Additional Sedation Research Articles

518 Optimizing Inpatient Colonoscopy Preparation: A QI Project

INTRODUCTION: Hospitalization is an independent risk factor of poor bowel preparation and it has a lower procedure completion rate as compared to outpatients. Ineffective inpatient colonoscopy preparation may lead to delayed or canceled procedures which subject the patient to additional bowel preparation and sedation. Subsequently it results in patient inconvenience, increased cardio-pulmonary complications, longer hospital stays, and increased hospital cost. METHODS: Defining the problem: Chart review of the inpatient colonoscopies performed between May and July 2017 revealed that 4 liters-single dose polyethylene glycol–electrolyte lavage solution [PEG-ELS] was used in more than 90% of the inpatient colonoscopies. The percentage of colonoscopies with a rating of fair or poor was 36%. On average, 15% of patients failed inpatient bowel preparation. Aim of the project: To reduce the percentage of failed inpatient colonoscopies to less than 10% by May 2018 and to reduce the percentage of inpatients colonoscopies with an inadequate bowel preparation by 5% by May 2019. Interventions: 1) Fellows education on the evidence based split-dose regimen. 2) Bowel prep quality deemed adequate if cecal intubation was successful and prep was satisfactory to identify the targeted lesions. 3) Nothing by mouth orders to be started at 4 am or later instead of traditional after midnight orders. 4) Notify MD orders if the patient has any problem with the bowel prep to enhance communication with nurses. 5) As needed orders for nasogastric tube placement for administration of the prep. 6) An order set was implemented in Epic to facilitate the process and make it uniform. RESULTS: After the first PDSA cycle (Sep 2017-May 2018), we were able to reduce the percentage of failed inpatient colonoscopies from an average of 15% to less than 5% and we reduced the percentage of inadequate bowel prep by 4% (Goal of 5%). In the second PDSA cycle (May 2018-May 2019), we maintained the percentage of failed inpatient bowel preparation under 10% (4.2-7.5%) and reduced the percentage of inadequate bowel prep 17% from the baseline. CONCLUSION: Implementing a split-dose regimen of 4 liter PEG-ELS for all inpatient colonoscopies, improving communication between nurses and ordering physicians, and executing a standard order set for bowel prep orders and instructions are successful strategies in optimizing inpatient bowel preparation. The reliability of the bowel preparation quality scales needs to be validated for use in inpatient colonoscopies.

Awake Sedation With Propofol Attenuates Intraoperative Stress of Carotid Endarterectomy in Regional Anesthesia

Carotid endarterectomy in regional anesthesia is often associated with increased perioperative stress. We assumed that carotid endarterectomy performed under awake sedation with propofol is more beneficial to prevent such stress than alprazolam premedication only. A total of 47 consecutive patients with significant carotid artery stenosis were enrolled into this investigation and followed up for 5years to explore vascular complications. All operations were performed under regional anesthesia. As premedication, all patients took 0.5mg of alprazolam 30minutes before the procedure. After randomization, 22 patients had awake sedation with target controlled propofol infusion, and the other 25 had only premedication. Cortisol plasma levels were serially analyzed: before surgery (T1), before (T2) and after release of carotid clamp (T3), and at 2 (T4) and 24 postoperative hours (T5). Alprazolam levels were also measured before and after the surgery. The plasma concentration of cortisol was significantly lower in the propofol sedation group at T2 (P<0.001), T3 (P=0.001), and T4 (P<0.001) than in the alprazolam-only group. Alprazolam levels did not correlate with cortisol levels at any time point. A significant positive correlation was found between the clamp time and plasma cortisol level at T3 (P=0.018), similarly between the degree of contralateral carotid stenosis and plasma cortisol level at T3 (P=0.03). Plasma cortisol concentration 2hours after the operation (T4) proved to be an independent predictor of carotid restenosis during the 5-year follow-up (odds ratio: 1.67, 95% confidence interval: 1.02-2.73, P=0.04). An additional intraoperative propofol sedation provides better stress relief than alprazolam-only premedication during awake carotid endarterectomy.

Study of online information for anxious patients requiring dental extractions.

