Administration Of Sedation Research Articles

Sedation during endoscopic procedures: a Hellenic Society of Gastroenterology Position Statement.

Administration of sedation by non-anesthesiologists during gastrointestinal endoscopy remains highly controversial in Greece. The aim of this set of 16 position statements prepared by experts in the field on behalf of the Hellenic Society of Gastroenterology is to aid gastroenterologists in their everyday clinical practice and provide evidence for the best use of drugs for the sedation of patients who undergo an endoscopy. The statements address issues such as the level of sedation required, the best drugs used, their mode of action, their side-effects and possible ways to counter their action, and were adopted if at least 80% of all participants agreed upon them.

Procedural sedation and analgesia in the pediatric intensive care unit

Children frequently experience more painful, stressful, and traumatic medical procedures and treatments in the pediatric intensive care unit (PICU) than when they are hospitalized in general wards. An essential part of care in the PICU is providing critically ill children with appropriate sedation and analgesia. Finding the perfect combination of adequate analgesia and sufficient sedation in a patient group with a wide range of ages, sizes, and developmental stages can be challenging. Administration of sedatives and analgesics to critically ill patients may be challenging and complicated by unpredictable pharmacokinetics (PK) and pharmacodynamics (PD). It is important to keep in mind that optimal agents for procedural sedation and analgesia (PSA) differ from those used for long-term sedation in the PICU. In addition to pharmacological measures, different non-pharmacological methods can be applied and have been shown to be effective for pain relief in children. Efforts are being made to improve PSA management with the use of national surveys, recommendations, and guidelines.

A Review of Current Oral Sedation Agents for Pediatric Dentistry

The administration of oral sedatives for minimal and moderate sedation is common practice for pediatric dentistry. Being up to date with contemporary medications and dosing recommendations is imperative for patient safety. Historic medications such as chloral hydrate have become obsolete with the introduction of benzodiazepines and other newer medications such as alpha-2 adrenergic agonists. Oral opioids are useful for analgesia and mild sedation but may result in significant respiratory depression when combined with other central nervous system depressants and, if left untreated, hypoxemia. Antihistamines can provide minimal sedation but may have other added benefits such as antiemetic and antisialagogue effects. This review will discuss relevant pharmacologic aspects, including onset, duration of action, metabolism, and adverse reactions, for several common agents used for minimal and moderate oral sedation to assist practitioners in determining ideal medications or combinations that fit the needs of the pediatric patient and dental procedure contingent upon the provider’s level of training.

Administration of paediatric intranasal sedation: Need for appropriate formulation & equipment for dispensation.

Administration of paediatric intranasal sedation: Need for appropriate formulation & equipment for dispensation.

Choice and adequacy of sedation in critically ill mechanically ventilated children

Background: Sedation management is a crucial element of pediatric critical care medicine, aiming at reducing children's anxiety, distress, and oxygen demand. Prolonged administration of sedatives may result in drug tolerance and physical dependency. Abrupt discontinuation of these drugs in children may cause withdrawal symptoms. Our study aims to evaluate the choice and adequacy of sedation in ventilated children using the University of Michigan Sedation Scale score. Subjects and Methods: All the children aged between 1 and 12 years who were subjected to invasive ventilation during the time period October 2019 to June 2021 in the tertiary care pediatric intensive care unit (PICU) were included in the study. Results: Of the 35 children enrolled in the study, most of them spend the majority of their time in adequate sedation which accounts for around 87.1% of the total time of ventilation. Fentanyl and midazolam were the most frequently used drug combination. Oversedation and undersedation accounted for 7.9% and 5% of total ventilation hours, respectively. Out of 35 children, 10 (28%) developed iatrogenic withdrawal symptoms and 4 (11%) developed severe withdrawal symptoms. Conclusions: Fentanyl and midazolam were the most frequently used drug combination for attaining adequate sedation in our PICU. Irrespective of adequate sedation, no increase in the incidence of iatrogenic withdrawal syndrome, undersedation, or oversedation was noted in our study population.

986: HOW ARE WE OVERSEDATING OUR MECHANICALLY VENTILATED PATIENTS IN THE MICU AT A TERTIARY CARE CENTER?

