Adequate Sedation Research Articles

Ketamine Boluses Are Associated with a Reduction in Intracranial Pressure and an Increase in Cerebral Perfusion Pressure: A Retrospective Observational Study of Patients with Severe Traumatic Brain Injury.

Background Increased intracranial pressure (ICP) and hypotension have long been shown to lead to worse outcomes in the severe traumatic brain injury (TBI) population. Adequate sedation is a fundamental principle in TBI care, and ketamine is an attractive option for sedation since it does not commonly cause systemic hypotension, whereas most other sedative medications do. We evaluated the effects of ketamine boluses on both ICP and cerebral perfusion pressure (CPP) in patients with severe TBI and refractory ICP. Methods We conducted a retrospective review of all patients admitted to the neurointensive care unit at a single tertiary referral center who had a severe traumatic brain injury with indwelling intracranial pressure monitors. We identified those patients with refractory intracranial pressure who received boluses of ketamine. We defined refractory as any sustained ICP greater than 20 mmHg after the patient was adequately sedated, serum Na was at goal, and CO2 was maintained between 35 and 40 mmHg. The primary outcome was a reduction in ICP with a subsequent increase in CPP. Results The patient cohort consisted of 44 patients with a median age of 30 years and a median presenting Glasgow Coma Scale (GCS) of 5. The median reduction in ICP after administration of a ketamine bolus was −3.5 mmHg (IQR −9 to +1), and the postketamine ICP was significantly different from baseline (p < 0.001). Ketamine boluses led to an increase in CPP by 2 mmHg (IQR −5 to +12), which was also significantly different from baseline (p < 0.001). Conclusion In this single-institution study of patients with severe traumatic brain injury, ketamine boluses were associated with a reduction in ICP and an increase in CPP. This was a retrospective review of 43 patients and is therefore limited in nature, but further randomized controlled trials should be performed to confirm the findings.

The true prevalence of cervical inlet patch in a specific center dealing with esophageal diseases.

Cervical Inlet Patch (CIP) is an interesting entity that is little known and often neglected by endoscopists. It has always been reported as less than expected. In this article, for the first time in the literature, we want to measure the true prevalence of CIP in a center dealing with specific esophageal diseases. From October 2020 to October 2021, a total of 283 patients, aged 15-95 years, with mainly dyspeptic and reflux-like complaints were included in this study. All endoscopic procedures were performed carefully by a single endoscopist. Patients were examined for any possible presence of CIP, with adequate sedation and time. The prevalence of CIP, which was the primary aim of our study, was detected at a rate of 14.8%. Most CIP was observed as a single lesion (73.8%), and many of them (45.2%) were larger than 10 mm. Plenty of patients had upper endoscopy due to dyspeptic complaints, but only 2.5% of them presented with a preliminary diagnosis of laryngeal reflux. The true CIP prevalence is higher than reported before. Our result is the highest prevalence rate of CIP was detected in Turkey. In this regard, data coming from centers dealing with specific esophageal diseases may be more reliable and true.

Descriptive analysis of palliative sedation in a pediatric palliative care unit

IntroductionData surrounding palliative sedation in pediatric patients is scarce. Our objective is to assess the utility of creating a quality standard for pediatric palliative sedation. Material and methodsA non-systematic review of the literature was used to find recommendations for pediatric palliative sedation, after which a definition was established based on three items: (1) indication, (2) consent, and (3) application. Afterwards, a retrospective analysis of palliative sedations applied by our unit over 5 years was performed. ResultsOut of 163 patients, palliative sedation was applied in 20, in 17 of them by our unit (14/20 males; median: 11.9 years). Twelve patients had oncological diseases, seven had neurological conditions, and one had a polymalformative syndrome. Nine patients had more than one symptom at the time of PS initiation with pain (11/17) and dyspnoea (10/17) being the most frequent. As for the definition, only three patients achieved a global completion, with the registration of the consent, specification of refractoriness and the establishment of an adequate initial sedative dose being the areas with more possible improvement. ConclusionsThe application of the definition allowed us to analyze and find areas of improvement for our clinical practice of palliative sedation in pediatric patients.

