Observations on the Pharmacokinetics and Pharmacodynamics of Dexmedetomidine. Clinical Studies on Healthy Volunteers and Intensive Care Patients

Patients treated in intensive care units require sedation and analgesia. However, sedative drugs also have potential adverse effects, and there is no single ideal sedativeanalgesic drug for these patients. Dexmedetomidine is an apha2-adrenoceptor agonist licenced for sedation of intensive care patients and patients undergoing surgery and other invasive procedures. Several routes of parenteral administration (intravenous, intramuscular, subcutaneous and intranasal) have been utilized. In the present series of studies, the pharmacokinetics and pharmacodynamics of intranasally administered dexmedetomidine as well as the gastrointestinal effects of intravenous dexmedetomidine were determined in healthy volunteers. Pharmacokinetics of dexmedetomidine during long lasting, high-dose infusions were characterized in intensive care patients. The bioavailability of intranasal dexmedetomidine was relatively good (65%), but interindividual variation was large. Dexmedetomidine significantly inhibited gastric emptying and gastrointestinal transit. In intensive care patients, the elimination half-life of dexmedetomidine was somewhat longer than reported for infusions of shorter duration and in less ill patients or healthy volunteers. Dexmedetomidine appeared to have linear pharmacokinetics up to the studied dose rate of 2.5 μg/kg/h. Dexmedetomidine clearance was decreasing with age and its volume of distribution was increased in hypoalbuminaemic patients, resulting in a longer elimination half-life and context-sensitive half-time. Intranasally administered dexmedetomidine was efficacious and well tolerated, making it appropriate for clinical situations requiring light sedation. The clinical significance of the gastrointestinal inhibitory effects of dexmedetomidine should be further evaluated in intensive care patients. The possibility of potentially altered potency and effect duration should be taken into account when administering dexmedetomidine to elderly or hypoalbuminaemic patients.

Alterations in The States and Contents of Consciousness: Empirical and Theoretical Aspects

The main purpose of the present doctoral thesis is to investigate subjective experiences and cognitive processes in four different types of altered states of consciousness: naturally occurring dreaming, cognitively induced hypnosis, pharmacologically induced sedation, and pathological psychosis. Both empirical and theoretical research is carried out, resulting in four empirical and four theoretical studies. The thesis begins with a review of the main concepts used in consciousness research, the most influential philosophical and neurobiological theories of subjective experience, the classification of altered states of consciousness, and the main empirical methods used to study consciousness alterations. Next, findings of the original studies are discussed, as follows. Phenomenal consciousness is found to be dissociable from responsiveness, as subjective experiences do occur in unresponsive states, including anaesthetic-induced sedation and natural sleep, as demonstrated by post-awakening subjective reports. Two new tools for the content analysis of subjective experiences and dreams are presented, focusing on the diversity, complexity and dynamics of phenomenal consciousness. In addition, a new experimental paradigm of serial awakenings from non-rapid eye movement sleep is introduced, which enables more rapid sampling of dream reports than has been available in previous studies. It is also suggested that lucid dreaming can be studied using transcranial brain stimulation techniques and systematic analysis of pre-lucid dreaming. For blind judges, dreams of psychotic patients appear to be indistinguishable from waking mentation reports collected from the same patients, which indicates a close resemblance of these states of mind. However, despite phenomenological similarities, dreaming should not be treated as a uniform research model of psychotic or intact consciousness. Contrary to this, there seems to be a multiplicity of routes of how different states of consciousness can be associated. For instance, seemingly identical time perception distortions in different alterations of consciousness may have diverse underlying causes for these distortions. It is also shown that altered states do not necessarily exhibit impaired cognitive processing compared to a baseline waking state of consciousness: a case study of time perception in a hypnotic virtuoso indicates a more consistent perceptual timing under hypnosis than in a waking state. The thesis ends with a brief discussion of the most promising new perspectives for the study of alterations of consciousness.