Introduction: Endotracheal intubation and invasive mechanical ventilation are distressing interventions in the Medical Intensive care Unit (MICU). Mechanically ventilated patients often receive analgesic and sedative medications to reduce agitation and pain. According to recommendations in the Society of Critical Care (SCC) PADIS guidelines, sedatives should be used only when pain and delirium have been addressed with specific pharmacologic and non-pharmacologic strategies. Despite this, we observe that many mechanically ventilated MICU patients are sedated on a routine basis without any clear indication. Methods: We performed a retrospective medical chart review of patients above 18 years of age who were intubated for more than 24 hours between January 2020 till October 2021. We analyzed indications for intubation and excluded patients requiring a deep level of sedation from the final study sample. We analyzed the type and number of sedatives initiated in the first 24 hours of intubation, associated RASS parameters set for sedation titration and its monitoring frequency by nurses, and the effect of our practices on intubation and hospitalization outcomes. Statistical analysis was performed using SPSS and SAS. Results: Of the 281 patients, 83% received fentanyl, 66% received propofol or dexmedetomidine, and 33% received midazolam in the first 24 hours. About 53% and 11% of patients were simultaneously started on a 2- and 3-agents sedative regimen in the first 24 hours, respectively. The most common upper and lower RASS limits for sedation titration were set at 0 and -3, respectively. The average frequency of nurses’ RASS documentation was once every 10 hours. There was a positive correlation between the number of sedative agents used in the first 24 hours and the associated length of intubation, hospitalization, and extubation failure. Furthermore, the use of benzodiazepine led to a higher rate of extubation failure, length of intubation, and hospitalization. Conclusions: In the absence of clear medical indication for deep sedation and appropriate sedation administration and titration parameter protocol, the indiscriminate use of sedatives leads to poor patient outcomes. There is a dire need to implement sedation protocols in institutions to standardize practices and improve sedation performance metric.

Preliminary investigation into change in packed cell volume (PCV) after administration of two premedication protocols followed by induction and maintenance of anaesthesia in goats

Administration of certain sedative and anaesthetic agents can cause a reduction in circulating packed cell volume (PCV) probably due to sequestration of red cells in the spleen, increasing its size. The effect on PCV after intravenous (IV) administration of butorphanol then diazepam, five minutes apart, or, these premedicants administered in reverse order, followed by propofol and isoflurane anaesthesia have not been investigated in goats. Two cohorts of Saanen goats, one for castration (males, 5 months, 13 goats) and one for experimental orthopaedic surgery for another study (females, 3 to 5 years, 12 goats) were included in this research. Goats were randomized to receive either butorphanol or diazepam first followed by the other agent IV five minutes apart prior to anaesthesia. Four blood samples to analyse PCV were taken per goat (baseline, after the first and second premedicant administration, and after propofol induction). A between and within-subjects design ANOVA was applied to determine the difference in PCV over time between treatment groups. Baseline PCV across all goats had a mean of 0.42 L/L (range 0.28 – 0.78 L/L). Both combinations of butorphanol and diazepam followed by induction of anaesthesia with propofol caused a clinically and statistically significant reduction in PCV (p < 0.001), with values dropping by 29.0% (diazepam-first) and 29.1% (butorphanol-first) from baseline values to the last sample (an overall decrease in PCV of 0.12 L/L for both groups). However, there was no statistical difference between groups (p = 0.696). Results demonstrate that clinicians need to be aware of the magnitude of reduction in PCV that can occur when butorphanol and diazepam are used as premedicants prior to propofol administration.

Erratum.

Heller ZA, Adlesic EC, Portnof JE. Implications of electronic cigarettes on the safe administration of sedation and general anesthesia in the outpatient dental setting. Anesth Prog. 2022;69(2):41–52.In the Discussion section, an incorrect dosage was given in the following sentence: “The IV premedication dosage is 0.33–0.67 mg/kg, while the IM premedication dosage is 2.5 lg/kg, either route should be administered 15 minutes prior to procedure start.” The online version has been corrected to read “0.33–0.67 μg/kg…”

What is this bump in my neck? Ultrasonographic evaluation of pediatric neck masses.

