Adequate Level Of Sedation Research Articles

Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

Comparison of Butorphanol, Methadone, and Pethidine in Combination with Alfaxalone for Premedication in Isoflurane-Anesthetized Cats Undergoing Ovariectomy.

The aim of this study was to compare three different anesthetic protocols administered intramuscularly (IM) in cats undergoing elective ovariectomy, while evaluating the quality of sedation, antinociceptive, isoflurane-sparing effect, and analgesia in the intra-operative and post-operative phases. A total of 71 female cats were sedated IM with alfaxalone (3 mg/kg) combined with either butorphanol (0.3 mg/kg), methadone (0.3 mg/kg), or pethidine (5 mg/kg). During surgery, vital parameters were constantly monitored; at the end of the procedure, the quality of recovery was assessed through a specific form and each cat was scored for perceived pain using the UNESP-Botucatu scale for 5 days, and rescue analgesia was provided with buprenorphine IM when indicated. Moreover, differences between two different post-operative resting regimens (hospital kennels vs. home) were also assessed. A significant difference emerged for the amount of IM dexmedetomidine required to achieve an adequate level of sedation for intravenous catheterization, highlighting a greater need in the pethidine group (p = 0.021). There was no significant difference between opioid groups for the requirement of intra-operative rescue analgesia, and the clinical parameters were kept within physiological ranges regardless of the opioid used in premedication. Lastly, differences between the UNESP-Botucatu scores were detected from day 3 to day 5 post-operatively, with lower scores in cats with home resting regimens compared to the hospitalized animals, likely due to the presence of an unfamiliar condition and the absence of a cat-friendly environment.

Comparative study of midazolam–dexmedetomidine combination with propofol for sedation during awake fiberoptic nasotracheal intubation

Aim and objective The present study was conducted to compare the efficacy and safety of dexmedetomidine and midazolam with propofol alone for sedation during awake fiberoptic nasotracheal intubation. The study was conducted on 40 patients of either sex aged between 18 and 60 years belonging to ASA I–II grade scheduled for elective surgery. The patients were randomly divided into two groups of 20 patients each. Group I patients received intravenous midazolam 0.02 mg/kg followed by dexmedetomidine 1 μg/kg bolus infusion over 10 min, and then an infusion of dexmedetomidine 0.1 μg/kg/h and titrated to 0.7 μg/kg/h to achieve an adequate level of sedation. Group II patients received intravenous propofol 6 mg/kg/h bolus over 10 min with an additional dose of 2.4 mg/kg/h as infusion until they were adequately sedated. Hemodynamic parameters, comfort scale values, and patient’s tolerance were assessed. Patients and methods Fiberoptic nasotracheal intubation was done in both groups of patients, and after securing the tube, general anesthesia was administered. Within 24 h of the surgical procedure, each patient was asked to assess their experience with awake fiberoptic intubation. The data were recorded in the proposed proforma, and the final result was analyzed statistically. Results During sedation during fibreoptic procedure (FOS) and ET insertion, pulse rate (P=0.0116), systolic blood pressure (P=0.30), diastolic blood pressure (P=0.326), oxygen saturation (P=0.53), total comfort score (TCS) (P=0.031), and patient tolerance (P=0.023) were observed and showed statistically significant values. Conclusion Dexmedetomidine and midazolam group had a lower baseline mean heart rate. Systolic and diastolic blood pressure responses measured at preoxygenation, fiberoscope insertion and endotracheal tube placement were not significantly different for both patient groups. The five-point fibreoptic intubation scores showed better patient tolerance in the dexmedetomidine and midazolam group of patients and better comfort score as compared with propofol, and patients were calmer in the dexmedetomidine group.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Postoperative analgosedation with dexmedetomidine in combination with paracetamol in pediatric cardiac surgery

