as leading international standards body has identified several use cases and scenarios of 5G satellite networks development. 5G satellite networks are understood to mean networks in which the NG-RAN radio access network is constructed using a satellite network technology. The chapter has discussed the spectral and technological aspects of 5G satellite network developments, issues of architecture and role of delays on quality of services of 5G satellite segment, and possibility of constructing a 5G satellite segment based on distributed and centralized gNB base stations. The issues of satellite payload utilization have considered for bent-pipe and on-board processing technologies in 5G satellite segment.",signatures:"Valery Tikhvinskiy and Victor Koval",downloadPdfUrl:"/chapter/pdf-download/70821",previewPdfUrl:"/chapter/pdf-preview/70821",authors:[{id:"305314",title:"Prof.",name:"Valery",surname:"Tikhvinskiy",slug:"valery-tikhvinskiy",fullName:"Valery Tikhvinskiy"},{id:"316696",title:"Dr.",name:"Victor",surname:"Koval",slug:"victor-koval",fullName:"Victor Koval"}],corrections:null},{id:"72121",title:"An LTE-Direct-Based Communication System for Safety Services in Vehicular Networks",doi:"10.5772/intechopen.91948",slug:"an-lte-direct-based-communication-system-for-safety-services-in-vehicular-networks",totalDownloads:816,totalCrossrefCites:0,totalDimensionsCites:3,hasAltmetrics:0,abstract:"With the expected introduction of fully autonomous vehicles, the long-term evolution (LTE)-based vehicle-to-everything (V2X) networking approach is gaining a lot of industry attention, to develop new strategies to enhance safety and telematics features. The vehicular and wireless industries are currently considering the development of an LTE-based system, which may co-exist, with the IEEE 802.11p-based systems for some time. In light of the above fact, our objective is to investigate the development of LTE Proximity Service (ProSe)-based V2X architecture for time-critical vehicular safety applications in an efficient and cost-effective manner. In this chapter, we present a new cluster-based LTE sidelink-based vehicle-to-vehicle (V2V) multicast/broadcast architecture to satisfy the latency and reliability requirements of V2V safety applications. Our proposed architecture combines a new ProSe discovery mechanism for sidelink peer discovery and a cluster-based round-robin scheduling technique to distribute the sidelink radio resources among the cluster members. Utilizing an OMNET++ based simulation model, the performance of the proposed network architecture is examined. Results of the simulation show that the proposed algorithms diminish the end-to-end delay and overhead signaling as well as improve the data packet delivery ratio (DPDR) compared with the existing 3GPP ProSe vehicle safety application technique.",signatures:"Shashank Kumar Gupta, Jamil Yusuf Khan and Duy Trong Ngo",downloadPdfUrl:"/chapter/pdf-download/72121",previewPdfUrl:"/chapter/pdf-preview/72121",authors:[{id:"2898",title:"Dr.",name:"Jamil Y.",surname:"Khan",slug:"jamil-y.-khan",fullName:"Jamil Y. Khan"},{id:"313099",title:"Ph.D.",name:"Shashank Kumar",surname:"Gupta",slug:"shashank-kumar-gupta",fullName:"Shashank Kumar Gupta"},{id:"313579",title:"Dr.",name:"Duy T.",surname:"Ngo",slug:"duy-t.-ngo",fullName:"Duy T. Ngo"}],corrections:null},{id:"77600",title:"Healthcare Application-Oriented Non-Lambertian Optical Wireless Communications for B5G&6G",doi:"10.5772/intechopen.98275",slug:"healthcare-application-oriented-non-lambertian-optical-wireless-communications-for-b5g-6g",totalDownloads:163,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"With the continuous improvement of user communication requirements and the rapid development of information services, optical wireless communication (OWC), which has unlimited bandwidth and precise positioning, is widely used in indoor scenes such as healthcare. For healthcare monitoring application, the optical wireless (OW) link using non-Lambertian emission pattern is investigated in the typical mobility scenario. Numerical results show that the potential gain could been provided by the concerned emission pattern to the OW performance uniformity.",signatures:"Jupeng Ding, I. 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\r\n\tSjögren’s syndrome is an autoimmune disease with a still unclear etiopathogenesis, diagnostic criteria being subject to a long-lasting discussion and new treatment methods being sought for. Epidemiological data indicate that Sjögren’s syndrome occurrence is not as rare as it is commonly perceived – yet the underestimation of its prevalence leads to the delay in diagnosis and relatively late referral of patients to rheumatologists. The disease takes various forms ranging from mild symptoms of dry eye or mouth to severe organ lesions. Such a situation requires the implementation of diverse therapeutical approaches, which may include methods as different as the symptomatic dryness treatment and the use of immunosuppressive drugs and biological molecules. The planned publication is devoted entirely to Sjögren's syndrome and aims at bringing together the most important aspects of the disease, useful for both researchers and clinicians. We welcome the participation of specialists of different fields in this project - especially immunologists, geneticists, pathophysiologists and clinical rheumatologists – so it will be possible to include chapters covering all topics essential for the presentation of the comprehensive knowledge of Sjögren’s syndrome. Once again, I encourage you to send your suggestions on chapter subjects! Taking part in this venture, which is a part of a book series devoted to rheumatic diseases and rheumatology, is important for spreading the knowledge of this vastly underestimated problem.
