Intervention to reduce sedative use.

BackgroundThe use of sedative drugs and intentional sedation in end-of-life care is associated with clinical, ethical and legal challenges. In view of these and of the issue’s great importance to patients undergoing intolerable suffering, we conducted a project titled SedPall (“From anxiolysis to deep continuous sedation – Development of recommendations for sedation in palliative care“) with the purpose of developing best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care and obtaining feedback and approval from experts in this area.DesignOur stepwise approach entailed drafting the recommendations, obtaining expert feedback, conducting a single-round Delphi study, and convening a consensus conference. As an interdisciplinary group, we created a set of best practice recommendations based on previously published guidance and empirical and normative analysis, and drawing on feedback from experts, including patient representatives and of public involvement participants. We set the required agreement rate for approval at the single-round Delphi and the consensus conference at ≥80%.ResultsTen experts commented on the recommendations’ first draft. The Delphi panel comprised 50 experts and patient and public involvement participants, while 46 participants attended the consensus conference. In total, the participants in these stages of the process approved 66 recommendations, covering the topics “indications”, “intent/purpose [of sedation]”, “decision-making”, “information and consent”, “medication and type of sedation”, “monitoring”, “management of fluids and nutrition”, “continuing other measures”, “support for relatives”, and “team support”. The recommendations include suggestions on terminology and comments on legal issues.ConclusionFurther research will be required for evaluating the feasibility of the recommendations’ implementation and their effectiveness. The recommendations and the suggested terminology may serve as a resource for healthcare professionals in Germany on the use of sedative drugs and intentional sedation in specialist palliative care and may contribute to discussion on the topic at an international level.Trial RegistrationDRKS00015047 (German Clinical Trials Register)

New sedation and general anesthesia guidelines: Why the changes?

Sedation Scales in the ICU

Background The epidemiology of independent use of sedatives or alcohol is well reported in previous research. However, the epidemiology of concurrent use of sedatives and alcohol is vastly understudied despite the unpredictable interactions associated with it. Objectives Our aim was to study the prevalence of concurrent use of alcohol and sedatives and further examine the use of sedatives in some subgroups of people with alcohol use. Methods A mailed questionnaire was sent to a randomly chosen representative sample of a Finnish population (n = 5000). The main outcome measure was the prevalence of the use of sedatives in five subgroups of people with alcohol use in the previous week. Results Of the participants, 7.8% (142/1818) reported use of both alcohol and sedatives in the previous week. Among the people with sedative use, 67.0% (142/212) reported at least some alcohol use, and 9.9. % (21/212) reported high use of at least 21 units of alcohol in the previous 7 days. The prevalence of sedative use was highest among those who had used at least 21 units of alcohol in the previous 7 days (19.4%). Conclusion The use of sedatives was especially common among those who reported having used large amounts of alcohol.

Raise the bar for safe sedation, not barriers for access to care

Flexible bronchoscopy is commonly performed by respiratory physicians and is the gold standard for directly visualising the airways, allowing for numerous diagnostic and therapeutic interventions. With the widespread use of flexible bronchoscopy and the evolution of interventional bronchoscopy with more complex and longer procedures, physicians are placing increasing importance on the use of sedation as a necessary adjunct to topical anaesthesia. There is no standardised practice for the use of sedation in bronchoscopy with a good deal of variation among physicians regarding the use of pre-procedure medication and pharmacological sedatives. In addition, there is ongoing debate and controversy about proceduralist-administered versus anaesthetist-administered sedation whilst at the same time there is a growing body of evidence that nonanaesthetist administered sedation is safe and cost-effective. In this review we summarise the evidence for the use of sedation as an adjunct to topical anaesthesia in bronchoscopy and provide the clinician with up-to-date concise guidance for the use of pharmacological sedatives in bronchoscopy and future directions for sedation in the bronchoscopy suite.