Discussion Guide for the May Article.

Discussion Guide for the May Article.

Effects of anxiety on sedation among pediatric patients undergoing esophagogastroduodenoscopy.

We investigated whether the severity of anxiety among children undergoing endoscopy could affect sedation. We prospectively recruited patients under 18years of age who were scheduled to undergo esophagogastroduodenoscopy (EGD). Baseline anxiety was evaluated using the Spence Children's Anxiety Scale (SCAS). Our analysis considered the type and dose of sedative drugs, degree of sedation, and complications associated with sedation according to the scale score. The mean total SCAS T-scores and each subscale score were significantly higher in the 6-12-year age group. The mean T-score among patients who exhibited irritability during EGD was higher than that among other patients, with significant differences in the Total, Obsessive Disorder, Panic Agoraphobia and General Anxiety subscales. The midazolam doses of children exhibiting irritability were more likely to need higher (p = 0.006). Other sedation-related complications were not associated with the T-scores in each subscale. Total sleep time was not associated with any T-score subscales. Anxiety levels were significantly higher among 6-12-year-olds and children exhibiting irritability. Anxiety was often associated with irritability, difficulties achieving adequate sedation during EGD, and additional sedative drug administration. We recommend higher doses or more potent drugs to facilitate endoscopy for children with high anxiety levels.

Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease.

Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children. Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 μg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg. A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 μg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 μg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 μg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg. Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.

Therapeutic hypothermia for acute myocardial infarction: a narrative review of evidence from animal and clinical studies.

Myocardial infarction (MI) is the leading cause of death from coronary heart disease and requires immediate reperfusion therapy with thrombolysis, primary percutaneous coronary intervention, or coronary artery bypass grafting. However, myocardial reperfusion therapy is often accompanied by cardiac ischemia/reperfusion (I/R) injury, which leads to myocardial injury with detrimental consequences. The causes of I/R injury are unclear, but are multifactorial, including free radicals, reactive oxygen species, calcium overload, mitochondria dysfunction, inflammation, and neutrophil-mediated vascular injury. Mild hypothermia has been introduced as one of the potential inhibitors of myocardial I/R injury. Although animal studies have demonstrated that mild hypothermia significantly reduces or delays I/R myocardium damage, human trials have not shown clinical benefits in acute MI (AMI). In addition, the practice of hypothermia treatment is increasing in various fields such as surgical anesthesia and intensive care units. Adequate sedation for anesthetic procedures and protection from body shivering has become essential during therapeutic hypothermia. Therefore, anesthesiologists should be aware of the effects of therapeutic hypothermia on the metabolism of anesthetic drugs. In this paper, we review the existing data on the use of therapeutic hypothermia for AMI in animal models and human clinical trials to better understand the discrepancy between perceived benefits in preclinical animal models and the absence thereof in clinical trials thus far.

Best Evidence-Based Dosing Recommendations for Dexmedetomidine for Premedication and Procedural Sedation in Pediatrics: Outcome of a Risk-Benefit Analysis By the Dutch Pediatric Formulary.

BackgroundDexmedetomidine is currently off-label for use in pediatric clinical care worldwide. Nevertheless, it is frequently prescribed to pediatric patients as premedication prior to induction of anesthesia or for procedural sedation. There is ample literature on the pharmacokinetics, efficacy and safety of dexmedetomidine in this vulnerable patient population, but there is a general lack of consensus on dosing. In this project, we aimed to use the standardized workflow of the Dutch Pediatric Formulary to establish best evidence-based pediatric dosing guidelines for dexmedetomidine as premedication and for procedural sedation.MethodThe available literature on dexmedetomidine in pediatrics was reviewed in order to address the following three questions: (1) What is the right dose? (2) What is known about efficacy? (3) What is known about safety? Relevant literature was compiled into a risk–benefit analysis document. A team of clinical experts critically appraised the analysis and the proposed dosing recommendations.ResultsDexmedetomidine is most commonly administered via the intravenous or intranasal route. Clearance is age dependent, warranting higher doses in infants to reach similar exposure as in adults. Dexmedetomidine use results in satisfactory sedation at parent separation, adequate sedation and a favorable recovery profile. The safety profile is good and comparable to adults, with dose-related hemodynamic effects.ConclusionFollowing the structured approach of the Dutch Pediatric Formulary, best evidence-based dosing recommendations were proposed for dexmedetomidine, used as premedication prior to induction of anesthesia (intranasal dose) and for procedural sedation (intranasal and intravenous dose) in pediatric patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40272-022-00498-y.