",isbn:null,printIsbn:"979-953-307-X-X",pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"b9bf08d92cab01eb43586d6c8f90ae7e",bookSignature:"Dr. Maria Maślińska",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9609.jpg",keywords:"Sjögren's Syndrome, Epidemiology, Epigenetic Factors, Pathogenesis, Classification Criteria, Dryness Assessment, Respiratory Tract, Cardiovascular System, Symptomatic Treatment, Immunosuppressant, Novel Autoantibodies, New Therapies",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 7th 2019",dateEndSecondStepPublish:"November 28th 2019",dateEndThirdStepPublish:"January 27th 2020",dateEndFourthStepPublish:"April 16th 2020",dateEndFifthStepPublish:"June 15th 2020",remainingDaysToSecondStep:"2 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"77007",title:"Dr.",name:"Maria",middleName:null,surname:"Maślińska",slug:"maria-maslinska",fullName:"Maria Maślińska",profilePictureURL:"https://mts.intechopen.com/storage/users/77007/images/system/77007.png",biography:"Maria Maślińska is the Deputy Head of the Early Arthritis Clinic of the Eleonora Reicher National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw; the Deputy Editor-in-chief of the Reumatologia journal of the Polish Society for Rheumatology. She is the member of the editorial boards of: the 'Autoimmune Diseases and therapeutic Approaches: Open Acess” (Aperito Online Publishing) and the Reumatologia News (Termedia). \nPrevious and current research projects: 'Unclassified arthritis”; 'Spondyloarthropathies” (Eleonora Reicher National Institute of Geriatrics, Rheumatology and Rehabilitation research projects) ; 'The influence of B cells on the clinical picture of the primary Sjögren’s disease – the immunohistochemical and serological assessment, the profile of cytokines regulating activity of these cells” (National Science Centre Grant no 2012/05 / N / NZ5 /838), the laureate of the Third Degree Group Award of the Rector of the Medical University of Warsaw for the scientific achievements in the field of the research related to the pathomechanism of inflammation and a member of the Polish Society for Rheumatology and of the Polish Union of the Physician-Writers. She authored and co-authored a number of scientific publications and gave lecturers at numerous courses, seminars and conferences for general practitioners and rheumatologists.\nHer fields of special interests include all aspects of primary Sjögren’s syndrome, early arthritis.",institutionString:"National Institute of Geriatric, Rheumatology and Rehabilitation",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"National Institute of Geriatrics, Rheumatology and Rehabilitation",institutionURL:null,country:{name:"Poland"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"297737",firstName:"Mateo",lastName:"Pulko",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/297737/images/8492_n.png",email:"mateo.p@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"7099",title:"Chronic Autoimmune Epithelitis",subtitle:"Sjogren's Syndrome and Other Autoimmune Diseases of the Exocrine Glands",isOpenForSubmission:!1,hash:"9f4f8334c0cc376a9b3022e256e847f2",slug:"chronic-autoimmune-epithelitis-sjogren-s-syndrome-and-other-autoimmune-diseases-of-the-exocrine-glands",bookSignature:"Maria Maślińska",coverURL:"https://cdn.intechopen.com/books/images_new/7099.jpg",editedByType:"Edited by",editors:[{id:"77007",title:"Dr.",name:"Maria",surname:"Maślińska",slug:"maria-maslinska",fullName:"Maria Maślińska"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. 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These compounds are the most effective catalysts of cationic polymerization of metalorganic monomers. Explanation of initiative action of such systems is very complicated because of their complex structure as well as contaminations in the reaction mixture.
Formation of active site is the main process in all initialization reactions (including metalorganic Lewis acid action). The process of interaction of vinyl monomers with metalorganic Lewis acid (MLA) consists of several equilibrium stages [1], such as formation of active charged particles and their counter ions and subsequent addition of the charged pair to the monomer. The initial equilibrium is usually slow process while the further attack of the monomer (initialization) is very fast and is comparable with the rate of the reaction of chain growth. Moreover, presence of the cationogenic contaminations in the reaction mixture causes a lot of confusion to chemistry of cationic processes. Now we can consider more or less confidently only two possible ways of initialization of polymerization of vinyl monomers by MLA: direct initialization and co-initialization [2-5].
During co-initialization the charged particles are formed as e result of bimolecular reaction or heterolytic decomposition of a molecule:
where SR – cationogen (H2O, HHal, R-Hal, etc.).
After injection of cationogen into the last stage the complexing between the monomer and MLA is completing; and initialization in this case consists in the cationogen attack on the complex:
The π-complex can cause the initialization if it is transformed to isomeric carbenium ion:
Such regrouping is possible if the electronic density of the double bond is small. Therefore, the heightened electronic density of the double bond of asymmetric substituted alkenes has to decrease significantly at interaction with MLA.
MLA can be divided into 2 types. The first type is presented by MLA of B and Al who has no d-electrons in the valence sphere of the central atom. The second one consists of compounds containing heavier atoms with d-electrons. Usage of MLA of the 2nd type makes possible formation of the π-complex from monomer and its further interaction due to overlapping of full d-orbitals of MLA and empty antibonding orbitals of vinyl monomer. Such interactions strengthen the complex and complicate transformation into the carbenium ions because of increasing the electron density of the double bond.
Thus, to start the initialization process it is usually necessary presence of cation donor. Role of MLA consists in assistance to cationogen to form the initiating particle by the way of complexing [6]. According to Ref. [7] MLA allows stabilizing and removing the anion; and initialization is caused by cationogen who is a principal initializer while MLA is only co-initializer.
A mechanism of initialization by alkylhalogenides is the most studied now. Role of R-Hal was cleared on the example of styrene polymerization because intermediate carbenium ion of styrene is rather stable [8]:
Efficiency of the initialization reaction (1.2) depends on stability of the carbenium ion and its availability. According to equation (1.1) the initialization has to be favored by R-Hal (or Ar-Hal) having low bond dissociation energies and low ionization potentials of alkyl groups [9,10] as well as by solvatation of the formed ions [11]. In the case of R-Hal producing primary or secondary carbonium ions (e.g., n-butylchloride or isopropylchloride) the direct reaction is not observed. If such very active ions can be formed they have to initiate styrene polymerization and produce comparatively stable styrene cations:
Tret-butylchloride forms rather stable tertiary carbonium cation. However, it is less stable as compared with styrene cation; that is why fast initialization takes place. In contrast, triphenylchloromethane forms very stable tret-cation which cannot cause styrene polymerization [9]. Thus, carbonium ion has to be less stable as compared with styrene cation, but not very unstable to exclude its formation from R-Hal and MLA.
