Agent For Procedural Sedation Research Articles

Clinical experience with remimazolam in pediatric anesthesiology: An educational focused review.

Remimazolam is a novel ultrashort-acting benzodiazepine, which like midazolam, results in sedation, anxiolysis, and amnesia through its agonistic effects on the gamma-amino butyric acid A receptor. As opposed to midazolam, its unique metabolism is via tissue esterases, which results in a rapid elimination with a limited context sensitive half-life and prompt dissipation of its effect when administration is discontinued. Remimazolam received FDA approval for use in adults in 2020. In preliminary and initial clinical trials, its efficacy and safety has been suggested in the adult population, both as a primary agent for procedural sedation or as an adjunct to general anesthesia. There are limited data regarding the use of remimazolam in infants and children and its use in this population remains off label as it does not hold FDA-approval in pediatric-aged patients. This narrative outlines the pharmacologic properties of this unique medication, reviews previous published reports of its role in pediatric-aged patients, and discusses dosing parameters and clinical use in this population.

Dream of the Endless: Updates in Agents for Procedural Sedation.

Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics.

Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity?

BackgroundProcedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult. DiscussionSuch requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, “ketofol,” etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, “ketofol,” and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure. ConclusionThere is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.

Comparison of intravenous ketamine hydrochloride plus dexmedetomidine hydrochloride and ketamine hydrochloride plus midazolam hydrochloride in procedural sedation for short surgical procedures: A prospective randomized double-blind study

Background: The growing popularity of ambulatory anesthesia has led to the development of newer drug regimens and combinations. We decided to compare the effects of ketamine plus dexmedetomidine versus ketamine plus midazolam in procedural sedation. Aims and Objectives: The present study aimed to compare the effects of ketamine plus dexmedetomidine versus ketamine plus midazolam on the adequacy of anesthesia, level of sedation and analgesia, hemodynamic and respiratory parameters, recovery time, and post-operative side effects in short surgical procedures. Materials and Methods: Hundred adult patients were randomized into two groups: Group KD: A bolus dose of Dexmedetomidine 1 mcg/kg in 100 ml NS over 10 min and Group KM: A bolus dose of Midazolam 0.05 mg/kg in 100 ml NS over 10 min. Both groups received bolus dose of Ketamine 1 mg/kg at the start of the procedure. Level of sedation, adequacy of anesthetic technique, hemodynamic parameters, time for rescue analgesia, post-operative recovery time, and complications was measured. Results: In Group KD 7 (14%) patients and in Group KM 13 (26%) patients had inadequate anesthesia. A significant reduction in pulse rate (P<0.001) was observed in Group KD as compared to Group KM. MAP between the two study groups showed a statistically significant reduction in Group KD as compared to Group KM (P<0.05). Time for first rescue analgesia was delayed in Group KD (70.20±14.35) compared to that of Group KM (49±4.73) (P=0.000). Four (8%) patients in Group KD and 11 (22%) patients in Group KM had post-operative nausea and vomiting. Conclusion: Dexmedetomidine-ketamine combination is a good and safe alternative agent for procedural sedation in patients undergoing short surgical procedures.

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.

Unilateral erector spinae plane block for procedural sedation- A case report

MRI of the spine requires the patient to stay still in lying down position. With patient on severe excruciating pain, lying down supine is not always feasible during MRI and any intervention with least possible adverse effect on the patient is preferred. Sedation in MRI suite requires MRI compatible monitors which is not readily available in all centers. The erector spinae plane block provides analgesia via its action on the ventral rami of spinal nerves. ESP block is a safe and easy procedure and it aids to overcome the side effects of administering intravenous agents for procedural sedation.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department

BackgroundDexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic. ObjectiveOur aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department. MethodsThis prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale. ResultsThirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment. ConclusionsThe combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine–ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.