BACKGROUND: Although the principles of postoperative multimodal analgesia have been discussed in several articles, this issue remains insufficiently studied in pediatric cardiac surgery.
 AIM: To increase the effectiveness of postoperative analgosedation in children after heart surgery by combining intravenous dexmedetomidine and paracetamol.
 MATERIALS AND METHODS: Prospective, nonrandomized, controlled study (n = 65, 24 yr). Elective heart surgeries were performed in children with congenital heart defects, such as ventricular and/or interatrial septal defect and tetralogy of Fallot, under cardiopulmonary bypass and general anesthesia. Patients were divided into two groups according to the type of postoperative analgesia: group 1, main (n = 35): 30 min after surgery, infusion of dexmedetomidine with a loading dose of 1.0 g/kg/h or 10 min, then infusion of 0.8 g/kg/h during the day against the background of planned analgesia with paracetamol (15 mg/kg, intravenously) 2 h after surgery and then every 8 h during the day; group 2, comparisons (n = 30), 0.3 mg/kg morphine, intramuscularly. The effectiveness of postoperative analgosedation in children was analyzed using the Richmond scale and FLACC + hemodynamics, acid-base balance, blood gases, cortisol, glucose, and blood lactate.
 RESULTS: Sufficient stabilization of the main hemodynamics and respiratory indicators confirmed the adequacy of postoperative analgosedation in group 1 patients. There was a 14% drop in heart rate, specific peripheral resistance, and mean arterial pressure. There was no respiratory depression observed, and the decrease in blood pressure and heart rate was hemodynamically modest. Postoperative stability of blood lactate, glucose, and cortisol levels demonstrated the absence of major metabolic diseases and emotional and physical stress in the main group of children. The transfer of 74.3% of the first group's patients to the specialized department 42.3 5.5 h after the procedure decreased costs and strain on the intensive care unit staff.
 CONCLUSIONS: Dexmedetomidine combined with paracetamol provides an adequate level of sedation, suppresses extubation irritations, prevents psychomotor agitation, and provides sufficient analgesia.

Alfaxalone provides reliable sedation for intradermal allergen testing in dogs and does not significantly affect results when compared to dexmedetomidine.

Dexmedetomidine (Dexmedetomidine hydrochloride-Dexdomitor; Zoetis) is the preferred sedative used for canine intradermal allergen testing (IDT) in the United States. Alfaxalone (Alfaxan Multidose; Jurox Animal Health) is a neuroactive steroid, and its effect on sedation and allergen reactivity scores is unknown. We hypothesised that alfaxalone would produce an adequate level of sedation with fewer cardiovascular adverse effects and would not affect allergen reactivity scores or histamine wheal size compared to dexmedetomidine. Twenty client-owned dogs were included in two groups: 10 atopic and 10 nonatopic. In a randomised, controlled, blinded, cross-over design all dogs underwent two modified IDT, 1-4 weeks apart, using intravenousdexmedetomidine (2.87-5.22 μg/kg) or alfaxalone (1.8-2.4 mg/kg). Anaesthetic parameters and sedation level were recorded over 25 min using a validated canine sedation scale described by Grint et al. (Small Anim Pract, 2009, 50, 62). Simultaneously, both objective and subjective reactivity scores were measured in technical triplicates at 10, 15 and 20 min. The modified IDT included eight allergens, histamine-positive and saline-negative controls. Alfaxalone produced a significantly higher sedation score across all time points (p < 0.05). All objective scores were significantly correlated to the corresponding subjective scores (Spearman R = 0.859, p < 0.0001). Sedative used did not significantly affect subjective allergen scores for nine atopic dogs (p > 0.05, 15 min). Sedative used did not affect the diameter of objective scores for individual allergens and histamine wheals (p > 0.05, 15 min). Intravascular alfaxalone is an alternative sedative for IDT in dogs. Alfaxalone may be preferred to dexmedetomidine in some clinical scenarios as a result of having fewer cardiovascular adverse effects.