Application of suitable R-Hal and Ar-Hal (together with MLA co-initiators) gives opportunity to control the initialization process [12,13]. In this case a type of alkylhalogenide influences structure of head group of the polymer:
Now it is known a great number of cationogens which can efficiently initiate cationic polymerization of vinyl monomers and ensure production of polymers with certain head group.
In the case of absence of cation donors (e.g., at high pure conditions) other mechanisms of initialization of polymerization of vinyl monomers may be realizes under the action of MLA. For example, if the monomer contains allyl hydrogen tearing off hydride-ion from the monomer may be one of possible ways of initialization [14]:
The formation of the metal-carbon bonds in the polymer can occur in various ways:
Direct conjunction of MLA to the double bond of monomer followed ejection of cationogen and the formation of complex counter ion [15]
The requirement of initiation according to the scheme 1 is a possibility of formation of cationogen at zwitterionic decay; according to scheme 2 – the presence of a polar solvent or electron-donating compounds such as ethers, thioethers, tertiary amines, etc. MLA easily adds such compounds forming a rather stable complexes [19]. Such complexes usually have a composition of 1:1. The NMR study of complexation of organoaluminum compounds with methylpyridine (D) in solutions of 1,2-dichloroethane and dichloromethane showed, that the solution may contain the following complex compounds [20]:
The presence in the solution structures of type A is also confirmed by determination of electrical conductivity.
By Wittig [21], one of the possible states of the MCL in the solutions are structures of
or
Such MLA ionization is characteristic not only for the individual MLA, but also for their mixtures. It was found that polymerization of butadiene in the presence of alkylaluminum-cobalt initiators is the most affective only in the presence of ion-pair Et2AI+EtCI3AI–. This ion pair is formed by mixing either AIEt2CI with AIEtCl2, or AlEt3 with AlCI3 [6]:
At present, the mechanism of the formation of MCL self-ionization ion pair is widespread [4, 23]. However, the equilibrium constant for the reaction
Is much lower than in the case of interaction of MLA with a suitable donor of cations. For example:
In this case a more stable carbonium ion is formed. Therefore, in order to a direct initiation we need to create conditions for guarantee the complete absence of cationogen impurities in the system. Only in this case MLA themselves can play a role of initiators.
Nevertheless, the polymerization of highly active monomers by initiation of the MCL self-ionization is possible. One of these monomers is a 9-vinylcarbazole (VC), it is very easy polymerizing for cationic mechanism [24−26]. Authors of Ref. [27] showed that the rate of chain growth in cationic polymerization of VC under the action of stable organic cations in more than 100 times higher than the corresponding value for vinyl ethers.
Authors [28] studied kinetics of polymerization of VC in toluene solution under the action of titanium tetrachloride by thermometric method [29-33] and found that the polymerization process begins with the formation of complex compounds TiCl4 with 1-6 solvent molecules forming the solvation shell. It was established that complex formation is accompanied by a large thermal effect, which is reflected in the curve recorded a sharp jump in temperature at the initial time of polymerization. Since the system contains monomer (VC) with a developed system of π-electrons, the latter one competes with toluene and partially displaces it from the solvation shell of TiCl4. As a result of new resolvation a complex compound of a rather complex structure is formed where the vinyl bond of the monomer is partially polarized. This facilitates the subsequent process of opening the double bond and leads to increasing reactivity of the monomer.
The active particle is formed by the further polarization of the monomer vinyl bond in the solvation shell of titanium tetrachloride. This is followed by the accession of the last one to the monomer double bond forming the corresponding ion (direct initiation). Direct connection TiCl4 to monomer is confirmed by data of X-ray fluorescence analysis of the polymer samples. Diffractogram shows that the polymer contains a small amount of titanium chloride as terminal groups (Fig. 1).
X-ray Fluorescence Spectrum of the sample Polyvinylcarbazole obtained under the action of TiCl4 in toluene solution
Concentration of active sites may increase during the slower stage; it causes S-shaped kinetic curves. The chain growth on contact or separated ionic pairs is the most probable mechanism of the polymerization in the studied system. It is confirmed by permanency of the chain growth constant depending on the initial concentration of the initiator.
Initialization of the monomer polymerization by the way of ionization of complex Lewis acids can be illustrated by oligomerization of dicyclopentadiene (DCPD) under the action of catalytic system TiCl4 : Et2AlCl [34–35]. This catalyst (similar to individual TiCl4 [30]) causes process of cationic polymerization of DCPD. Lower value of
In both cases dicyclopentadiene polymerization goes according to the following mechanism:
Firstly, active complex (solvated ion pair) is formed as a result of self-ionization of Lewis acids:
Also, we can suppose formation of π-complex (I) MLA with cyclopentadiene which is present at the system in small amount:
Then sandwich-complex is formed (II):
Complex equilibrium during initialization may be completed by regrouping the π-complex to σ-complex and isomer carbonium ion or by transformation of the sandwich-complex to semi-sandwich-complex (I):
Then the reaction is also completed by regrouping the π-complex to σ-complex and isomer carbonium ion. Further chain growth occurs using one of two unsaturated bonds of DCPD – norbornene or cyclopentene [36].
In the case of initiation of olygomerization of vinyltoluene by TiCl4 the active particle is formed due to further polarization of vinyl bond of the monomer in solvate shell of TiCl4. Finally it adds to the double bond forming the respective ions (direct initialization). The obtained carbocation transfers to indane dimer and oligomeric products. At room temperature of the reaction mixture the indane dimer finally decomposes into toluene and indanyl cation [37, 38]:
Then the cationic oligomerization of vinyltoluene takes place. In the case of use of catalytic system TiCl4 : Et2AlCl (1:1) oligomerization of vinyltoluene occurs under similar conditions and is characterized by the presence of counter-ion of more complex composition.