Introduction Standard practice for dental extractions is to provide treatment under local anaesthesia (LA) without additional sedation or general anaesthesia. Even in oral surgery departments, the majority of patients receive this anxiety-provoking treatment under LA alone. All patients undergoing extractions could benefit from information on relaxation and anxiety management. This study aims to perform an in-depth analysis of the quality of websites that provide information on dental extractions and anxiety.Materials and methods Key phrases were searched on Google. The content, reliability and readability of the top ten websites for each key phrase were qualitatively evaluated using three tools: DISCERN, Flesch-Kincaid, and a specialised oral surgery website checklist (OSWC).Results Patient education was limited, with 70% of websites being either advertisements, forums or articles for healthcare professionals. The majority of websites poorly described treatment such as sedation and only 16% provided methods for relaxation. Readability was poor, with 92% above average UK adult literacy ability.Conclusion Extraction patients should be signposted to effective resources before treatment or referral. Dental anxiety advice can easily be incorporated into all treatment plans, with recommended website links included in digital communication, such as text messages or practice websites.

Deep Tracheal Extubation Using Dexmedetomidine in Children With Congenital Heart Disease Undergoing Cardiac Catheterization: Advantages and Complications.

Objective. Deep tracheal extubation using dexmedetomidine is safe and provides smooth recovery in children with congenital heart disease undergoing cardiac catheterization. Design. Single-institution, retrospective study of prospectively collected data. Participants. All patients aged between 1 month and 5 years who underwent general endotracheal anesthesia for diagnostic and interventional cardiac catheterizations in the cardiac catheterization suite from January 2015 (change in standard operating procedure) through October 2016 (approval of institutional review board for study). Measurement and Main Results. One hundred and eighty-nine patients (81%) of the 232 patients who underwent cardiac catheterization during the study period were noted to undergo deep tracheal extubation. Cyanotic heart disease was present in 87 patients (46%), history of prematurity in 51 (27%), and pulmonary hypertension in 26 (14%) patients. A documented smooth recovery in the postoperative care unit (PACU) requiring no additional analgesics or sedatives was observed in 91% of the patients. The majority of patients required no airway support after deep extubation (n = 140, 74%, P = .136). The presence of pulmonary hypertension (odds ratio = 4.45, P = .035) and presence of a cough on the day of the procedure (odds ratio = 7.10, P = .03) were significantly associated with the use of oxygen or use of oral airway for greater than 20 minutes in the PACU. After extubation, there were no reported events of aspiration, the use of noninvasive positive pressure ventilation, reintubation, heart block, or systemic hypotension requiring treatment or cardiac arrest. Conclusions. Deep extubation using dexmedetomidine in infants and toddlers after cardiac catheterization is feasible and enables smooth postoperative recovery with minimal adverse effects.

Sonotherapy in the reduction of anxiety and postoperative pain in patients with regional anesthesia as a sole technique: randomized, controlled clinical trial.

To determine if sonotherapy reduces the anxiety level and postoperative pain in adults undergoing outpatient orthopedic surgery under regional anesthesia. A randomized, double-blind, placebo-controlled study in 80 adult patients undergoing orthopedic surgery, 40 received intervention with sonotherapy and 40 did not receive it. Pain, anxiety in the preoperative period, immediate postoperative, high, 24 and 48 hours later were measured. Hemodynamic parameters were measured in four moments. No significant differences were found between the two groups in the pain scales neither anxiety. A significant reduction of the systolic blood pressure was observed after the application of sonotherapy and in recovery. There was no difference in other hemodynamic variables such as heart rate, respiratory rate, arterial oxygen saturation or diastolic blood pressure between groups, however, the observed changes in some of them occurred faster in the intervention group. In adult patients undergoing outpatient orthopaedic surgery under regional anaesthesia, sound therapy is a novel strategy that significantly reduces systolic blood pressure, considered as an indicator of decreased anxiety. However, in our study, no difference could be demonstrated in terms of pain control or the need for additional sedation or analgesia.