Neck masses are common in pediatric patients, with benign etiologies such as congenital or inflammatory lesions accounting most of these masses. Anatomic location (most important), clinical history, and the appearance in ultrasonography (US) are helpful clues to narrow down differential diagnosis. Because of widespread availability, lack of ionizing radiation, and no need for sedation or contrast administration, US is the preferred initial modality for the evaluation. Further evaluation with cross-sectional imagings is needed for more extensive lesions with trans-spatial extension or suspicion of intrathoracic or retropharyngeal extension. This review will focus on US appearance and clinical presentation of masses of the neck in children, to enable radiologist to arrive at a reasonable differential diagnosis. We also briefly discuss more complex pathologies that need to be evaluated with cross-sectional modalities such as CT scan and magnetic resonance imaging.

P005Effect of medicaid coverage on administration of anesthesia during abortion procedures: An interrupted time series analysis

<h3>Objectives</h3> To determine if cost impacts administration of local anesthesia vs. sedation during abortion procedures by comparing rates of anesthesia provided before and after Illinois mandated Medicaid coverage of abortion. <h3>Methods</h3> This is a retrospective cohort study of patients presenting for a first-trimester procedural abortion at Planned Parenthood of Illinois from January 1, 2016 to December 31, 2019. Effective January 1, 2018, Illinois House Bill 40 (HB40) mandated Medicaid coverage of abortions. Our primary outcome was to compare rates of local anesthesia vs. sedation before and after HB40 implementation. Segmented logistic regression models appropriate for an interrupted time series analysis were performed. <h3>Results</h3> Of the 32,259 patients who met inclusion/exclusion criteria, 14,592 had an abortion procedure prior to HB40 and 17,667 had a procedure afterward. When we used an interrupted time series, we found a statistically significant level change in the rates of sedation following HB40, with rates increasing by 5.39% (p=0.0007). <h3>Conclusions</h3> It is well established that abortion can be cost-prohibitive. However, no studies have examined how cost affects the administration of anesthesia during an abortion procedure. An interrupted time series model allows us to adjust for confounders and analyze the effect of HB40 alone. When looking at the period immediately following the mandated Medicaid coverage, we found a statistically significant increase in sedation administration, suggesting that cost may affect the anesthesia that a patient receives.

This Month in Anesthesiology

This Month in Anesthesiology

Robust surgical scheduling for nonoperating room anesthesia (NORA) under surgical duration uncertainty

AbstractNonoperating room anesthesia (NORA) refers to the practice and administration of anesthesia or sedation outside the operating room (OR), which has been increasingly implemented in practice. The novelty of NORA is to separate the anesthesia preoperative stage from an OR for the sake of saving OR time and improving its efficiency. In this article, we study the scheduling problem for NORA considering both anesthetic rooms (ARs) and operating rooms (ORs) based on ambiguous information about surgical durations. Our goal is to devise a robust and efficient scheduling mechanism for NORA. To address this problem, we develop a two‐stage mixed‐integer Robust Optimization (RO) model that minimizes the total costs, including the sum of operating costs of opened ORs and ARs, delay cost of surgeries, and overtime cost of ORs. Decisions include the number of ARs and ORs to open, the allocation of patients to ARs and ORs, the sequence of surgeries, and the planned starting time for each surgery. Accordingly, a heuristic algorithm, so‐called column‐and‐constraint generation (C&amp;CG), is developed that renders a desirable performance. Some salient properties of the problem are also discussed. In addition, by leveraging practical data in conjunction with data reported in the extant research, the computational efficacy of the proposed algorithm is verified under various sets of parameters. Our numerical experiments reveal that (1) the implementation of NORA can reduce the OR overtime cost and the waiting time of patients; (2) our proposed Robust Optimization (RO) model possesses stronger robustness and computational efficiency than the distributionally robust model (DRO); and (3) while considering surgical duration uncertainty, the developed scheduling approach outperforms the corresponding deterministic setting in terms of decreasing the total cost and alleviating the surgery delay. Generally, the proposed approach is more adaptive to take the advantage of the surgical duration uncertainty to enhance its efficacy.