Initiation of the polymerization by complete or partial electron transfer from the monomer to the initiator is a special case of interaction of the initiator with the monomer. This process is usually accompanied by the formation of intermediate charge-transfer complexes (CTC):
The last scheme is the most universal and attracts increasing attention in the field of polymerization of the polar electron-donor monomers. The phenomenon of charge transfer is evident not only in initiating the polymerization of such monomers with organic electron acceptors, but also occurs at the interaction with typical cationic polymerization initiators such as Lewis acids (including MLA) and stable organic cations, which act as acceptors relative to the electron-donating monomers [39, 40]. For example, in Ref. [41] it was shown that the initiation of polymerization of 9-vinylcarbazole under the action of
Then dication 9-vinylcarbazole is formed; and it is responsible for the polymerization:
As MCL are very strong v-acceptors, their lowest molecular orbital is vacant v-valence orbitals of the metal atom. We can assume that stage of electron transfer from the monomer to a v-orbital of the MLA precedes the initiation process. Till now there is no adequate attention to the question of which kind of orbital electron-donating monomer delivers its electron acceptor. It is usually assumed that π-complex is formed as a result of this interaction [42, 43]. However, data concerning formation of π-complexes of vinyl monomers with MCL are practically absent, that is probably associated with their rapid transition to the σ-complexes, ionic and radical products.
In [44] VC polymerization was studied in the presence of Ph3C+AlEt2Cl2– in CHCl3 solution at 20 °С. Process kinetics was studied using the stopped flow method with the registration in the IR range [2, 45–47]. In this case, the active site of polymerization is a stable organic cation Ph3C+, which is formed from the reaction of equivalent amounts of Ph3CСl и AIEt2CI. However, counter-ion AlEt2Cl2–, in contrast with hexa-fluoro-arsenate, hexa-chloro-antimonate and the like inorganic counter-ions of low nucleophilicity [27, 41, 47–50], associates with the organic cation. It allows concluding that the most likely type of active sites are separated solvate-ion pairs or even complex between VC and the contact ion pair.
The first reaction order was observed until complete consumption of the monomer. It indicates the absence of the chain break reactions. Moreover, when new portion of the monomer is added the reaction rate is not changed. It indicates the presence of the “live chains” in this system [51–54]. The behavior of this system is similar to the system VC – DEAC – chloroform studied earlier [46]. However, kinetic correlations have some differences which mean other mechanism of the active site formation. Kinetic measurements revealed that the most probable polymerization mechanism in the studied system CHCl3…Ph3C+Et2AlCl2–…VC is the chain growth on contact or solvate-separated ion pairs. It is confirmed by permanency of the kP value depending on the initial concentration of the initiator as well as its similarity to the ones known from literature.
The absorption spectra of solutions in chloroform BK (1) AIEt2CI (2) and complex of BK–AIEt2CI (3)
For assessing reactivity of VC in the cationic polymerization the kinetics of its polymerization in solution under the action of diethylaluminum chloride was studied [46]. It was shown that the reaction is greatly influenced by the complexation among the monomer and initiator. In particular, this leads to the fact that the polymerization process in general is limited by the formation of active particles that are supposed to be dication of VC. Appearance of new charge-transfer band in the electronic spectrum of the products of their interaction is clear evidence of the formation of donor-acceptor complexes between AIEt2CI and VC (Fig. 1, curve 3).
Figure 2 shows that the spectra of the initial VC (curve 1) or AIEt2CI (curve 2) similar band is absent, and the observed charge-transfer band actually consists of two bands with maxima at λ = 584 and 614 nm. One of them, apparently, is associated with the transition of π-electron VC to the d-orbital AIEt2CI, and another one - with the transition of n-electron. The obtained data reveal that the interaction of VC with a molecule of the initiator in the initial phase of the formation of donor-acceptor complex of medium strength; and degree of charge transfer from donor to acceptor is 0.29 of electron charge. The resulting donor-acceptor complex between VC and AIEt2CI has λmax = 584 and 614 nm. It is close to the form shown in the literature for the complex value of λmax VC with tetra-cyano-ethylene (590 nm, [55]). The interaction between VC and AIEt2CI leads to the fact that the effective charge on the β-carbon atom of the vinyl group BK significantly decreases; the length of the vinyl connection increases and its order is reduced. This greatly facilitates the subsequent process of formation of the active particles.
Formation of VC cation-radical followed by merge of two these cation-radicals to the dication may be such process. In this case evidence of formation of the latter one is the appearance in the electron spectrum of products of interaction and VC AIEt2CI a band at λmax = 820 nm attributable to the long-wavelength absorption maximum dication VC (curve 3, Fig. 2). Authors [56] gave a value of λmax = 850 nm for the cation formed by the interaction of ethyl-carbazole with SnCl4. Further cationic polymerization of VC mechanism takes place.
In all cases the polymerization of VC under the action of DEAC occurred until complete consumption of the monomer and accompanied by formation of colored intermediate. This color did not disappear after complete monomer consumption.
Such polymerization character indicates the absence of the chain break reaction in the system. It is confirmed by the fact that after contact of the reaction mixture with moisture in air the color disappeared and did not appear after addition of new portion of the monomer. However, stopping the growth of the molar weight of the polymer at repeated addition of the monomer proofs availability of the chain transfer reactions in the system.
In some cases, the problem of donor site in the monomer molecule requires special study. For example, vinyl compounds containing a hetero atom in the structure (such as vinyl ethers, N-vinyl heterocyclic monomers, etc.) can function as both n-donors and π-donors, giving unshared electron pair of heteroatoms or electrons of the highest π-level for the intermolecular bond [57, 58]. It is largely dependent on the properties of an electron acceptor. When interacting with stronger acceptors (e.g., MCL metals of the third group of the Periodic table) sufficiently strong high polar nv-complexes are formed [59]:
This will undoubtedly influence the formation of active particles in the system.