Paraphimosis Pain Treatment with Nebulized Ketamine in the Emergency Department

BackgroundParaphimosis is an acute urological emergency occurring in uncircumcised males that can lead to strangulation of the glans and painful vascular compromise. Ketamine has been used in the emergency department (ED) as an anesthetic agent for procedural sedation, and when administrated in a sub-dissociative dose (low dose) at 0.1–0.3 mg/kg, ketamine has been utilized in the ED and prehospital settings for pain control as an adjunct and as an alternative to opioid, as well as for preprocedural sedation. This report details the case of a pediatric patient who presented to our Pediatric ED with paraphimosis and had his procedural pain treated with ketamine administrated via a breath-actuated nebulizer (BAN). Case ReportThis case report illustrates the potential use of ketamine via BAN to effectively achieve minimal sedation for a procedure in pediatric patients in the ED. The patient was a 15-year-old boy admitted to the Pediatric ED complaining of groin pain due to paraphimosis. The patient was given 0.75 mg/kg of nebulized ketamine via BAN, and 15 min after the medication administration the pain score was reduced from 5 to 1 on the numeric pain rating scale. The patient underwent a successful paraphimosis reduction without additional analgesic or sedative agents 20 min after the administration of nebulized ketamine. The patient was subsequently discharged home after 60 min of monitoring, with a pain score of 0. Why Should an Emergency Physician Be Aware of This?The use of nebulized ketamine via BAN might represent a viable, noninvasive way to provide a mild sedative and be an effective analgesic option for managing a variety of acute painful conditions and procedures in the pediatric ED.

The Influence of Age on Propofol Dosing Requirements During Procedural Sedation in the Emergency Department.

Propofol is a frequently used agent for procedural sedation in the emergency department (ED). Some have suggested that propofol dosing in this setting should be adjusted in elderly patients; however, limited data exist supporting this recommendation. Additional factors that may contribute to altered propofol dose requirements in this setting have not been thoroughly explored. The objective of this analysis was to ascertain the effect age may have on the propofol dose required during procedural sedation in the ED. This retrospective study was conducted at a Level 1 academic medical center ED and included patients 18 years or older who received propofol for procedural sedation from 2015 to 2017. Those patients who were 18-64 years of age were compared with those 65 years or older. Between the two groups, total and weight-based propofol requirements for sedation, opioid doses, and adverse events were compared. This analysis included 101 procedural sedations. The median induction dose and opioid requirements before or during the procedure were not significantly different between the two groups. Compared with patients 18-64 years of age, those 65 years or older had significantly less total weight-based propofol requirements (p = 0.024) and required less total propofol for sedation (p = 0.007). In addition, patients 65 years or older required fewer repeat doses of propofol during the procedure than younger patients (p = 0.043). The incidence of adverse effects, including respiratory suppression, was not significantly different between the two groups. Patients 65 years or older may have lower weight-based propofol dosing requirements than younger patients. Utilizing a reduced total dose and repeat dosing strategy for propofol in this setting may be indicated. Further investigations are recommended to clarify factors that signal the need for more tailored dosing.

Dexmedetomidine for Procedural Sedation in the Emergency Department: A Systematic Review

Context: Procedural sedation (PS) plays an important role in facilitating emergency procedures. Dexmedetomidine is an alpha-adrenergic agonist which can play a role in this issue. This study aimed to systematically review the literature about the role of dexmedetomidine in PS in the emergency department (ED). Methods: In this study, several databases, namely PubMed, Embase, Ovid, ProQuest, Scopus, Web of Science, and Cochrane Library, were searched since 1999 up to November 30, 2020. The inclusion criteria in this study were randomized clinical trials performed on ED patients using dexmedetomidine for PS and articles only in the English language. The exclusion criteria were the studies that were not clinical trials or were not performed in the ED, low-quality studies or animal studies. Results: A total of 473 articles were identified in this study. Five studies fulfilled the inclusion and exclusion criteria. Three articles studied the adult population. One study used dexmedetomidine in an intranasal way, and one study used an intramuscular route for drug administration. Conclusions: Although the reviewed studies reported dexmedetomidine as a safe and effective agent for PS, there are not sufficient data on this issue. Therefore, it is required to perform further studies to a draw firmer conclusion.

Ketamine Prolonged Infusions in the Pediatric Intensive Care Unit: a Tertiary-Care Single-Center Analysis.