Subcoronal inflatable penile prosthesis under local anesthesia

Utilizing local anesthesia (LA) with inflatable penile prosthesis (IPP) surgery is getting more attention worldwide due to its favorable effect on postoperative pain control and cost effectiveness in patients without third party coverage. From Jan 2015 to Dec 2018, we have performed subcoronal incision under LA in 557 first time IPP patients and 84 cases (15%) required additional sedation particularly for reservoir placement. Compared to infrapubic and penoscrotal incisions, subcoronal approach seems to be particularly suited to LA because of unhampered visual field after the anesthetic injection. LA was achieved with 1% lidocaine & 0.75% ropivacaine mixture injected through 10 cc syringe with 25G, 1.5-inch needle. Two injections were done; one before the incision and one following penile degloving. The patient’s skin is prepped with Chlorhexidine while patient is in the frog leg position; the frog leg position is maintained for the preoperative block consisting of bilateral pudendal blocks, penile root blocks & direct inguinal block on the side utilized for reservoir placement. 25 cc of the anesthetic mixture is consumed by these injections. After circumcision incision and penile degloving, we inject the following intraoperative sites: each anterior area of proximal corpora, scrotal septum, and each corpus where incision will be made. If inguinal block was uncertain, additional anesthetic injection under direct vision while inguinal ring is retracted. Mean patient pain scale on local anesthesia was 2.74 and following the surgery was 4.24. Conscious sedation was used as a supplement in 84 cases (15%). There was no case of conversion to spinal or general anesthesia and 485 patients (87%) said that they would have IPP surgery again under local anesthesia. We firmly believe IPP Placement via subcoronal incision under local anesthesia can be done to first time implant patient cost effectively and with acceptable patient discomfort.

Assessment of different pain management methods for the treatment of claw lesions in Meat Merino ewes

Pain management during veterinary procedures is a significant component of animal welfare and has legal as well as ethical implications. Even though regional intravenous anaesthesia (RIVA) is an accepted method for painful procedures involving the distal digits of sheep, this anaesthetic technique is rarely applied in the field. The primary goal was to investigate the feasibility, safety and efficacy of RIVA in sheep. A secondary goal was to examine whether the anaesthetic procedure can be improved by combining RIVA with sedation and whether these methods have a positive effect on the postoperative wellbeing of the animals. A total of 36 Meat Merino sheep with contagious interdigital dermatitis and 12 healthy control sheep were used. Behaviour was observed during treatment of the lame sheep using various pain management protocols and during routine claw trimming of the healthy sheep, and all the sheep were observed after the procedures. The observed behaviours were assessed using scores and the scores compared among the animals of the 4 study groups (RIVA, sedation with xylazine hydrochloride + RIVA, placebo, control). RIVA was successfully conducted in sheep. Local reactions at the application sight and in the tourniquet area in 2 animals resolved completely. A significant reduction in defensive movements during the painful procedure confirmed the efficacy of RIVA. Stress-associated behaviours, including head shaking and idle chewing, occurred with a similar frequency in RIVA and placebo animals, leading to the conclusion that stress levels due to the handling in dorsal recumbency were comparable between these 2 groups. Sedation reduced the frequency of pain- and stress-associated behaviours, including guarding, favouring limbs, vocalisation, idle chewing and bruxism. Xylazine hydrochloride-RIVA animals displayed better weight-bearing in the affected limb, better food uptake and ruminated more postoperatively than sheep from the other study groups. RIVA in sheep is straightforward, safe and effective. Additional sedation reduces the stress and pain response. This pain and stress management has a positive effect on the postoperative wellbeing of sheep.

Pruritus and myoclonus following five consecutive doses of morphine administered through an epidural catheter in a dog

A 2-year, 10-month-old male entire whippet had an epidural catheter placed to provide postoperative analgesia following lateral thoracotomy. He received 0.1 mg/kg preservative free morphine every 12 hours via the...