Two-center randomized controlled trial comparing oral chloral hydrate and intranasal combination of dexmedetomidine and ketamine for procedural sedation in children: study protocol

BackgroundOral chloral hydrate is widely used in pediatric sedation. Intranasal dexmedetomidine has been increasingly used for pediatric sedation; however, its improvement is warranted. The combination of dexmedetomidine with ketamine can improve onset and hemodynamic stability while maintaining sedative efficacy. This study aims to determine the efficacy and safety of intranasal combination of dexmedetomidine and ketamine compared to oral chloral hydrate.MethodsThis is a prospective, parallel-arm, single-blinded, two-center, superiority randomized controlled trial with 1:1 allocation, designed to compare the effects of intranasal combination of dexmedetomidine and ketamine with those of oral chloral hydrate. We shall enroll 136 patients aged < 7 years old in this study. Prior to the procedure, we shall randomize each patient into the control group (oral chloral hydrate 50 mg/kg) or study group (intranasal dexmedetomidine 2 μg/kg and ketamine 3 mg/kg). The primary outcome will be the rate of achieving an adequate sedation level (6-point Pediatric Sedation State Scale 1, 2, or 3) within 15 min. In addition, we shall measure the sedation time, sedation failure rate, completion of procedure, adverse events, patient acceptance, and physician satisfaction.DiscussionThis study will provide evidence of the efficacy and safety of the intranasal combination of dexmedetomidine and ketamine in comparison with oral chloral hydrate.Trial registrationClinicalTrials.gov, NCT04820205. Registered on 19th March 2021

Evaluation of Propofol-Sparing Effect of Intravenous Lignocaine in Patients Undergoing Daycare Upper Gastrointestinal Endoscopic Procedures.

Background Propofolis the most commonsedativefor endoscopies. Propofol alonemay require larger doses for adequate level of sedation. Lignocaine is known for its anesthetic-sparing effect. We tested whether the addition of intravenous lignocaine to propofol-based sedation reduces its dose. Methods Thisprospective, randomized study was performed on 90 patients of 18 to 60 years of age, of either sex of the American Society of Anesthesiologists (ASA) Grade-I & II, and was divided into two groups. Group L + P received IV bolus of 1.5 mg/kg 2% lignocaine over 10 minutes followed by 1.5 mg/ kg/ h infusion andgroup NS + P- received the equivalent volumes of normal saline in bolus and infusion. Patients were induced with fentanyl (2 µg/kg) and propofol (1 mg/kg).To maintain an adequate sedation level, a supplemental bolus of 0.5 mg /kg propofol was administered. Theoutcomes recorded werethe totaland supplemental amount of propofol administered, as well as recovery time. Results The mean supplemental propofolfor group L + P and group NS + P- 37.00 ± 29.93 and 58.67 ± 19.49 mg, respectivelyandmean total propofol consumption was 98.22 ± 34.00 mg and 131.11 ± 23.18 mg, respectively, (p < 0.001). Mean recovery time in group L + P was also shorter (5.22 ± 2.14 versus 9.96 ± 2.14). The incidence of adverse events like gag reflux, upper airway obstruction, pain on injection, and hypotension was significantly lower in group L + P (p < 0.05). Conclusion The addition of lignocaine to propofol-based sedation reduced the overall propofol requirement at the same time maintaining hemodynamic stability, spontaneous respiration, and early recovery.

Safety and Efficacy of Propofol- and Ketamine-Based Procedural Sedation Regimen in Pediatric Patients During Burn Repetitive Dressing Change: 10 Years Single Center Experience.