Ketamine is commonly used as an anesthetic and analgesic agent for procedural sedation, but there is little evidence on its current use as a prolonged continuous infusion in the PICU. We sought to analyze the use of ketamine as a prolonged infusion in critically ill children, its indications, dosages, efficacy, and safety. We retrospectively reviewed the clinical charts of patients receiving ketamine for ≥24 hours in the period 2017-2018 in our tertiary care center. Data on concomitant treatments pre and 24 hours post ketamine introduction and adverse events were also collected. Of the 60 patients included, 78% received ketamine as an adjuvant of analgosedation, 18% as an adjuvant of bronchospasm therapy, and 4% as an antiepileptic treatment. The median infusion duration was 103 hours (interquartile range [IQR], 58-159; range, 24-287), with median dosages between 15 (IQR, 10-20; range, 5-47) and 30 (IQR, 20-50; range, 10-100) mcg/kg/min. At 24 hours of ketamine infusion, dosages/kg/hr of opioids significantly decreased (p < 0.001), and 81% of patients had no increases in dosages of concomitant analgosedation. For 27% of patients with bronchospasm, the salbutamol infusions were lowered at 24 hours after ketamine introduction. Electroencephalograms of epileptic patients (n = 2) showed resolution of status epilepticus after ketamine administration. Adverse events most likely related to ketamine were hypertension (n = 1), hypersalivation (n = 1), and delirium (n = 1). Ketamine can be considered a worthy strategy for the analgosedation of difficult-to-sedate patients. Its use for prolonged sedation allows the sparing of opioids. Its efficacy in patients with bronchospasm or status epilepticus still needs to be investigated.

Comparative study of haemodynamic stability of Propofol versus Etomidate during Endoscopic Retrograde Cholangio pancreatography

Background: Endoscopic procedures like ERCP are performed with patient under moderate sedation. Recently sedation with etomidate and propofol was compared for colonoscopy. Etomidate–Remifentanil administration for sedation and analgesia during colonoscopy resulted in more stable haemodynamic responses and shorter recovery and discharge time. So the purpose of the study was to compare study of haemodynamic stability of propofol versus etomidate during Endoscopic Retrograde Cholangiopancreatography.Material and Methods: Patients were divided for sedation into 2 groups – etomidate and propofol. Haemodynamic response to induction agent etomidate or propofol by measuring the systolic pressure, diastolic pressure, mean arterial pressure and heart rate starting from baseline values followed by measuring the same at serial intervals during the procedure. Results were analysed in both groups Results: It was found that the average time from stoppage of sedation to the time to reach a Ramsay sedation score of lesser than 3 was higher in the patients receiving propofol. The mean time of recovery was 8.68 minutes for propofol and 6.28 min for etomidate; this was found to be statis tically significant, with a p value < 0.05. Conclusion: our study shows that etomidate as an agent for procedural sedation during ERCP caused more stable haemodynamics compared to propofol, Thus we conclude that etomidate is a good sedative agent for ERCP in ASA I – III patients.

Dexmedetomidine Sedation for Paroxysmal Supraventricular Tachycardia Ablation Is Not Associated With Alteration of Arrhythmia Inducibility.

Dexmedetomidine (Dex) is an attractive agent for procedural sedation due to its unique pharmacodynamic profile, specifically affording predictable sedation without concurrent respiratory depression. However, Dex has previously been reported to prevent or terminate arrhythmias. The purpose of this study was to investigate paroxysmal supraventricular tachycardia (PSVT) inducibility and homeostatic stability during electrophysiology studies (EPSs) and ablation when a standardized Dex protocol was used as the primary sedation agent. We performed a retrospective review of 163 consecutive procedures for PSVT ablation that received Dex as the primary sedative with adjunct fentanyl and midazolam boluses (DEX-FENT-MIDAZ). This cohort was compared to 163 consecutive control procedures wherein strictly fentanyl and midazolam were used for sedation. The primary outcome reviewed was PSVT inducibility assessed before ablation. Reviewed secondary outcomes included level of sedation and intraprocedure hemodynamics and oxygenation. The arrhythmia profiles of the DEX-FENT-MIDAZ and control cohorts were very similar. The overall incidence of a "negative" EPSs in which arrhythmia was not induced was 24% in the DEX-FENT-MIDAZ group and 26% in the control group (P = .7). Unintended deep sedation was significantly less with DEX-FENT-MIDAZ (4.3% vs 27%; P ≤ .0001). However, DEX-FENT-MIDAZ use was associated with a higher incidence of intraprocedure hypotension. Dex sedation during EPSs is not associated with a reduction in PSVT inducibility. The therapeutic utility of Dex during EPS arises from the predictable sedation Dex affords but is associated with an increased incidence of intraprocedure hypotension.

Chloral Hydrate Sedation in a Dexmedetomidine Era.