Sedative administration in Spanish hospitals in the context of perinatal loss: findings from a mixed-methods study

ABSTRACT This article explores the contexts, processes and motivations behind the administration of sedatives (minor tranquilisers) in the time around perinatal loss. Using a mixed methods design, an online survey of 796 women and 13 narrative interviews were conducted. The participants had experienced a stillbirth or termination of pregnancy from 16 weeks or a neonatal death in Spanish hospitals. The quantitative (univariate and CHAID decision-tree) and qualitative (narrative-linguistic) analysis found that sedative administration was pervasive across care contexts and appears to be naturalised despite contradicting practice recommendations. Sedative administration was associated with emotional control and avoidance of loss, lack of accompaniment and on occasion with managing disruptive patients. Lack of informed consent was very common, with little explanation of side-effects prior to administration. In the participants’ narratives, health professionals tended to construct sedatives as benign, but for some women the effects were counterproductive to loss and grief and related to persistent regrets about decisions. The study concludes that, in the context of perinatal loss, sedative administration was highly integrated into the fabric of medicalised care. As a socio-political and cultural practice underscored by gender-based care dynamics, there seems to be an imbalance between benefit and risk to women’s welfare.

Evaluating the effect of an artificial intelligence system on the anesthesia quality control during gastrointestinal endoscopy with sedation: a randomized controlled trial

BackgroundSedative gastrointestinal endoscopy is extensively used worldwide. An appropriate degree of sedation leads to more acceptability and satisfaction. Artificial intelligence has rapidly developed in the field of digestive endoscopy in recent years and we have constructed a mature computer-aided diagnosis (CAD) system. This system can identify the remaining parts to be examined in real-time endoscopic procedures, which may help anesthetists use anesthetics properly to keep patients in an appropriate degree of sedation.AimsThis study aimed to evaluate the effects of the CAD system on anesthesia quality control during gastrointestinal endoscopy.MethodsWe recruited 154 consecutive patients at Renmin Hospital of Wuhan University, including 76 patients in the CAD group and 78 in the control group. Anesthetists in the CAD group were able to see the CAD system’s indications, while anesthetists in the control group could not. The primary outcomes included emergence time (from examination completion to spontaneous eye opening when doctors called the patients’ names), recovery time (from examination completion to achievement of the primary recovery endpoints) and patient satisfaction scores. The secondary outcomes included anesthesia induction time (from sedative administration to successful sedation), procedure time (from scope insertion to scope withdrawal), total dose of propofol, vital signs, etc. This trial was registered in the Primary Registries of the WHO Registry Network, with registration number ChiCTR2100042621.ResultsEmergence time in the CAD group was significantly shorter than that in the control group (p < 0.01). The recovery time was also significantly shorter in the CAD group (p < 0.01). Patients in the CAD group were significantly more satisfied with their sedation than those in control group (p < 0.01). Vital signs were stable during the examinations in both groups. Propofol doses during the examinations were comparable between the two groups.ConclusionThis CAD system possesses great potential for anesthesia quality control. It can improve patient satisfaction during endoscopic examinations with sedation.Trial registrationChiCTR2100042621.

Protocolized nurse-guided intravenous conscious sedation for cryoballoon ablation of paroxysmal and persistent atrial fibrillation