Dexmedetomidine in anesthesia for planned endovascular myocardial revascularization

Introduction. Endovascular stenting of coronary arteries is an effective, minimally invasive and rapidly developing method of coronary heart disease (CHD) treatment. The question regarding the choice of a drug for adequate and safe monitoring sedation in patients during this type of surgical procedures remains open. The aim of the study was to discuss a clinical case of dexmedetomidine in elective endovascular stenting of coronary arteries. Materials and methods. A clinical case of dexmedetomidine in anesthesia during elective stenting of the right coronary artery and its analgesic effect in the development of right coronary artery (RCA) dissection are described. Results. Patient S., 72 years old, after planned endovascular stenting of the right coronary artery with 3 stents at the time of his admission to the intensive care unit (ICU) had no angina pains and sternal discomfort. The patient was transferred to the specialized department 8 hours after stenting in a stable condition. Serum cardiospecific troponin T level was less than 0.2 ng/ml 6 hours after RCA stenting. No negative dynamics was described on the control ECG after surgical intervention. Discussion. Dexmedetomidine has a proven analgesic effect due to its direct effect on the peripheral nervous system. Conclusion. The use of dexmedetomidine has its place in periprocedural sedation in patients with coronary heart disease during planned endovascular coronary artery stenting, including patients with significant (over 90%) and extended coronary artery stenoses. The clinical use of dexmedetomidine in elective minimally invasive coronary interventions requires closer attention and study.

Comparative study between S-(+)-ketamine–midazolam and fentanyl–droperidol in black-tufted marmosets (Callithrix penicillata)

Sedative and antinociceptive effects of two anesthetic protocols in black-tufted marmosets were compared in this study. Twenty-six marmosets underwent chemical immobilization for physical examination, blood sampling, tattooing, and microchipping. Animals were randomly treated with S-(+)-ketamine (10 mg/kg) and midazolam (1 mg/kg) (KM) or fentanyl (12.5 µg/kg) and droperidol (625 µg/kg) (FD) given by intramuscular injection. Heart and respiratory rates were recorded. Sedation, antinociception, muscle relaxation, posture, auditory, and visual responses were evaluated using a scoring system. Sedation in KM was achieved faster (p &lt; 0.001) and lasted for a shorter period of time (p = 0.0009). KM was similar to FD in its cardiorespiratory effects, auditory and visual responses. Both protocols promoted adequate sedation to allow manipulation. Animals in KM assumed lateral recumbency while animals in FD maintained a quadrupedal posture during evaluation. FD produced less intense sedation and muscle relaxation but a higher degree of antinociception compared to KM and is suitable for procedures that require analgesia in black-tufted marmosets.

Prospective study of haloperidol plus lorazepam versus droperidol plus midazolam for the treatment of acute agitation in the emergency department

Study objectivesThe objective of this study was to compare the combination of intramuscular (IM) droperidol/midazolam to haloperidol/lorazepam regarding time to sedation in patients with acute undifferentiated agitation in the emergency department (ED). MethodsThis was a prospective, unblinded observational study in the ED of a university teaching hospital. Subjects with acute undifferentiated agitation refractory to verbal de-escalation were assigned to receive a combination of either haloperidol 5 mg/lorazepam 2 mg or droperidol 5 mg/midazolam 5 mg IM. The primary outcome was the proportion of patients adequately sedated at 10 min defined as ED Sedation Assessment Tool (SAT) score of 0 or less. Secondary outcomes included change in ED SAT score at 5, 15, 30, and 60 min, the need for oxygen supplementation, and the need for airway intervention. ResultsA total of 86 patients were enrolled in the study, with 43 patients receiving droperidol/midazolam and 43 patients receiving haloperidol/lorazepam. Ten minutes after receiving medication, 51.2% of patients in the droperidol/midazolam group were adequately sedated compared to 7% of patients in the haloperidol/lorazepam group (OR: 14; 95% CI: 3.7, 52.1). Median time to adequate sedation was 10 min for the droperidol/midazolam group and 30 min for the haloperidol/lorazepam group. Eleven patients (25.6%) in the droperidol/midazolam group received oxygen supplementation compared to four patients (9.3%) in the haloperidol/lorazepam group. No study patients experienced extrapyramidal symptoms or required endotracheal intubation. ConclusionIntramuscular droperidol/midazolam was superior to intramuscular haloperidol/lorazepam in achieving adequate sedation at 10 min. Patients in the droperidol/midazolam arm may be more likely to receive oxygen supplementation than those in the haloperidol/lorazepam arm.