Brief Overview: The use of chloral hydrate as the primary sedation agent has declined across the nation after commercial production of the liquid formulation ceased. Although alternative sedatives have gained popularity, some pharmacies have continued to provide oral chloral hydrate by compounding it from raw ingredients. Thus, oral chloral hydrate use has continued in children despite the availability of alternative effective agents. Objective: The purpose of this investigation was to evaluate institutional chloral hydrate utilization as the primary agent for procedural sedation. Design/Methods: We conducted a retrospective study of patients given chloral hydrate for procedural sedation from October 2010 to December 2016. The hospital pharmacy database of chloral hydrate use at our 2 free-standing children's hospitals was reviewed and matched to procedure billing data. Results: There were 5874 chloral hydrate administrations for procedural sedation during the study period. The highest rates of use occurred in 2014, when there were 1420 chloral hydrate orders within our hospital. The large majority of sedations were for cardiac studies/procedures (n = 4250, 72.4%). Conclusions: Despite significant declines in use of chloral hydrate for procedural sedation across the country, local utilization of oral chloral hydrate remains high. Recent declines may be due to high-use clinical sites transitioning to alternative sedatives such as intranasal dexmedetomidine.

Ketamine or Ketofol: Do We Have Enough Evidence to Know Which One to Use?

Ketamine and propofol are both commonly used emergency department (ED) procedural sedation agents. Their concurrent administration, often referred to as “ketofol”, is widely used for procedural sedation. A simple google search can lead to a lot of opinions on why we should use propofol, ketamine, or ketofol in a given situation for moderate or deep procedural sedation in the ED, but finding evidence that supports differences these opinions assume is much harder to come by. This article is protected by copyright. All rights reserved.

Procedural sedation with dexmedetomidine for ultrasound guided central venous cannulation in agitated, high risk critically ill patients. A series of three cases

Central venous cannulation is a commonly performed procedure in ICU. Even in the experienced hands, it is not free of complications. Acute mechanical adverse events are more likely in agitated and uncooperative patients. Ultrasound guided cannunation of internal jugular vein is associated with higher success rate and fewer mechanical complications when compared with traditional techniques. Dexmedetomidine has been used as a safe and effective agent for procedural sedation in a wide variety of patients. Here we successfully used dexmedetomidine for ultrasound guided central venous cannulation of internal jugular vein in uncooperative high risk patients, even at the extremes of age.Bangladesh Crit Care J March 2017; 5(1): 68-69

Memory effects of sedative drugs in children and adolescents—protocol for a systematic review

BackgroundSome sedatives used in children and adolescents can affect memory function. Memory impairment of traumatic experience can minimize the chance of future psychological trauma. Knowledge about the potential of different sedatives to produce amnesia can help in the decision-making process of choosing a sedative regimen. The aim of this systematic review is to evaluate the effect of different sedatives on memory of perioperative events in children and adolescents.Methods/designElectronic databases and other sources, such as trial registers, gray literature, and conference abstracts will be searched. Randomized controlled trials will be included that assess memory of perioperative events in children and adolescents 2–19 years old receiving sedative drugs as premedication or as agents for procedural sedation in a medical or dental settings. The outcomes will be loss of memory after and before sedative administration (anterograde and retrograde amnesia). Two independent reviewers will perform screening, study selection, and data extraction. Disagreement at all levels will be resolved by consensus or by involving a third reviewer. Assessment of the risk of bias of included studies will be performed according to “Cochrane Collaboration’s Tool for Assessing Risk of Bias in Randomized Trials.” Clinical and methodological heterogeneity across studies will be evaluated to determine if it is possible to combine or not combine study results in a meta-analysis.DiscussionTo the best of our knowledge, there is no systematic review that specifically addresses this question. Findings from the review will be useful in the decision-making process about the best sedative for minimizing recall of the medical/dental event and possible psychological trauma.Systematic review registrationPROSPERO CRD42015017559Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0192-x) contains supplementary material, which is available to authorized users.

Dexmedetomidine for sedation in pediatric patients who received more than 20 sessions of radiation therapy: two cases report.

Dexmedetomidine is a highly selective α2-adrenoceptor agonist that demonstrates anxiolytic and analgesic properties without inducing respiratory compromise, which makes it a suitable agent for procedural sedation and imaging studies. In our current case reports, intravenous dexmedetomidine infusion was used to provide sedation to 2 pediatric patients over more than 20 sessions of radiation therapy. On both occasions, dexmedetomidine provided adequate sedation without respiratory depression. However, the required dosage increased with repeated radiation therapy sessions.

Rapidly Metabolized Anesthetics: Novel Alternative Agents for Procedural Sedation

The increased demand for procedural sedation in the ambulatory setting has prompted the development of anesthetic agents that anesthesiologists and non-anesthesiologists could administer easily and safely. In this article, we discuss novel short-acting agents in development or in clinical trials that may serve as alternatives to current anesthetics for procedural sedation.