It is crucial to provide an adequate level of sedation and analgesia during burn dressing changes in the pediatric population due to the amount of pain and anxiety patients experience during the procedure. To evaluate the safety and efficacy of an intensivist-based deep sedation regimen using a combination of propofol and ketamine to provide procedural sedation to pediatric burn patients. This is a retrospective chart review of pediatric patients who underwent inpatient burn wound dressing changes from 2011 through 2021. Demographic and clinical data, including age, length of the procedure, recovery time, medication doses, and adverse events, were collected. A total of 104 patients aged between 45 and 135 months with a median total burn body surface area (TBSA) of 11.5 percent (interquartile range [IQR] 4.0, 25.0) underwent 378 procedural sedation encounters with propofol- and ketamine-based sedation. The median total dose of propofol was 7 mg/kg (IRQ 5.3, 9.2). Of these sedations, 64 (17 percent) had minor adverse events, of which 50 (13 percent) were transient hypoxemia, 12 (3 percent) were upper airway obstruction, and 2 (0.5 percent) were hypotension. There were no serious adverse events. Hypoxemia was not related to age, weight, gender, burn TBSA, or total dose of propofol. There were 35 (33.6 percent) patients who had repetitive sedation encounters with no statistically significant changes in propofol dose or adverse events with the repeated encounters. Children can be effectively sedated for repetitive inpatient burn dressing changes. Given the high-risk patient populations, this procedure should be performed under the vigilance of highly trained providers.

Comparison of Monitored Anesthesia Care with Propofol Versus Dexmedetomidine for Awake Craniotomy: A Retrospective study

Abstract Background Anesthetic agents used for awake craniotomy should be safe, short-acting, titratable, and provide an adequate level of sedation and analgesia, along with facilitating adequate neurological assessment during the functional testing. Our study aims to review the efficacy and safety profile, along with the potential for neurophysiological monitoring, of two commonly used anesthetic regimens, i.e., propofol and dexmedetomidine. Methods After the Ethics Committee approval, a retrospective analysis of 51 patients who underwent awake craniotomy for brain tumor excision over a period of 7 years was done. Those who received monitored anesthesia care (MAC) were divided into two groups, namely, Group P for that received propofol, and Group D that received dexmedetomidine and their hemodynamic profile, perioperative complications, neuromonitoring techniques, and postoperative course was noted from the records. Results A total of 31 patients were administered MAC with propofol and 20 with dexmedetomidine. The baseline demographic data, duration of surgery, intensive care unit (ICU), and hospital stay were comparable between the two. The hemodynamic profile as assessed by the heart rate and blood pressure was also comparable. The incidence of intraoperative seizures was found to be less in Group P, though. Episodes of transient desaturation were observed more in Group P (9.7%) than in Group D (5%), but none of the patients required conversion to general anesthesia. Direct cortical stimulation was satisfactorily elicited in 80% in Group P and 85% in Group D. Conclusion MAC with propofol and dexmedetomidine are acceptable techniques with comparable hemodynamic profile, intraoperative and postoperative complications, and potential for neurophysiological monitoring.

Safety of Dexmedetomidine as an Alternative Pediatric Magnetic Resonance Imaging (MRI) Sedative: A Retrospective Single-Center Study.

BackgroundDexmedetomidine provides anxiolysis, sedation, dose-dependent hypnosis, and mild analgesia with minimal respiratory function effects. The aim of this study was to assess the efficacy and safety of dexmedetomidine for pediatric patients during MRI.Material/MethodsWe retrospectively analyzed 87 cases of pediatric sedations for MRI. Dexmedetomidine and a single dose of midazolam were used in all the cases, according to the in-house pediatric sedation protocol for MRI. The patients were divided in to 2 groups: group 1, who reached adequate sedation up to 10 min of induction and group 2, who achieved proper sedation after 10 min.ResultsThe median age was 3 years (0–17). The median duration of procedure was 75 min (40–150). The induction of standardized sedation was performed without additional sedatives and proper depth of sedation was reached in the majority of cases (94.3%). Five patients (5.7%) received additional sedative after 10 min of induction. The median time of adequate sedation was 8 min (3–13) after induction, and 51% of patients achieved RASS-4 in 8 min. There was no significant difference between groups 1 and 2. Ten patients (11.5%) experienced bradycardia, regardless of the usage of additional drugs, dexmedetomidine boluses, duration of the procedure, or induction time.ConclusionsHigh-dose dexmedetomidine with a single dose of midazolam might be an effective combination at the induction stage for pediatric sedation for MRI, with very few adverse events. Over 50% of enrolled patients achieved an adequate level of sedation before 10 min. We conclude that induction of dexmedetomidine infusion can be shortened up to 8 min.