TOTAL INTRAVENOUS ANAESTHESIA (TIVA) WITH DEXMEDETOMIDINE VERSUS NALBUPHINE IN COMBINATION WITH PROPOFOL IN UPPER LIMB ORTHOPAEDIC CLOSED MANIPULATION PROCEDURE- A COMPARATIVE STUDY IN A TERSIARY HEALTH CARE CENTRE IN TRIPURA

Background: Manipulation under anaesthesia is a closed short non-surgical procedure but it demands a cool and calm patient with immobility and relaxation of body parts, to be manipulated. Thus, the role of anaesthesia is vital for success of the procedure. At the same time, it is a challenge for the anaesthesiologist because immobility requires to be maintained and as these procedures are treated as minor, muscle relaxants and intubation are avoided. Adequate analgesia, rapid and complete recovery and controlled sedation is essential to avoid hospital stay.&#x0D; Materials and Methods: It was an observational analytical study with longitudinal design. This study was conducted at AGMC &amp; GBP hospital, Tripura and the duration was one and half year. Patient of sex, normal BMI and age between 20-60 years are served as study population. 60 cases are divided into two groups and coded as group D &amp; N. Intra-procedural hemodynamic (MAP, HR, RR, SPO2), operation time, post procedural (up to 2 hour) pain by Wang – Baker faces pain rating scale and post procedural sedation by Ramsey sedation scale are observed and measured and analysed in this study.&#x0D; Results: Intra-operative MAP and HR were significantly higher in nalbuphine group than Dexmedetomidine group (p&lt;0.05). No significant difference was there in RR and SPO2 (intra-operative). Recovery of orientation was significantly lesser in dexmedetomidine group. Post procedural perception of pain was significantly lower in dexmedetomidine group (P&lt;0.005). Post procedural sedation was lower in Dexmedetomidine group which was statistically significant (P&lt;0.005).&#x0D; Conclusion: Dexmedetomidine is superior to nalbuphine in respect of recovery of orientation, pain control after procedure and control of sedation after procedure. Dexmedetomidine is superior to nalbuphine as it provides adequate analgesic and sedation without increasing MAP and HR in the above said procedure.&#x0D; Keywords: Dexmedetomidine, Nalbuphine, MAP- Mean arterial pressure, HR- Heart Rate, RR- Respiratory Rate

Sedation with Intranasal Dexmedetomidine in the Pediatric Population for Auditory Brainstem Response Testing: Review of the Existing Literature.

Background: Intranasal dexmedetomidine (IN DEX) is a relatively new sedative agent with supporting evidence on its efficacy and safety, which can be used for procedural sedation in children, and could have a major role in auditory brainstem response testing, especially in the case of non-cooperative children. The goal of this systematic review is to assess the role of IN DEX in ABR testing, evaluating the reported protocol, potential, and limits. Methods: We performed a comprehensive search strategy on PubMed, Scopus, and Google Scholar, including studies in English on the pediatric population, without time restrictions. Results: Six articles, published between 2016 and 2021, were included in the systematic review. Sedation effectiveness was high across the studies, except for one study; 3 μg/kg was the dosing most often used. A comparison group was present in three studies, with oral chloral hydrate as the drug of comparison. Adverse effects were rarely reported. Conclusion: This systematic review showed how IN DEX can represent an adequate sedative for children undergoing ABR testing; larger and more rigorous trials are warranted in order to recommend its systematic utilization.