Are Office-Based Oral and Maxillofacial Surgical Procedures Profitable? A Benefit–Cost Analysis

Although many oral and maxillofacial surgical (OMS) procedures might seem to be profitable, no current data have analyzed the costs versus benefits of performing office-based OMS procedures. The purpose of the present study was to analyze the costs of performing 6 common office-based OMS procedures compared with the reimbursement rates for those same procedures. The present study was a cross-sectional, microcosting survey analyzing the costs of materials used in the outpatient Oral-Maxillofacial Surgery clinic at the University of Texas Health Science Center at San Antonio. The costs incurred were based on dental procedure coding and national statistical databases and not on actual patient interactions. The primary predictor variable was the procedure costs for 6 commonly performed outpatient OMS procedures using 3 types of trays: a simple tray, a surgical tray, and an implant tray. The ancillary materials were listed for as-needed use for each tray. The primary outcome variable was the revenue after expenses per procedure. Descriptive statistics were computed. The net profit or net loss of performing 6 commonly performed outpatient OMS procedures was analyzed by subtracting the cost of performing the procedure from the insurance reimbursement for those procedures. Without the addition of sedation to the procedures, routine extractions had a net loss of $230 to $261, surgical extractions had a net loss of $153 to $242, and incision and drainage procedures had a net loss of $212 to $311. Furthermore, preprosthetic procedures had a net loss to net profit of -$269 to+$140, and pathologic procedures had a net loss to net profit of -$269 to+$326. Only implant procedures yielded a net profit of $847. The results of the present study have demonstrated that not all routine OMS procedures are profitable when performed alone without the inclusion of additional procedures or sedation.

Subpectoral pacemaker implantation under tumescent local analgesia

Tumescent local analgesia (TLA) is an anesthetic technique used for inducing local analgesia over large areas and is rarely used in cardiothoracic surgery. An 83-year-old, extremely thin woman was hospitalized with sick sinus syndrome, requiring pacemaker implantation. We chose a subpectoral mode of implantation to prevent skin complications. General anesthesia was deemed risky due to the history of chronic pulmonary disease; therefore, the operation was successfully performed under TLA. Moreover, TLA helped introduce a subpectoral pocket for implanting the pacemaker with minimal trauma and bleeding. The analgesia was sufficient, with minimal postoperative pain, and required no additional sedatives and analgesics. The patient was discharged without any complications.

Ultrasound-guided combined pectoral nerve block and axillary venipuncture for the implantation of cardiac implantable electronic devices.

Combined ultrasound (US)-guided pectoral nerves (PECS) block and axillary vein (AV) puncture for cardiac implantable electronic devices can be effective to achieve optimal perioperative pain management and prevent access-related complications. A total of 36 patients who underwent combined US-guided PECS block and AV puncture were included. All routinely recorded parameters, including clinical and demographic characteristics, periprocedural medical administrations, the time taken for both PECS block and AV puncture, procedure time, postprocedural pain score, and procedure-related complications, were collected and analyzed. In total, 54 leads were placed in 36 patients. The combined US-guided PECS block and AV puncture was performed successfully in 35 (97.2%) patients without the need for fluoroscopy or venography. AV access for each lead was achieved in a single attempt in 80.6% of cases. The time for both PECS block and AV puncture was 223.6 ± 52.1 s, including the time to apply incision site anesthesia. Additional sedatives and/or local anesthetics were required in two patients during procedure. Visual analog scale average of the patients in the 1st, 6th, and 24th h was 3.7 ± 1.14. 1.61 ± 1.29, and 0.08 ± 0.28, respectively. After the procedure, four patients (three of them woman) needed analgesics. There were no venous access-related complications. This new combined technique maintains both surgical and postoperative analgesia and prevents vascular access-related complications without significant increase on procedure time.

Effects of easy listening music intervention on satisfaction, anxiety, and pain in patients undergoing colonoscopy: a pilot randomized controlled trial.