Advantages of the combined use of dexmedetomidine and magnesium sulphate in alcohol withdrawal delirium

Annotation. The search for effective sedation schedule in management of alcohol withdrawal delirium, which would ensure both an adequate sedation level and sufficient safety profile, is an urgent problem of modern anesthesiology and intensive care medicine. In this respect, the aim of our study is to research the use of dexmedetomidine combined with magnesium preparations, which seems to be promising. The study was conducted on 80 patients with alcoholic delirium randomized into 4 groups, in which the following parameters were evaluated: delirium duration, plasma magnesium, hemodynamics parameters, presence of respiratory disorders, as well as the levels of urea, creatinine, transaminase, cortisol and serotonin in plasma. The control group patients underwent standard sedation therapy. In experimental group 1, standard sedation with benzodiazepines was supplemented magnesium sulfate. In group 2, we maintained infusion of dexmedetomidine. In group 3, we combined intravenous magnesium sulfas with dexmedetomidine infusion. Statistical processing was performed using: Mann-Whitney U-test, Wilcoxon T-test, and Kruskal-Wallace H-test. Duration of delirium proved to be significantly shorter in all study groups as compared to the controls, p &lt;0.05. The best sedation therapy results were recorded in group 3, p &lt;0.05. On the first day of treatment, all patients were found to have elevated MAP and heart rate, while significant improvement in hemodynamic parameters was observed on the third day, p &lt;0.05. Cases of hypotension were detected in groups 1 and 2. On the third day of treatment, the patients of groups 2 and 3 showed significant improvement in plasma levels of cortisol and serotonin as compared to the controls, p&lt;0.05, while serotonin level was higher in experimental group 3 as compared to the control patients, p&lt;0.05. The use of combination of magnesium with dexmedetomidine infusion proved to be beneficial and effective in treatment of patients with alcohol withdrawal delirium improving the quality of patients’ care and shortening delirium duration.

Deep sedation predicts pressure injury in patients admitted to intensive care units.

Patients in intensive care units (ICU) are frequently prescribed sedatives, which might increase the risk for pressure injury (PI). Although the association between sedation and incidence of PI has been noted, the adequate sedation level to prevent the incidence of PI in patients admitted to ICU is still unclear. This study aimed to investigate the association between fluctuating sedation levels and the incidence of PI in patients admitted to ICU. We retrospectively reviewed the medical records of 104 patients admitted to ICU. Data regarding the length of ICU stay (LOS) and comorbid infection were abstracted from medical records. The Richmond Agitation-Sedation Scale (RASS) was scored twice per day, and the standardized RASS (S-RASS, summation of RASS values divided by the number of samples) was used to evaluate changes in sedation levels. Among the 104 included patients, 65 patients (62.5%) were male (median age: 68.0 years), and 13 patients (12.5%) had PI during ICU admission. S-RASS scores were lower in patients with PI than in those without PI (P=.0001) even after adjustment for confounders (OR [95%CI]: 0.14 [0.03-0.58], P=.006). The LOS and infections were higher in patients with PI than in those without PI (P < .0001 and P=.005, respectively). The cut-off value of S-RASS for PI incidence was -3.2 (sensitivity: 88%; specificity: 85%), and a significant predictor of PI incidence (HR [95%CI]: 20.07 [2.53-159.11], P=.005). Deeper sedation levels based on S-RASS scores, which account for the effects of fluctuating sedation levels, were a strong, highly accurate predictor of PI incidence in patients admitted to ICU. Assessing fluctuations in the level of sedation using the S-RASS might help to identify sedative-induced PI in patients admitted to ICU.