Thus, the generation of primary cations can pass through a series of relatively slow equilibrium stages, especially in the case of polymerization of monomers containing hetero atoms in the structure with an unshared electron pair. So often the formation of active sites becomes the limiting stage of the polymerization process as a whole, exerting a strong influence on the rest of the process.
It is known that the influence of the reaction medium is a decisive factor, which determines the rate constants of individual stages of ionic polymerization [60]. We can distinguish two effects of medium influence: change of reactivity of the active sites and the stabilization of the formed ionized particles.
Process rate and reactivity of the active sites in various media will be determined by a number of factors: the influence of the polarity of the medium, co-catalytic action of solvents, specific solvation, and the formation of complexes with components of the reaction system. Experimental results show that the major factor is the polarity of the medium. It plays particularly noticeable role at the stage preceding the initiation and growth of the polymer chain. This is expected, since the processes occurring at the same time are due to the formation of intermediate active particles: free ions, contact and solvate-separated ion pairs, as well as other more complex aggregates:
Large dipole moment of the ion pairs leads to a strong interaction with polar molecules including molecules of polar solvents. Solvate separated ion pairs exist only in mediums where at least one of the ions in a free state is coordinated with solvent molecules. In the case of a slightly solvating solvents their function can be performed by the monomers, changing the dielectric constant of the medium, or other components that are directly involved in the polymerization. It results in a change in the kinetic order of reaction with respect to these components. This is explained by the fact that in media not providing the necessary solvation energy the ion pairs are stabilized by most polar or polarizable molecules from those ones presented in the system, i.e. monomer and initiator. They can be incorporated into the kinetic equation corresponding to the reaction, although they do not take direct part in it [8].
The existence of free ions in organic media because of their low stability is possible only under the following conditions [7]:
ionization equilibrium is shifted toward preferably a covalent bond, i.e. there is a rapid reverse stabilization of charge;
active formation of stabilized specific solvation of cations and anions with suitable solvents;
nucleophility of the counter-ion is strongly reduced by acceptors in solvents with the prevailing acceptor character (H2CCI2, 1,2-diloretan, etc.); and there is no exchange with the cation except its electrostatic compensation.
The last condition, which would correspond to an almost "naked" cation takes place only at a strong intramolecular stabilization by delocalization of the charge (exchange interaction with the aromatic rings with a high density of π-electron, oxo-carbonium acids, allyl cations). Otherwise inductive effect of the ion carbenes on adjacent carbon atoms is so strong that the isomerization and cleavage for example, β-H-atoms will go faster than the reaction of chain growth:
In such hard conditions the monomer itself is the strongest π-donor in the reaction system, which can reduce the high electrophilicity of carbonium ion. Therefore, the literature points to the special role the monomer solvation as a stabilizing factor for the active particles, helping them to implement the reaction growth [68].
Obviously, the ion pairs and free ions may have a different activity, and ion pairs are usually less active as compared with free ions. For example, for the polymerization of 9-vinylcarbazole in H2CCI2 solution under the
In real systems the situation is complicated by the fact that the reaction of chain growth can be represented as the competition of the monomer, solvent, and counter-ions around the electrophilic center [7]. The exchange interaction of solvent separated ion pair with the monomer leads to resolvation of the ion pair and its expansion in order to the counter-ion:
According to current ideas about the mechanism of chain growth in cationic polymerization at high electrophilicity of the cation (aliphatic vinyl monomers) and the high nucleophilicity of the counter-ion
Ketamine was first synthesised in 1962 and put into clinical practice in 1970.It has a chiral structure and consists of two optical isomers S (+) and R (−) forms. Ketamine is commonly used for anaesthesia in the paediatric population. A recent survey identified standard induction agents used in children varied from Etomidate in 26.9% (7/26), propofol in 19.2% (5/26), a combination of benzodiazepines and ketamine in 19.2% (5/26), and barbiturates in 11.5% (3/26) [1]. The use of anaesthesia in paediatric age group outside the OR includes dental offices, endoscopy suites, cardiac catheterization laboratory, radiology facilities, radiation oncology departments, paediatric intensive care units (PICUs), and emergency departments. Patients aged less than 3 years routinely require anaesthesia prior to any procedure. By 7 years of age however most children can tolerate non-painful exams and treatments without anaesthesia support [2, 3]. In the OR Ketamine may be used for sedating the child prior to inducing GA in order to decrease anxiety due to parental separation. However the psychological side effects of Ketamine as well as availability of other agents made Ketamine less popular as an induction agent. Induction technique preferred in children is usually inhalational route especially with the availability of Sevoflurane.
The American Society of Anaesthesiology (ASA) defines four levels of sedation (Table 1): minimal (anxiolysis), moderate (conscious), deep (purposeful response to vigorous stimulation), and general anaesthesia (unresponsive). A variety of pharmacologic agents are available to sedate and anaesthetise patients. Conscious sedation can be defined as, “A controlled state of depressed consciousness that allows the protective reflexes to be maintained, retaining the patient’s ability to maintain a patent airway independently and continuously and allows appropriate response by the patient to physical stimulation or verbal command.” A patient can progress from one level to another during sedation given in various doses. Hence continuous monitoring and vigilance is of utmost importance. The drugs used must be titrated to achieve the desired effect, prevent overdose and sudden loss of consciousness. Prior to even short procedures requiring sedation, the child must be evaluated thoroughly –check for any comorbidities like seizure history, previous surgeries, allergic reactions, birth history, developmental milestones attained etc. Airway should be examined to anticipate any difficult airway-enlarged tonsils, congenital defects etc. The blood investigations necessary should be ordered as per need just like prior to a child for major surgical procedure. Adequate fasting guidelines should be explained and ensured. An understanding of the pharmacodynamics and pharmacokinetic effects of sedating drugs which are going to be used is essential. Appropriate sized airway equipment, venous access, appropriate intraoperative monitoring equipment, properly equipped staff in recovery area and proper discharge criteria should also be checked. Sedation drugs can be administered through various routes—oral, nasal, intramuscular, intravenous (IV), subcutaneous, and inhalational routes.