Purpose: The purpose of this study was to examine the effects of an easy listening music intervention on satisfaction, anxiety, pain, sedative and analgesic medication requirements, and physiological parameters in Chinese adult patients undergoing colonoscopy in Hong Kong.Patients and methods: Patients undergoing colonoscopy, aged 45 or older, able to communicate in Chinese, and hemodynamically stable were invited for the study. A randomized controlled trial was adopted. Eligible patients were randomly assigned either to a music group, which received standard care and additional easy listening music (a series of 15 popular non-rock Chinese songs) through earphones and MP3 for 20 mins before and during the procedure, or to a control group which received standard care only. Standard care comprised of all nursing and medical care provided for patients undergoing colonoscopy. Measures comprised of the State-Trait Anxiety Inventory, visual analog scales of pain level, procedure satisfaction and satisfaction with pain management, the use of sedative and analgesic drugs, heart rate, and blood pressure data were collected at baseline (T0), during (T1) and 30 mins after the procedure (T2).Results: Eighty participants (40 music vs 40 control) completed the study with no attrition. Participants in the music group reported significantly higher levels in both procedure satisfaction (p=0.043) and satisfaction with pain management (p=0.045) than those in the control group. No significant difference was found between groups on anxiety, pain, additional sedative and analgesic use, heart rate, and systolic and diastolic blood pressure (p>0.05). Nevertheless, most participants appreciated the songs provided in MP3 and found it helpful for relaxation during the procedure and would prefer it again (p<0.001).Conclusion: Easy music listening can enhance patients’ satisfaction in both procedure and pain management for adults undergoing a colonoscopy procedure.

Dexmedetomidine Sedation After Tracheal Surgery: A Prospective Pilot Study

Fourteen adults undergoing tracheal resection and reconstruction surgery were enrolled in this prospective observational pilot study to evaluate dexmedetomidine-based sedation after tracheal surgery in an intensive care unit. Patients remained electively intubated with an uncuffed nasal endotracheal tube, awake and exhibiting spontaneous breathing. The neck was maintained in flexion through chin-to-chest sutures. Infusion of dexmedetomidine was started from a dosage of 0.7 μg·kg-1·h-1 followed by dose titration to the target level of the sedation Richmond Agitation Sedation Scale (RASS) score -1 to -2 using a dose range of 0.2 to 1.4 μg·kg-1·h-1. The mean sedation levels were within the target ranges during the entire 18-hour observation period with a significant decrease in RASS (baseline RASS, 1.43 ± 0.51; 18h RASS -0.86 ± 0.95; p < 0.005). The mean arterial pressure (MAP) and heart rate (HR) weresignificantly decreased during dexmedetomidine infusion (baseline MAP 90.29 ± 14.33 mm Hg versus 18-hour MAP 82.50 ± 15.44 mm Hg; baseline HR 81.50 ± 12.76 beats/min versus 18-hour HR 69.29 ± 10.21 beats/min; p < 0.005). The visual analog scale (VAS) scores significantly decreased (baseline VAS 4.14 ± 0.86 versus 18-hour VAS 2.79 ± 0.67; p < 0.005). Peripheral oxygen saturation did not exhibit any significant decrease. Bradycardia occurred in 1 patient who assumed beta-blocker therapy without significant changes in blood pressure and was resolved by titration of the infusion without suspending sedation. No cases of delirium were encountered, and no additional sedative or analgesic was required. Dexmedetomidine provided safe and effective sedation after tracheal surgery in spontaneous breathing patients without causing respiratory depression.

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics.

Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. There were 15,918 patients included (median age 37years, 75% male). Rescue rates at 1h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. Olanzapine and droperidol lead to lower rates of rescue sedation at 1h and overall, compared with haloperidol. There were no significant differences in major adverse events.

Ectopic Balloon Device Placement to Correct the Positional Hepatic Venous Outflow Obstruction in Liver Transplantation.

Hepatic vein outflow obstruction in liver transplantation can lead to graft or patient loss. We used an intrauterine balloon to overcome this complication in 13 liver transplant recipients. Here, we report the results of these cases; our report, as far as we know, involves the highest number of patients on this issue. Positional hepatic vein outflow obstruction was diagnosed in 13 of 651 liver transplant recipients between January 2014 and December 2016. The grafts were repositioned by intrauterine balloon placed to the right subdiaphragmatic area. Data of donors, recipients, and grafts and postoperative courses were analyzed. Of the 13 patients, 9 were men, with age range of patients of 22 to 70 years. The amount of saline used to inflate the balloon was variable (200-450 cm3), and hepatic vein outflow obstruction was relieved after balloon implantation in all patients. There were no balloon-related complications. Removal was done at bedside, without any additional sedation or any additional skin incision on days 2 to 15. Doppler ultrasonography scans were performed before and after the balloon removal. There were no vascular complications after removal. Intrauterine balloon can be safely and efficiently used for hepatic vein outflow obstruction during liver transplant when needed.