Comparison of the Sedative Effect of Inhaled Nitrous Oxide and Intranasal Midazolam in Behavior Management and Pain Perception of Pediatric Patients: A Split-mouth Randomized Controlled Clinical Trial.

BackgroundManagement of children has always been a challenging task in the dental office, as many children exhibit extreme fear, apprehension, and anxiety toward dental procedures. Pharmacological means of behavior management such as sedation are now at the forefront. Midazolam and nitrous oxide are the commonly employed pharmacological agents for sedation in pediatric dentistry. Though each route has its advantages and disadvantages, we compared the effect of atomized intranasal midazolam (dosage 0.3 mg/kg body weight) and nitrous oxide oxygen sedation in evaluating the behavior of child, pain experienced during local anesthesia administration, sedation level, and patient's acceptance.Materials and methodsA total of 35 (n = 35) anxious pediatric patients aged 4-7 years with negative and definitely negative behavioral rating were randomized to receive intranasal midazolam and inhalational nitrous oxide through mask. The overall behavior, alertness, and cry were recorded using Houpt rating scale while pain and sedation were assessed by face, legs, activity, cry, and consolability (FLACC) and Ellis sedation scores, respectively.ResultsThe children who received intranasal midazolam sedation were calm, had less adverse effects, and had better acceptance of the drug. Both the techniques of sedation were found to be equally effective in terms overall behavior rating.ConclusionIntranasal midazolam was found to be as effective as nitrous oxide sedation for controlling behavior and providing adequate sedation in pediatric dental patients. It can also be an effective alternative for anxious patients who are unable to maintain the nitrous oxide mask throughout the dental procedure.How to cite this articleSrinivasan NK, Karunagaran P, Panchal V, et al. Comparison of the Sedative Effect of Inhaled Nitrous Oxide and Intranasal Midazolam in Behavior Management and Pain Perception of Pediatric Patients: A Split-mouth Randomized Controlled Clinical Trial. Int J Clin Pediatr Dent 2021;14(S-2):S111-S116.

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.

Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis.

Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED). The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome. Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA=93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA=78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety. Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.

Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit

BackgroundProper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We...

Comparative evaluation of two different doses of intravenous dexmedetomidine infusion for sedation in patients undergoing lower abdominal general surgical procedures under spinal anesthesia

BACKGROUND: Spinal anesthesia is the most popular regional anesthesia technique for lower abdominal surgeries. The failure of many spinal anesthesia techniques is more due to inadequate sedation and anxiolysis than technically faulty blocks. This study was designed to determine the appropriate dose of intravenous dexmedetomidine maintainance infusion to provide adequate sedation for spinal anesthesia. METHODS: A prospective, randomized, controlled double-blind study was carried out on 75 patients aged 18-60 years with ASA I and ASA II physical status who were scheduled for elective lower abdominal surgery under spinal anesthesia. Before the spinal anesthesia, all study participants were given an initial loading dose of 0.5 µg/kg dexmedetomidine infusion. Participants were randomly divided into three groups for maintenance drug infusion, Group A (to receive dexmedetomidine infusion at 0.2 µg/kg/hr), Group B (to receive dexmedetomidine infusion at 0.4 µg/kg/hr) and Group C to receive an intravenous infusion of normal saline during surgery. The Ramsay Sedation Scale (RSS) score, duration of analgesia, hemodynamic variables and occurrence of adverse events were monitored in all patients. RESULTS: Dexmedetomidine group had increased RSS score in intraoperative period and upto first 30 minutes in postoperative period compared to control group . Time to request for first analgesic was prolonged and incidence of shivering and PONV in postoperative period was less in group B than group A. The hemodynamic parameters, Respiratory parameters were not statistically significant among group A and group B. CONCLUSION: We conclude that intravenous administration of dexmedetomidine0.5 µg/kg loading dose followed by 0.4 µg/kg/hr as maintenance infusion is the optimum dose to produce sedation during spinal anesthesia with an additional advantage of increased duration of analgesia and reduced postoperative sideeffects .