Mild | Moderate | Deep sedation | General anaesthesia | |
---|---|---|---|---|
Response to verbal stimulus | Normal | Only responds purposefully | Response seen only on repeated painful stimulation | No response even to painful stimulus |
Airway | Not affected | Usually able to maintain airway without intervention | May not be able to maintain airway reflexes | Airway adjuncts like supraglottic airway device or endotracheal intubation required |
Spontaneous Ventilation | Maintains spontaneous respiration | Adequate | May be inadequate | Frequently inadequate |
Cardiovascular Function | No cardiovascular depression | Usually normal | Usually normal | Cardiovascular depression may occur |
ASA levels of sedation.
For conscious sedation drugs are used in sub anaesthetic doses and titrated to obtain adequate effect. Various drugs have been used for conscious sedation in paediatric age group which includes Ketamine. The doses of drugs used for Conscious sedation is given in Table 2.
Drug | Route of administration |
---|---|
Midazolam | IV/Intranasal |
Ketamine | IV/IM/rectal/oral/intranasal |
Dexmedetomidine | IV |
Propofol | IV |
Ketofol | IV |
Opioids (Fentanyl/Remifentanyl) | IV |
Drugs used for conscious sedation.
Ketamine is a phencyclidine derivative which acts as an N-methyl-D-aspartate (NMDA) receptor antagonist at the dorsal horn of the spinal cord [2, 4]. It induces dissociative amnesia and analgesia [5]. Ketamine has the advantage of various routes of administration available for use. Administration routes include intravenous (1–2 mg/kg), intramuscular (2–10 mg/kg), oral (3–6 mg/kg), intranasal (2–4 mg/kg), and rectal (5–10 mg/kg) (Refer Table 3) [6]. Ketamine has many advantages over other drugs especially due to its relative cardiovascular steadiness and restricted effect on the respiratory mechanics. Recovery occurs within 30–120 min, and this allows the patient to be discharged on the same day as the procedure. It has a dose dependent cardiovascular stimulant effect. In children with congenital heart disease, it causes only minor increases in heart rate and mean pulmonary artery pressure during cardiac catheterization procedures [1]. It has various effects on the other systems in the body some of which are listed in Table 4.
Route | Dose |
---|---|
IV | 1–2 mg/kg |
IM | 2–10 mg/kg |
Oral | 3–6 mg/kg |
Intranasal | 2–4 mg/kg |
Sedation | 0.2–0.75 mg/kg IV or 2–4 mg/kg IM |
Dosages of ketamine.
Organ system | Effect |
---|---|
Cardiovascular | Increases heart rate, blood pressure, cardiac output |
Respiratory | Increases the oral secretions, bronchodilator, maintains the airway reflexes |
Neurologic | Dissociative anaesthesia Increase in intracranial pressure, excitatory effects on thalamus and limbic systems, increase in intraocular pressure, increase in cerebral metabolism, increase in cerebral oxygen consumption Emergence delirium |
Effects of ketamine on various systems.
Adverse reactions associated with ketamine include dreams, hallucinations, delirium, agitation, vomiting, increased salivation, and laryngospasm [7]. It causes increase in intraocular and intracranial pressures after its administration. Hence it is not used in patients with glaucoma, open globe injuries, or elevated intracranial pressure [5]. Clinically, ketamine is frequently used to facilitate short, painful procedures in the emergency department [4, 8]. Sedation can be achieved with minimal respiratory depression. However when higher doses are used, one can easily induce general anaesthesia [5].
Ketamine causes hyper salivation and thus needs to be administered with an antisialagogue like Atropine or glycopyrrolate. To prevent hallucinations and delirium it is often combined with short acting benzodiazepines like midazolam.
The combination of ketamine and propofol, known as ketofol is also a popular drug used for procedural sedation. The two drugs when combined act synergistically and thus helps to decrease the dose of each drug independently. The side effects of ketamine which includes vomiting, laryngospasm, and emergence delirium, can be decreased by adding propofol. In the same way using ketamine along with propofol decreases the risk of propofol-induced respiratory depression and hypotension. The combination also provides for analgesia [9]. There is no standard combination mentioned but usually Ketamine and Propofol are mixed in a 1:1 ratio (mg) [10]. According to a prospective randomised controlled study involving paediatric patients undergoing cardiac catheterization, using a propofol: ketamine combination in the ratio of 10:2 (mg) preserved mean arterial pressure without affecting recovery time [11]. Studies which have compared ketofol with propofol have shown that ketofol produces consistent depth of sedation. Patient satisfaction scores were also found to be similar. Propofol causes pain on injection but the combination of propofol with Ketamine reduces pain on injection. The risk of airway and respiratory complications were similar in both groups [12, 13, 14, 15]. Ketofol decreases the requirements of both opioids and propofol. Ketofol is thus an acceptable choice for short procedures in the emergency department or critical care setting [10]. The efficacy, safety, pharmacokinetics, and pharmacodynamics require further evaluation with additional prospective trials in the paediatric population.
With currently available IV anaesthetic agents such as Propofol, barbiturates, opioids etc. which are used frequently in combination with Ketamine for procedures done outside the OR, the complication rates has declined from 23% [16] seen in the 1980s to 1–2%. This is somewhat similar to the complication rates in the ORs [17, 18, 19]. A current study by Owusu-Agyemang et al. [3] showed that use of propofol either alone or in combination with Dexmedetomidine and Fentanyl lowered complication rates to 0.05%.Some newer drugs like Fospropofol have been approved by FDA for sedation purposes. Some drugs like Remimazolam and other Etomidate derivatives are still in clinical trial stages. Some centres have seen the resurgence of inhalational anaesthetic nitrous oxide.