A Simplified Digital Workflow for the Treatment of Pediatric Mandibular Fractures Using Three-Dimensional (3D) Printed Cap Splint: A Case Report

Pediatric mandibular fracture needs special consideration by clinicians. The management of pediatric mandibular fracture differs from that in adults considering the presence of tooth germs and the potential for mandibular growth. One of the most common forms of conservative management for pediatric mandibular fractures is the use of cap splint along with circummandibular wiring. The conventional workflow prior to performing surgery with this technique is impression taking and dental model fabrication. Additionally, it is also recommended that mock surgery should be performed to achieve proper reduction before acrylic splint fabrication. However, these procedures are effortful and time consuming when performed under general anesthesia during surgery and require additional sedation if performed prior to surgery. The aim of this case report is to describe a simpler preoperative digital workflow for the treatment of pediatric mandibular fractures, in which closed reduction is achieved with a three-dimensional printed cap splint stabilized with circummandibular wiring under general anesthesia.

Passive Leg Raise: Feasibility and Safety of the Maneuver in Patients With Undifferentiated Shock.

Passive leg raise (PLR), in combination with technologies capable of capturing stroke volume changes, has been widely adopted in the management of shock. However, dedicated evaluation of safety, feasibility, and receptiveness of patients and nursing staff to PLR maneuver is missing. A noninterventional, prospective trial recruited adult patients with onset of undifferentiated shock within 24 hours with persistent vasopressor requirements despite fluid resuscitation. A standardized PLR maneuver was used to compare two noninvasive hemodynamic monitoring systems, each without significant impact on the performance of the maneuver. Safety and efficacy of the PLR were evaluated via subjective and objective measures. Objective measures of patient comfort and tolerance were evaluated through changes in vital signs, sedation, and analgesia requirements. Nurses and awake patients completed surveys on their experience. Seventy-nine patients were enrolled. Testing was aborted in 2 cases for medical reasons (one patient developed rapid atrial fibrillation, second had profound desaturation). Of all, 5.4% of patients required additional vasopressor support after completion of the PLR maneuver due to persistent hypotension and 4.1% of patients required additional sedation. Among awake patients (N = 35), 6% reported pain and 29% reported discomfort. A total of 11% of nurses reported minor technical difficulties with the maneuver. Passive leg raise maneuver leads to a few serious but reversible complications in a selected population of hemodynamically unstable patients. Although it provides relevant diagnostic information, it may impact patient care. Treating physician should be aware of infrequent but possible complications and appreciate the impact of the maneuver on patients' comfort and nursing workload.

A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance

Study objective: Although uncommon, children (<16 years) with acute behavioral disturbance are a significant issue for emergency medical service providers. In this study, we aimed to investigate the safety and effectiveness of droperidol in children with prehospital acute behavioral disturbance. Methods: This was a prospective observational study over 1 year investigating the use of droperidol (0.1–0.2 mg/kg) for children (< 16 years) with acute behavioral disturbance. Inclusion criteria for acute behavioral disturbance were defined by a sedation assessment tool score of ≥2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturation <90% and/or respiratory rate <12, systolic blood pressure <90 mmHg, sedation assessment tool score of −3 and dystonic reactions). Secondary outcomes included time to sedation (sedation assessment tool score decreased by 2 or more, or a score of zero), requirement for additional sedation, failure to sedate and proportion of sedation success defined as the number of patients successfully sedated who did not suffer any adverse events or receive additional sedation. Results: There were 96 patients (males 51 [53%], median age 14 years [range 7–15 years]) who presented on 102 occasions over the one year study period. Self-harm and/or harm to others was the commonest (74/105 [70%]) cause of acute behavioral disturbance followed by alcohol (16/105 [15%]). There were 9 adverse events in 8 patients (8/102 [8%]; 95% confidence intervals [CI]: 3–13%) Five patients had hypotension, all asymptomatic and only one required treatment; 2 dystonic reactions managed with benztropine and one patient with respiratory depression. Median time to sedation was 14 min (interquartile range (IQR): 10–20 min; range: 3–85 min). There was no requirement for prehospital additional sedation (0/102 [0%]; 95% CI: 0–4%) and additional sedation in the first hour of arrival to hospital was required by 4 patients (4/102 [4%]; 95% CI: 1–10%). Overall successful sedation was achieved in 89 (87%) patients. Conclusions: The use of droperidol in children for acute behavioral disturbance in the prehospital setting is both safe and effective.