Systematic Review and Meta-analysis of Efficacy and Safety of Melatonin and Triclofos for Inducing Adequate Sedation for Sleep Electroencephalogram in Children.

Introduction Triclofos and melatonin are commonly used oral sedatives in children for obtaining a sleep electroencephalogram (EEG) record. There has been no systematic review till now to compare the efficacy and safety of these two medications. Objectives The review intended to compare the efficacy of oral triclofos and melatonin in children <18 years of age for inducing adequate sedation for obtaining a sleep EEG record. We also attempted to compare the adverse effects, impact on EEG record, the yield of epileptiform abnormalities, and sleep onset latency in both groups. Methods A systematic search was conducted on “MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, and Google Scholar” till November 30, 2020, with the following keywords/the Medical Subject Headings (MESH) terms while searching: “sleep EEG,” “electroencephalogram,” “triclofos,” “melatonin” OR “ramelteon” AND “epilepsy,” “seizure,” OR “convulsion.” ROB 2.0 and ROBINS-I tool was used to determine the risk of bias. To assess heterogeneity in studies, Higgins and Thompson's I 2 method was utilized. When I 2 was more than 50%, a random effects model was utilized and a fixed-effect model was used for other parameters. To assess the presence of publication bias, Egger's test was used. Results For describing the efficacy of triclofos in 1,284 and melatonin in 1,532 children, we selected 16 articles. The indirect comparison between the pooled estimate of all children receiving individual medications revealed comparable efficacy in obtaining successful sleep EEG record with a single dose (90 vs. 76%, p = 0.058) and repeat dose ( p = 0.054), detection of epileptiform abnormalities ( p = 0.06), and sleep onset latency ( p = 0.06), but more proportion of children receiving triclofos had adverse effects ( p = 0.001) and duration of sleep was also higher with triclofos ( p = 0.001). Conclusion Efficacy of triclofos and melatonin are comparable in inducing sleep for recording EEG in children, although triclofos is more likely to cause adverse effects. However, the level of evidence is low for this conclusion and the weak strength of recommendation for the results of this review is likely to change in the future after completion of controlled trials exploring these two medications.

A Comparative Study of Dexmedetomidine and Tramadol for Prevention of Post-Spinal Anesthesia Shivering

Background: Shivering is an unpleasant and stressful symptom for the patient undergoing surgery. It occurs as a thermoregulatory response to hypothermia. Shivering obscures intraoperative monitoring. It can be detrimental to patients with low cardiorespiratory reserve as it increases oxygen demand, produces arterial hypoxemia and lactic acidosis. This study aimed to evaluate the relative efficacy of intravenously administered Inj. Dexmedetomidine 0.5µg/kg in 100 ml NS and Tramadol 0.5 mg/kg in 100 ml NS and 100 ml NS as a placebo group in controlling shivering posted for lower abdominal surgeries and lower limb general surgeries under spinal anaesthesia. Method: 120 participants, aged 18 to 65 years, of ASA Physical status I and II, scheduled for lower abdominal surgeries and lower limbgeneral surgeries under spinal anaesthesia. The patients were randomly allocated into 3 groups of 40 each and were named as group D (Dexmedetomidine 0.5µg/kg), group T (Tramadol 0.5mg/kg) and group N (100ml Normal Saline) as aplacebo. Vital parameters of the patients such as heart rate, blood pressure, spo2, temperature and shivering score, sedation score were monitored at regular intervals as per protocol. Statistical tests like Chi square test, Student’s t test (unpaired and paired) were applied to the data collected. Results: Both the dexmedetomidine and tramadol were effective in the prevention of postspinal shivering. Dexmedetomidine had better sedation profile (P value&lt;0.00001) without any respiratory depression and had fewer incidences of nausea and vomiting when compared to Tramadol. Thus, it can be used as a better alternate for shivering prophylaxis for patients undergoing surgeries under regional anesthesia. Conclusion: Dexmedetomidine is more effective in the prevention of shivering when compared with tramadol and placebo (normal saline). Dexmedetomidine has an added advantage of adequate reliable sedation. Hence we conclude that Dexmedetomidine at 0.5µg/ kg is most effective in the prevention of shivering when compared with tramadol.