Abstract Background Nursing staff is playing an increasingly important role in arrhythmia units and it entails acquiring more specialized knowledge. Intravenous conscious sedation is being administered more frequently in a wide variety of cardiac procedures including cryoballoon ablation (CBA). Nurses and physicians have distinct yet collaborative roles in the management and care of the patient receiving conscious sedation. It is imperative that the nurse be aware of her/his role in caring for the patient before, during, and after the administration of intravenous conscious sedation. Purpose We aimed to evaluate the nurse's role, working in coordination with the medical staff, in intravenous conscious sedation for CBA following a standardized protocol ensuring proper handling and administration of the different drugs, monitorization of vital signs and management of drug infusion in order to avoid pain but also complications inherent to the procedure and sedation. Method We included consecutive patients with paroxysmal or persistent AF who underwent a CBA from 2017 to 2021. We evaluated a nurse-guided sedation, under medical surveillance, in CBA procedures using propofol. The dosage was based on the patient's weight, starting sedation with a bolus of 1 ml (1% solution) for every 20 kg of weight, and starting a perfusion at 10 ml/h (2% solution), monitoring constantly patient's vital signs, especially blood pressure and O2saturation. This infusion was adjusted according to the patient's response. During the procedure, on a stable hemodynamic situation, booster bolus of 1 ml (1% solution) could be administered approximately every 15 minutes when needed for sedation. When systolic blood pressure was under 100 mmHg, a solution of midazolam (1mg/ml) and fentanyl (0.05mg/ml) in a mixture of 1cc + 1cc was preferred as booster. Saline and colloid solutions andephedrine (30mg/ml) bolus could be used when severe hypotension to revert propofol's hypotensive effect. Systematic standardized CBA was performed and intraprocedural and periprocedural complications were recorded. Results 104 patients were included (mean age 58±8 year-old, 85% male). Of these patients, 76 (73%) had recurrent paroxysmal AF, failure of antiarrhythmic drugs was present in 96% and prior radiofrequency ablation in 4%, 61 (59%) showed left atria enlargement (&amp;gt;40 mm or area &amp;gt;20 cm2), and 11 (10%) had structural heart disease. Mean CHA2DS2VASc score was 1. Baseline characteristics in Table 1. Procedural-related complications occurred in 6 patients (5%), transient phrenic nerve palsy in 2 patients and vascular damage in 4. All sedations were performed without complications. Conclusions In our experience, protocolized nurse-guided intravenous conscious sedation under medical surveillance in CBA procedures is safe and really useful. It contributes to help medical operators to focus on the procedure sharing the patient's sedation management with trained nurses. Funding Acknowledgement Type of funding sources: None.

348 Differences in Antipsychotic and Sedative Administration in Community vs Academic Emergency Departments Across a Health System

Antipsychotic and sedative medications are commonly used in the emergency department (ED) for a variety of reasons, including procedural sedation and treatment of agitation. Administration of these medications in older adults may result in harm, including increased risk of delirium and falls, but knowledge of practice patterns of administration of these medications to older adults in the ED is limited. The purpose of this study is to characterize the use of parenteral antipsychotic and sedative medications in geriatric patients in the ED and compare utilization at academic and community sites.

Perioperative dexmedetomidine reduces delirium after coronary artery bypass graft surgery: A prospective, single-blind, observational study.

Delirium is a commonly seen complication of cardiac surgery. Dexmedetomidine, by its anti-inflammatory properties and other effects, can attenuate postoperative delirium. The aim of this work was to study the incidence of delirium after coronary artery bypass graft surgery, and to compare the effects of dexmedetomidine and propofol on the incidence of postoperative delirium in coronary artery bypass graft surgery patients. A prospective, observational study was conducted on 180 consecutive patients undergoing off-pump or on-pump coronary artery bypass graft surgery. The patients were administered either intravenous dexmedetomidine (n = 90) or propofol (n = 90) after hemostasis was achieved, till they were ready for weaning from the ventilator. The Confusion Assessment Method was used to assess the incidence of postoperative delirium. A total of 25 (13.8%) patients developed delirium after coronary artery bypass graft surgery. Sedation with dexmedetomidine was associated with a significantly reduced incidence of postoperative delirium (8.9% v 18.9% propofol, P = 0.049). Subgroup analyses showed reduced incidence of postoperative delirium in off-pump patients compared to on-pump coronary artery bypass graft patients (3.3% vs. 20%, P = 0.009 dexmedetomidine group and 11.6% vs. 33.3%, P = 0.047 propofol group respectively). The mean age of the patients who had delirium was significantly more (64.9 ± 8.1 years vs. 52.5 ± 5.8 years, P = 0.046) compared to those who did not have delirium. Administration of dexmedetomidine-based sedation resulted in the reduced incidence of postoperative delirium compared to propofol-based sedation in patients after coronary artery bypass graft surgery.