BackgroundThe use of sedative drugs in specialist palliative care is common but presents challenges due to specific medical, ethical, and legal considerations. There is little to no assistance for administering adequate sedative drug doses, ensuring accurate documentation before and during sedation, or managing ethically and legally challenging situations. In 2021, the SedPall study group published recommendations on the use of sedative drugs in palliative care. The German Association for Palliative Medicine endorsed the dissemination of the recommendations nationwide. However, disseminating recommendations alone does not necessarily lead to changes in clinical practice. In the project “Development and piloting of a multi-modal intervention for the use of sedative drugs in specialist palliative care (iSedPall)”, we will develop a multi-modal intervention that implements these national recommendations into practical tools for healthcare professionals in specialist inpatient and home care settings. In the pilot study described below, we aim to test the feasibility of the multi-modal intervention, its appropriateness, and acceptability as primary feasibility outcomes of the multi-modal intervention. Additionally, we aim to assess the feasibility of measuring healthcare professionals´ confidence in using sedative drugs as an outcome indicator for a possible subsequent study.Methods and analysisWe will use a mixed-methods approach to develop and pilot a multi-modal intervention. The primary feasibility outcomes and formative evaluation of the implementation process will be explored using quantitative (retrospective cohort study, survey) and qualitative elements (focus groups, interviews). Additionally, we will pilot the measurement of healthcare professionals´ confidence in using sedative drugs as an outcome indicator through a pre-post survey. Four specialist palliative care services will pilot the complex intervention for nine months. Due to the complexity of the intervention, we will follow the principles of the MRC framework for complex interventions and will apply a Theory of Change approach. The intervention will include different elements to be used throughout the patients’ treatment in inpatient and home specialist palliative care considering medical, ethical, and legal aspects for the use of sedative drugs and intentional sedation. The evaluation of the overall feasibility and the decision about proceeding to an implementation study will be based on the integration of quantitative and qualitative data, according to our mixed-methods approach.DiscussionThis project is the first attempt to translate national recommendations on best practices for sedative drug use into a multi-modal intervention and tests its feasibility. The study group identified potential risks and challenges related to the intervention´s feasibility, acceptability, and appropriateness in advance. To mitigate these risks, the study protocol is based on a theoretical framework, developed through a Theory of Change approach. Participatory elements and the involvement of different stakeholders are expected to enhance user acceptance and feasibility, potentially improving the development of supporting materials for sedative drug use in specialist palliative care while considering the interests of non-professionals.Trial registrationRegistered in the German Clinical Trials Register, DRKS-ID: DRKS00027241; Registered: 10/12/2021; https://www.drks.de/drks_web/setLocale_EN.do.

Data on sedation at the end of life (eol) in different medical disciplines are scarce and mostly based on subjective reports. We aimed to assess the use of sedatives with continuous effect in the last week of life and associated factors in different hospital departments, with the aid of objectifiable criteria. We conducted a retrospective cohort study based on the medical records of patients who died in one of five clinical departments of German hospitals between January 2015 and December 2017 (hematology/oncology [two different departments], neurology, geriatrics, and gynecology). The use of sedatives that are recommended in guidelines for palliative sedation was analyzed, irrespective of indication and treatment intent, with the aid of published definitions of continuous effect and of at least moderately sedating doses. The analysis consisted of descriptive statistics and multivariate logistic regression analysis. 260/517 (50%) of the patients who died were given sedatives with continuous effect in the last week of life, 53/517 (10%) in at least moderately sedating doses. For 76/260 (29%) patients, no indication was noted. The term "sedation" was used in the medical records of 20/260 (8%) patients. The use of sedatives with continuous effect was significantly associated with the department in which the patient was treated (hematology/oncology II: OR 0.32, 95% CI [0.16: 0.63]; geriatrics: OR 0.23, 95% CI [0.10:0.50]; reference, hematology/oncology I). It was not possible to draw a clear distinction between the use of sedatives for symptom control, without sedating effect or intent to sedate, and intentional sedation to relieve suffering. The observed differences between hospital departments and deviations from recommended practice, e.g. lack of documentation of the indication, warrant further exploration. Moreover, context-specific supportive measures for the use of sedatives and sedation at the end of life should be developed.