A comparative study of dexmedetomidine and propofol infusion during monitored anesthesia care (MAC) in endoscopic retrograde cholangiopancreatography (ERCP): a randomized controlled trial

BackgroundEndoscopic retrograde cholangio-pancreatography (ERCP) is an invasive procedure and hence is distressing for awake patients, requiring adequate level of sedation and analgesia. Recent advancements have encouraged use of monitored anesthesia care (MAC), that allows the patient to tolerate unpleasant procedures while maintaining cardio-respiratory function. The main aim is to compare the effect of dexmedetomidine and propofol on the hemodynamics during ERCP, quality of sedation, recovery profile, and any side effects. A total of 100 patients were randomized by a computer-generated random number table into two groups of 30 patients each. The group P received continuous propofol infusion at a rate of 25-75 mcg/kg/min to achieve a Ramsay sedation scale (RSS) of 3-4 before starting the procedure. Group D received dexmedetomidine at loading dose of 1 μg/kg i.v. over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4.ResultsThe present study shows significant decrease in heart rate in group D (65.27 ± 4. 3 vs.77.27 ± 9.3) with more stable blood pressure values throughout than group P. There were episodes of transient desaturation in few patients in group P while no patient showed any signs of respiratory depression or desaturation in group D. The time to achieve Ramsay sedation score (RSS) 3-4 is significantly more in group D (11.4 ± 1.37 vs. 7.93 ± 1.32) with increased tendency to use rescue drug but shows better and early recovery.ConclusionDexmedetomidine is a better substitute to propofol for patients undergoing ERCP; however, use of adjunct may be necessary to decrease the need for rescue drug.

Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial

ObjectiveThis study aims to assess the effect of a preoperative parasternal plane block (PSB) on opioid consumption required to maintain hemodynamic stability during sternotomy for coronary artery bypass graft surgery.MethodsThis...

Age-Specific Dose Regimens of Dexmedetomidine for Pediatric Patients in Intensive Care Following Elective Surgery: A Phase 3, Multicenter, Open-Label Clinical Trial in Japan.

To demonstrate the efficacy, safety, and pharmacokinetics of dexmedetomidine as a potential sedative for pediatric surgery patients in the ICU. Phase 3, multicenter, open-label study. This study included 61 patients at 13 tertiary hospitals in Japan. Pediatric patients (≥ 45 wk corrected gestational age to < 17 yr) undergoing intensive care treatment with mechanical ventilation requiring greater than 6 hours estimated duration of sedation following elective cardiac surgery. Dexmedetomidine was IV administered without a loading dose at age-specific dose regimens 0.2-1.4 (< 6 yr) and 0.2-1.0 µg/kg/hr (≥ 6 yr). The primary endpoint was the percentage of patients who did not require a rescue sedative (midazolam) infusion during mechanical ventilation or for the first 24 hours of a greater than 24 hours ventilation following the commencement of dexmedetomidine administration. Overall, 47 of the 61 patients (77.0%) did not require rescue midazolam. Adverse events were reported in 53 patients (86.9%). Frequently observed adverse events were hypotension (47.5%), bradycardia (31.1%), and respiratory depression (26.2%). Most of these adverse events were mild, a few moderate, and none severe. Although serious adverse events occurred in four patients, including one cardiac tamponade resulting in the withdrawal of dexmedetomidine, none of the adverse events resulted in mortality or were directly related to dexmedetomidine. The plasma dexmedetomidine concentration generally reached the target concentration of 0.3-1.25 ng/mL at 1-2 hours prior to completion of administration or immediately prior to the commencement of tapering. The age-specific dose regimens of dexmedetomidine without an initial loading dose achieved an adequate sedation level during mechanical ventilation and caused no clinically significant adverse events in the intensive care pediatric patients. These effects were achieved within the therapeutic range of dexmedetomidine plasma concentration and were accompanied by minimal effects on hemodynamics and respiration.

Factors affecting successful use of intranasal dexmedetomidine: a cohort study from a national paediatrics tertiary centre.