Cancer pain management, especially in terminal stages, can be challenging. Cancer pain is mediated through various pathways, including visceral, nociceptive, neuropathic and central. Currently used agents have limited role in addressing each component and have significant adverse events. The safety profile of Ketamine has been evaluated in a number of trials. The WHO ladder for pain management includes acetaminophen, non-steroidal anti-inflammatory drugs, weak opioids like tramadol and the strong opioids like morphine for cancer pain management. In addition to this, topical local anaesthetics like lignocaine can also be used. However US FDA approval for many of these medications is lacking for use in the paediatric age group.
Safety and efficacy as an anaesthetic and analgesic has been well documented; however, ketamine has not yet been approved as an analgesic agent by the US FDA. This may prevent its free use by many for cancer pain management [20, 21, 22, 23]. When Ketamine is used in doses <1 mg/kg it has minimal depressant effects on cardiovascular and respiratory systems as it produces only minimal sedation (Refer Table 1) [20, 24]. However it produces analgesia and modulate central sensitization, hyperalgesia, and opioid tolerance. Hence the National Comprehensive Cancer Network guidelines has recommended considering oral or intravenous (IV) ketamine for pain not responding to other analgesics [20, 25]. Ketamine has been used through various routes of administration-IV, IM, oral, sublingual Intranasal rectal and even epidural in patients with malignancy. The bioavailability of intranasal Ketamine was found to be 45–50% [26, 27].
A review of five studies of ketamine for cancer pain in children showed that patients treated with oral and IV ketamine had only few adverse events reported. However, these studies were all retrospective. Participants’ cancer diagnoses include acute myelogenous leukaemia, myelodysplastic syndrome, osteosarcoma, metastatic giant malignant mesenchymal tumour, glioblastoma multiforme, neuroblastoma, Ewing sarcoma, spindle cell sarcoma, synovial cell sarcoma, and Wilm’s tumour [28]. There are several very small case series or individual case reports of children being treated with ketamine for pain with promising results. For example, at Melbourne, a protocol for IV ketamine administration is being used to treat children who have been unresponsive to two doses of morphine. Additional dose of ketamine (0.1 mg/kg) given as a bolus has helped to achieve effective pain control. These doses have not been associated with hallucinations or dysphoria. However, this report does not enumerate percentages of patients with adequate pain control after treatment with ketamine [29]. A prospective phase I trial of oral ketamine in the dose of 0.25–1 mg/kg given in divided doses in children with chronic noncancer pain has been undertaken [30].
Children with severe cancer pain have been treated with ketamine in doses of 3 mg/kg/day given orally [31] and 0.1–1 mg/kg/h given intravenously. In a retrospective review, 8 of the 11 (73%) children and adolescents had decreased need for opioids and improved pain control [32]. The results of these reports suggest that pain control may be achieved with the use of ketamine in children with cancer pain. These doses were well tolerated by the children between 3 and 17 years of age with cancer pain without nausea, sedation, hallucination, respiratory distress, or psychotomimetic effects.
The common side effects of ketamine include nausea, vomiting, occurrence of bizarre dreams, hallucinations, emergence agitation, seizures. It causes tachycardia and hypertension and thus is contraindicated in patients with cardio vascular illnesses. It also increases in intra ocular pressure and is thus contraindicated in open eye injuries.
Some studies have shown lorazepam given along with Ketamine to decrease the psychotomimetic side effects of ketamine [32]. Ketamine administered through the epidural route in children has shown to produce fewer side effects due to Ketamine. This also decreased the opioid consumption during the procedure [33]. The neurotoxicity caused due to Ketamine appears to be less in children than in adults. There are a few case reports of laryngospasm caused when Ketamine is given intramuscularly or in higher doses [33, 34]. One case report of a ketamine infusion for a child reports mycolonic movements in the child [35]. The report is unclear as to whether this was related to ketamine or the child’s spinal cord tumour. There have been occasional incidences of reversible cystitis with chronic exposure to ketamine [36, 37].
The incidence of respiratory complications has been found to be higher with the use of intramuscular administration of Ketamine as compared to intravenous use. An increased incidence of laryngospasm has been reported especially due to the higher dose of ketamine required for effect as well as delayed absorption of intramuscularly administered drug. The incidence of respiratory adverse events was 2.4% with IM ketamine [34].
A retrospective study evaluated the usefulness of combining intranasal Dexmed (2 mcg/kg) and Ketamine (1 mg/kg) for procedural sedation found it to be useful in 93% of patients. The onset of sedation was 15 min and duration was found to be 62 min. Minor complications like nausea and vomiting only were observed in the study in 0.3% of the patients.
More than 11,000 cases have been reported of its use in children with no fatalities being described in the literature by Green et al. [5] the most frequently cited disadvantage is the emergence phenomenon, seen more commonly in adults where the incidence is 5–50% while in children it has been found to be 0–5%. Ketamine increases the salivary and tracheobronchial mucus gland secretions, and hence needs to be combined with an antisialagogue during GA. Emesis is the one of the most common side effect of ketamine. In a review by Green the incidence of vomiting was found to be 10% and more commonly seen in children undergoing dental procedures. Atropine has been found to decrease the emesis by reducing the salivary secretions. Laryngospasm was reported in 0.4% of cases. Laryngospasm was managed with 100% oxygen and positive pressure ventilation using bag and mask [38].
In his study, Embu has described various techniques for burns contracture release. Some case were done with intermittent doses of Ketamine while patients were spontaneously breathing. Some patients were maintained on inhalational anaesthetic after Ketamine induction-either via face mask or LMA (laryngeal mask airway). After adequate surgical release, the patients were intubated by direct laryngoscopy. No airway complications were reported in the study. However, maintaining anaesthesia with an inhalation agent via facemask was found to be technically difficult owing to the proximity to the sterile surgical field [39].