RANDOMIZED CONTROLLED TRIAL COMPARING KETAMINE VS STANDARD MODERATE SEDATION FOR OUTPATIENT FLEXIBLE BRONCHOSCOPY

RANDOMIZED CONTROLLED TRIAL COMPARING KETAMINE VS STANDARD MODERATE SEDATION FOR OUTPATIENT FLEXIBLE BRONCHOSCOPY

Post-cardiac arrest Sedation Promotes Electroencephalographic Slow-wave Activity and Improves Survival in a Mouse Model of Cardiac Arrest.

Patients resuscitated from cardiac arrest are routinely sedated during targeted temperature management, while the effects of sedation on cerebral physiology and outcomes after cardiac arrest remain to be determined. The authors hypothesized that sedation would improve survival and neurologic outcomes in mice after cardiac arrest. Adult C57BL/6J mice of both sexes were subjected to potassium chloride-induced cardiac arrest and cardiopulmonary resuscitation. Starting at the return of spontaneous circulation or at 60 min after return of spontaneous circulation, mice received intravenous infusion of propofol at 40 mg · kg-1 · h-1, dexmedetomidine at 1 µg · kg-1 · h-1, or normal saline for 2 h. Body temperature was lowered and maintained at 33°C during sedation. Cerebral blood flow was measured for 4 h postresuscitation. Telemetric electroencephalogram (EEG) was recorded in freely moving mice from 3 days before up to 7 days after cardiac arrest. Sedation with propofol or dexmedetomidine starting at return of spontaneous circulation improved survival in hypothermia-treated mice (propofol [13 of 16, 81%] vs. no sedation [4 of 16, 25%], P = 0.008; dexmedetomidine [14 of 16, 88%] vs. no sedation [4 of 16, 25%], P = 0.002). Mice receiving no sedation exhibited cerebral hyperemia immediately after resuscitation and EEG power remained less than 30% of the baseline in the first 6 h postresuscitation. Administration of propofol or dexmedetomidine starting at return of spontaneous circulation attenuated cerebral hyperemia and increased EEG slow oscillation power during and early after sedation (40 to 80% of the baseline). In contrast, delayed sedation failed to improve outcomes, without attenuating cerebral hyperemia and inducing slow-wave activity. Early administration of sedation with propofol or dexmedetomidine improved survival and neurologic outcomes in mice resuscitated from cardiac arrest and treated with hypothermia. The beneficial effects of sedation were accompanied by attenuation of the cerebral hyperemic response and enhancement of electroencephalographic slow-wave activity.

The Effect of Complementery Acupressure Therapy for Morning Sickness

Emesis gravidarum is a physiological thing but if it is not treated immediately, it will become a pathological thing. Most of emesis gravidarum can be treated with outpatient treatment and administration of sedatives and anti-vomiting drugs, but a small percentage of pregnant women cannot cope with ongoing nausea and vomiting so that it interferes with daily activities and falls into a condition called hyperemesis gravidarum. Not all pregnant women can undergo therapy using drugs, there are some mothers who do not really like it when they must take drugs, so the provision of non-pharmacological therapy is needed here. One of the non-pharmacological therapies that can be used to treat emesis gravidarum is acupressure. Research Objectives: This study aims to determinethe effect of complementary acupressure therapy on morning sickness in Mojokarang village, Dlanggu, Mojokerto in 2020. The research design used in this study was a Quasy Experiment with a pretest and posttest design with a control group. The population was 30 people with 15 people as the treatment group and 15 people as the control group. The sampling technique in this research is done by purposive sampling. Data analysis using t-test. Results: Showed vomiting before intervention Mean 10.53 Min 9 Max 13 and Standard Deviation 1.408 and Standard Error 0.257, after being given acupressure Mean 7.30 Min 5 Max 10 and Standard Deviation 1.317 and Standard Error 0.240. Statistical test results obtained value of P-value = 0.000 means that their Effect Therapy Complementary Acupressure to The Morning Sickne ss pregnant women in the village Mojokarang Dlanggu District of Mojokerto 2020. Conclusion: Acupressure stimulates the regulatory system and activates endocrine and neurologic mechanisms, by stimulating the hypothalamus to secrete endorphins that provide a sense of relaxation. Suggestion: As input in providing information about morning sickness, understanding, treatment and impact if morning sickness left, besides the benefits and resources for mothers on treatment of nausea and vomiting using complementary acupressure in daily life.