Ostéosynthèse des fractures du radius distal en mini-open et en WALANT par plaque verrouillée antérieure

The aim of this comparative and prospective study was to evaluate the feasibility and benefits of a mini invasive pronator-sparing technique for radius distal fracture treated with volar locking plate performed with a WALANT anesthesia. Sixty patients (from June 2016–June 2017) with an extra articular fracture of the distal radius and a mean age of sixty two years were managed with a distal volar plate and an in situ catheter for continuous diffusion of Ropivacaine during 48 hours after surgery. There were two groups (30 patients per group). Patients of the first group receive a WALANT anesthesia (Lidocaine 1%, epinephrine 0.05/10 ml). In the second group patients have had an ultrasound guided axillary block and a tourniquet. The following points were monitored: duration of the procedure, need for additional anesthesia or sedation during the surgery, patient discomfort. Pain was evaluated with a visual analog scale at Day 0, Day 1, Day 2, Day 3, Day 7, and Day 45. A clinical and radiological evaluation was made at 6 weeks and 3 months after surgery (range of motion, anatomical alignment and screw placement). The study was approved by our local ethics committee. All the patients were available at the last follow up. In the group I (WALANT) VAS (D0/D1/D2) was significantly lower than in the group II (2.2/3.5/4.9 vs 4.1/4.8/6.2). The were no difference of the results of VAS after Day 2. In the group I no patients received a sedation, while in group II 4 patients required additional analgesia. During the procedure, and only in group II, 2 patients complained about pain at the wrist, 12 of discomfort at the tourniquet and 8 patients were anxious about not knowing where their arms were located. At the last follow up there was no significant difference between the two groups for the duration of the procedure, range of motion and for the anatomical alignment. A reflex sympathetic dystrophy syndrome occurred for 3 patients of the second group. The use of WALANT for open reduction and internal fixation of distal radius fractures allows clinical and anatomical results identical to those obtained with conventional techniques. Moreover, WALANT seems to be a powerful tool for risk management of reflex sympathetic dystrophy syndrome.

Intravenous magnesium sulphate infusion as first-line therapy in the control of spasms and muscular rigidity in childhood tetanus

ABSTRACTBackground: Reports suggest that, in tetanus, magnesium sulphate (MgSO4) alone may control muscle spasms, thereby avoiding sedation and mechanical ventilation.Aim: To study the efficacy and safety of intravenous MgSO4 in controlling spasms and rigidity in children with tetanus.Methods: All children with tetanus consecutively admitted over a 2-year period in a tertiary-care teaching hospital were recruited. In addition to human tetanus immunoglobulin and parenteral metronidazole, patients received MgSO4 100 mg/kg intravenously followed by infusion at 40 mg/kg/hr. The infusion rate was increased by 5 mg/kg/hr every 6 h until cessation of spasms or abolition of the patellar tendon reflex. Efficacy was determined by control of spasms. Time to commencement of feeds, frequency of autonomic instability, the need for ventilatory support, duration of hospitalisation and mortality were also recorded.Results: Twenty-seven children with tetanus aged between 18 months and 10 years were recruited. A contaminated wound was the most common portal of entry of tetanus spores. The incidences of severity were: grade I, 3; grade II, 7; grades IIIa and b, 17. Rigidity and spasms were controlled by magnesium therapy alone in 14 patients. Additional sedation was required for 13 patients (grade II, 1; grade III, 12). Feeding could be commenced early in five patients. Mechanical ventilation was required in eight patients. The mean (SD) duration of hospitalisation was 26.5 (12.0) days. Five patients died (18.5%). Asymptomatic hypocalcaemia was a universal finding and was treated with calcium supplements.Conclusion: MgSO4 alone is effective in mild-to-moderate tetanus but not when it is severe.