Agarwal et al. have reported use of tumescent local anaesthesia for the release of neck contracture due to burns in 30 patients. 0.5–1.0 mg/kg of IV ketamine were used in these children at the start of the case. They were maintained on ketamine during the procedure also as intermittent IV boluses (dose has not been specified). No airway complications had been reported. All patients were maintained on spontaneous ventilation throughout the case [40].
Preservative-free ketamine added to caudal bupivacaine has been shown to improve the duration of analgesia, without affecting the analgesic intensity in a study done by Martindale et al. [41]. In a recent survey conducted among paediatric anaesthetists in UK by Sanders 32% had reported using epidural ketamine [42]. It is used in a dose of 0.25–1 mg/kg as an additive to bupivacaine or Ropivacaine.
Children often are given regional anaesthesia for pain management following General anaesthesia (GA) in contrast to adult patients. Hence it is difficult to assess the usefulness of the regional technique except by use of surrogate indicators like tachycardia, hypertension. Perfusion Index is a newer technique to detect effectiveness of regional anaesthetic under GA.
Studies have demonstrated that PI can provide an early and reliable indication of the onset of epidural anaesthesia. Intravascular injection of epinephrine-containing local anaesthetic test dose can also be identified in the adult population [6, 8]. However, caudal blocks in paediatric patients are mostly performed under sedation or general anaesthesia, using ketamine or sevoflurane [9, 10]. Data has shown that ketamine itself can affect PI. Thus it is difficult to predict the onset of caudal block using PI in the paediatric patients who have been sedated using Ketamine. A previous study has shown that intravenous ketamine used in paediatric patients produced a fast and long-lasting decrease in peripheral PI. However the study also showed that caudal block reversed the decrease of PI measured in the toe, caused by ketamine anaesthesia in paediatric population. The PI was found to increase beyond the preinduction level. The study also showed that PI response criterion achieved 100% sensitivity and specificity in detecting the effects of caudal anaesthesia under IV ketamine anaesthesia in paediatric patients. However, neither HR nor MAP criteria were 100% reliable. Furthermore, the changes of PI caused by caudal block under ketamine anaesthesia were much earlier than those of HR and MAP.
Ketamine being a widely used intravenous anaesthetic in paediatric patients, it has been shown to produce an immediate and long-lasting decrease in peripheral PI due to its sympathomimetic effects through its effects on both central and peripheral mechanisms [17, 18]. In this study, a drop in PI was observed within one minute after the injection of ketamine (2.36 ± 0.79 to 1.58 ± 0.61) and after 30 min PI it had decreased to 0.80 ± 0.26, which was far below the baseline value of PI. The changes of MAP lasted about 15 min, and the changes of HR lasted about 5 min following ketamine injection. Caudal block not only reversed the decrease of PI on the toe caused by ketamine anaesthesia in paediatric patients, but also increased PI far beyond the preinduction PI value [43].
The sensory association areas of the cortex, components of the limbic system, and thalamus are directly depressed by ketamine. Consequently, higher central nervous system (CNS) centres are unable to receive or process sensory information and its emotional significance cannot be assessed. The result of ketamine administration is anaesthesia, analgesia, suppression of fear and anxiety, and amnesia, which appear to be ideal for the uncooperative child patient.
Ketamine is commonly used for sedation and analgesia during painful procedures because it maintains the cardiovascular and respiratory systems while providing effective sedation, analgesia, and amnesia. However Ketamine-induced emergence reactions like hallucinations, delusions, nightmares, and agitation are shown to be less in children [44]. Ketamine can be used prior to invasive procedures in the ICU like Lumbar puncture, central line insertions. It can be used in management of children with status asthamaticus.
Ketamine has many advantages due to which it is used for sedation in the paediatric population viz. a relatively short duration of action, multiple routes of administration, preservation of airway reflexes, and sympathomimetic properties including increase heart rates and blood pressure. Sedation can be achieved without much respiratory depression. However ketamine has various adverse effects too. These include hallucinations, emergence delirium, agitation, nausea and vomiting, hyper salivation, and laryngospasm. This can cause distress to both the child and parent. Reports of patients developing random movements of the extremities has been reported which renders this drug less than ideal for procedures where the patient must lie perfectly still like in the MRI suite. Thus, ketamine is used along with other sedative agents to counterbalance the side effects and enhance the beneficial effects for each drug rather than as a sole sedative agent for MRI. Ketamine can prevent the cardiorespiratory depression effect of propofol and prolonged recovery of dexmedetomidine by reducing the dose requirements of each drug when used for sedation in children in MRI suite [44, 45, 46, 47, 48].
Exposure to ketamine and other anaesthetic agents during early stages of postnatal brain development increases central nervous system neuronal apoptosis in animals receiving significantly larger and more prolonged doses than used for procedural sedation [49]. No evidence of neuronal injury after a single ketamine based sedation has been seen in small children but repeated use of ketamine for procedures may have detrimental effects. [50, 51].
Ketamine has been used as an induction agent in children with cyanotic congenital heart conditions like Tetralogy of Fallot. This is due to its effect in increasing the systematic vascular resistance and thus decreasing the incidence of righto left shunt. However it can increase the infundibular spasm. Thus it is combined with opioids or propofol. Another recently described alternative to this is Etomidate combined with Ketamine [52].
Recent studies have explored the use of Ketamine in other situations in adult population as well like prevention of postoperative sore throat, treatment of status epilepticus, alcohol withdrawal syndrome, status asthamaticus etc. There has been an increased usage of Ketamine in the acute pain setting to prevent excessive opioid use but these require further studies in the paediatric population. Thus Ketamine is a very useful drug in the paediatric age group which may be combined with other drugs to alleviate its side effects and achieve anaesthesia as well as analgesia.
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