BackgroundUse of intranasal (IN) dexmedetomidine for procedural sedation has been reported in recent years. Good patient selection is important to ensure high success rates. We aimed to identify factors that influence the successful use of IN dexmedetomidine in non-invasive investigations.MethodsAll paediatric patients who received IN dexmedetomidine for investigations between 01 July 2019 to 01 July 2020 were included. Baseline demographics, time to reach adequate sedation level, duration of sedation, dose, indications for sedation and need for rescue sedatives were recorded. Procedures were classified into “long” or “short” according to completion time. Successful sedation was defined by completion of investigations by IN dexmedetomidine alone.ResultsOf 105 patients included, median age was 20.0 months, and median weight 11.0 kg. Magnetic resonance imaging (56, 53.3%) was the most common indication. Sixty (57.1%) were successfully sedated using IN dexmedetomidine alone. Automated auditory brainstem response, computerised tomography and mercaptoacetyltriglycine-3 renogram scans had the highest success rate (83.3%, 83.3%, and 100% respectively). On multivariate analysis, short procedures had an adjusted odds ratio of 5.30 (95% CI: 1.69–16.61; P=0.004) compared to long procedures.ConclusionsIN dexmedetomidine is effective for procedural sedation for paediatric patients. The most important predictor for sedation success was indication of sedation and duration of procedures.

P0042 / #525: COMPARISION OF ALPHA-2AGONISTS FOR SEDATION IN CHILDREN RECEIVING NONINVASIVE VENTILATION: A RETROSPECTIVE COHORT STUDY

Aims & Objectives: Clonidine (Clo) and dexmedetomidine (Dex) are usually drugs used for sedation during non-invasive ventilation (NIV). We compared the safety of sedation with Dex vs. Clo in children receiving NIV Methods: Design: Retrospective cohort study with propensity-matched analysis between June 2018 and June 2019. Setting and participants: Pediatric intensive care unit (PICU) within a tertiary care children´s hospital. Patients from 1 month to 15 years with respiratory failure, who received NIV and infusion of Clo or Dex, according to physician decision to achieve sedation [State Behavior Scale (SBS) -1-0], within 48 hours of admission. Cardiorespiratory parameters, SBS and adverse events were recorded. Main outcome measure: incidence of adverse events (hypotension and bradycardia) Results: Of 139 patients, propensity match identified 47 pairings of patients who received Clo or Dex. After matching there was no difference in the participants among both groups. One hypotension event was observed in the Dex group (2.1%) and none in the Clo group (p = 0.999).The incidence of bradycardia was different between both groups [Dex vs Clo; 19 (40.4%) vs. 6 (12.8%); RAR 0.274 (95% CI 0.111 to 0.425); p = 0.02]. The use of Dex was an independent factor for the development of bradycardia, both in the total sample [adjusted OR 3.34 (95% CI 1.47-7.78); p = 0.004] as well as in the paired sample [OR adjusted 3.81 (95% CI 1.31-11.0); p = 0.014]. Conclusions: Both drugs achieved an adequate level of sedation during NIV. The Clo group was associated with lesser bradycardia.

Surgeons Beware: Some Red Heads Have Increased Requirements for Inhalation, Infiltration, and Topically Administered Anesthetic Agents

There is not a clinician in our specialty who cannot vividly recall the facial features of specific patients who inexplicability experienced a greater need than expected for anesthetic agents to obtain adequate levels of sedation and pain control. That being acknowledged, we were intrigued by the results of 2 articles published in the peer-reviewed academic journal Anesthesiology in which clinician scientists sought to verify or refute the anecdotal observations of anesthesiologists, dermatologists, ophthalmologists, and dentists that red-headed patients have a heightened sensitivity to pain with a concomitant increased requirement for volatile (inhalation) and local anesthetic agents.

Ketamine in acute phase of severe traumatic brain injury \u201can old drug for new uses?\u201d

Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.