Sex differences in the associations of nonmedical use of prescription drugs with self-injurious thoughts and behaviors among adolescents: A large-scale study in China

Introduction: Conscious sedation is a safe and effective method of anxiolysis. However, the use of conscious sedation in pediatric dental patients is a controversial topic as it involves the intersection of dentistry and medicine. Among the many questions that could be asked, it is necessary to find out what dental practitioners think about the use of sedatives in their routine pediatric dental practice. Therefore, the above survey was conducted aiming to evaluate the perceptions of dentists on the use of Conscious Sedation in pediatric dental practice in Vadodara city, Gujarat.
 Methods: Questionnaires were sent electronically to Indian Dental Association (IDA) members of Vadodara at the time of the study. The contact details of these dental practitioners were obtained from the IDA members list. Details on personal status, use of, and training in, conscious sedation techniques were sought via the questionnaires to find the knowledge, attitude, and awareness towards the use of Conscious Sedation in pediatric dental practice.
 Results: The questionnaire was sent to IDA members in Vadodara city, Gujarat. 64.37% (150 dentists) responded to the questionnaire. 48% were female practitioners and 52% were male practitioners. 78.5% were in favor of using conscious sedation as a behavior management technique in pediatric dental practice, irrespective of their qualification or years of experience. Maximum knowledge about conscious sedation was obtained through the curriculum.
 Conclusion: It can be concluded that the dentists of Vadodara city, Gujarat state developed a positive attitude towards the use of conscious sedation, however, complained of a lack of training to the subject.

Earlier it has been found that female Seventh-day Adventists (SDA) and Baptists have an increased incidence of psychiatric affective disorders, in contrast to findings that religious practice is associated with better health. In this study, we examined whether the increase in incidence is due to less use of prescribed antidepressants, sedatives and antipsychotics by members of these religious societies than by the general population. In a cohort study, we examined records of all drugs redeemed by 3121 SDA and 2888 Baptists and 29,817 age- and gender-matched members of the general population between 1995 and 2010 in the Danish Prescription Register and compared the prevalence and incidence of use of antidepressants, sedatives and antipsychotics. The prevalence of antidepressant use by women was lower in 1998 but no different from that in controls in 2003 and 2008; the prevalence of antidepressant use by men was higher in both 1998 and 2008 than in the Danish population. The incidence of antidepressant use was lower for female members in 1996-2000, but no difference was observed in the other periods. The prevalence and incidence of use of sedatives and antipsychotics did not consistently differ from those of the general population. The prevalence and incidence of use of antidepressants, sedatives and antipsychotics by female SDA and Baptists were not consistently lower than in the general Danish population. Our findings hence do not explain the increased incidence of psychiatric disorders among female members of these Danish religious societies.

Backgrounds: In terminally ill cancer patients, delirium must be considered to be important clinically and for the quality of life. We reviewed cases of delirium in hospitalized cancer patients with the aim to recognize and treat delirium. Methods: We reviewed retrospectively the medical records of patients admitted with terminal cancer from April 2003 to April 2004 in the department of family medicine, National Health Insurance Corporation Ilsan Hospital. A total of 71 patients were evaluated with age, sex, oncological diagnosis, metastases, morphine (oral morphine equivalents/day, OME) use and amount, sedatives use, duration from delirium to death, and laboratory fi ndings. Analysis was conducted to fi nd the characteristics of delirium patients and to quantify the relationship between delirium and predicting factors. Results: Among 71 cases, those patients who developed delirium were 41 (57.7%). Among them, gastric cancer was the most common diagnosis with 10 patients (24.4%), followed by colon and lung cancers (9: 22%, 5: 12.2%). The patients receiving sedatives or morphines were 24 (58.5%) and 28 (68.3%), respectively. The mean amount of morphine was 168.6 ± 125.5 mg OME/day. Hyperbilirubinemia (4.2 ± 9.2 mg/dL) and hyponatremia (132.5 ± 4.5 mM/L) were found. Not only bone metastasis and the use of morphine or sedatives but serum Na were signifi cant (P = 0.047; P < 0.001; P = 0.069; P = 0.029). By logistic regression analyses, the occurrence of delirium was increased with decreased serum Na (odds ratio [95% CI] 0.798 [0.649-0.981]) and increased use of sedatives (5.955 [1.080-32.835]). Conclusion: In terminally ill cancer patients, the risk factors of delirium were bone metastasis, the use of morphine or sedatives, and serum Na level. Among these, the use of sedatives and serum Na level were independent risk factors.

ContextGuidelines about palliative sedation typically include recommendations to protect the well-being of relatives. ObjectivesThe aim of this study was to systematically review evidence on the experiences of relatives with the practice of palliative sedation. MethodsPubMed, Embase, Web of Science, PsycINFO, and CINAHL were searched for empirical studies on relatives' experiences with palliative sedation. We investigated relatives' involvement in the decision-making and sedation processes, whether they received adequate information and support, and relatives' emotions. ResultsOf the 564 studies identified, 39 were included. The studies (30 quantitative, six qualitative, and three mixed methods) were conducted in 16 countries; three studies were based on relatives' reports, 26 on physicians' and nurses' proxy reports, seven on medical records, and three combined different sources. The 39 studies yielded a combined total of 8791 respondents or studied cases. Caregivers involved relatives in the decision making in 69%–100% of all cases (19 quantitative studies), and in 60%–100% of all cases, relatives were reported to have received adequate information (five quantitative studies). Only two quantitative studies reported on relatives' involvement in the provision of sedation. Despite the fact that the majority of relatives were reported to be comfortable with the use of palliative sedation (seven quantitative studies, four qualitative studies), several studies found that relatives were distressed by the use of sedation (five quantitative studies, five qualitative studies). No studies reported specifically about the support provided to the relatives. ConclusionRelatives' experiences with palliative sedation are mainly studied from the perspective of proxies, mostly professional caregivers. The majority of relatives seems to be comfortable with the use of palliative sedation; however, they may experience substantial distress by the use of sedation.

Describe the trends in pediatric sedation use over time and determine variation in use of procedural sedation across children's hospital emergency departments (EDs). We analyzed ED data from 35 hospitals within the Pediatric Health Information System for patients <19 years old who received sedation medications and were discharged from 2009 to 2014. Patients with chronic comorbidities or undergoing intubation were excluded. We determined frequency and trends in use of sedation and compared these between EDs. Descriptive statistics with appropriate weighting were used. Of the 1 448 011 patients potentially requiring sedation who presented to the ED, 99 951 (7.9%) underwent procedural sedation. Medication usage in 2014 included ketamine (73.7%), fentanyl and midazolam (15.9%), ketofol (7.3%), and propofol (2.7%). Use of fentanyl and midazolam increased, whereas use of ketamine, pentobarbital, etomidate, chloral hydrate, and methohexital decreased over time. Significant variation exists in the use of sedation across hospitals; in 2014, the sedation rate ranged 0.2% to 32.0%, with a median of 8.0%. The diagnosis with the largest variation in procedural sedation use was dislocation, with sedation rates ranging from 2% to 35%. There is significant variability across pediatric EDs in the use of procedural sedation, suggesting sedations may be performed too often or too little in some hospitals.

To estimate the prevalence of and identify sociodemographic risk factors for sedative medication use in the general Canadian population, and to examine the association between sedative medication use and body mass index (BMI). Cross-sectional study Canadian population Participants from the 1994-2003 Canadian national health surveys, the National Population Health Survey (NPHS) and the Canadian Community Health Survey (CCHS). For the 2003 CCHS, n = 134,072, ages 12-80+ years. Not applicable The overall prevalence of sedative medication use in Canada in 2003 was 5.5%, having more than doubled since 1994. Notable rises in sedative medication use have occurred among men, non-elderly, and obese individuals. After adjusting for potential sociodemographic and health status confounders, including psychiatric comorbidities, the odds of sedative use were significantly greater among morbidly obese (BMI ≥ 35 kg/m(2)) men (OR = 1.89, 95%CI = 1.02-3.53) and underweight (BMI < 18.5 kg/m(2)) women (OR = 2.11, 95%CI = 1.26-3.53). The use of sedative medications has substantially risen among the general Canadian population, and among particular population subgroups. The greater odds of sedative medication use found among morbidly obese men may reflect the presence of underlying obstructive sleep apnea, which may in turn serve to explain in part the known relationship between sedative medications and mortality. The increase in sedative medications coupled with their known adverse health associations raises potential public health concerns.