Agitation Scores Research Articles

Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study.

Physiological alterations during the perianesthetic period may contribute to secondary neurocognitive injury after a concussion. Patients exposed to concussion and who received an anesthetic within 90 days were matched to unexposed patients without concussion. Intraoperative and postoperative events were compared. Subgroup analyses assessed relationships among patients with a concussion in the prior 30, 31 to 60, and 61 to 90 days and their respective unexposed matches. To facilitate identification of potential targets for further investigation, statistical comparisons are reported before, as well as after, correction for multiple comparisons. Sixty concussion patients were matched to 176 unexposed patients. Before correction, 28.3% postconcussion versus 14.8% unexposed patients reported postanesthesia care unit pain score≥7 (P=0.02); 16.7% concussion versus 6.5% unexposed patients reported headache within 90 days of anesthesia (P=0.02) and 23.5% of patients who received surgery and anesthesia within 30 days of concussion experienced headache within 90 days of anesthesia compared with 7.1% in the unexposed group (P=0.01). Patients who experienced concussion and had anesthesia between 31 and 60 days after injury had a postanesthesia care unit Richmond Agitation and Sedation Scale score of -1.61±1.29 versus a score of -0.2±0.45 in unexposed patients (P=0.002). After adjusting the P-value threshold for multiple comparisons, the P-value for significance was instead 0.0016 for the overall cohort. Our study revealed no significant associations with application of adjusted significance thresholds. There were no differences in intraoperative and postoperative outcomes in patients with recent concussion compared with unexposed patients. Before correction for multiple comparisons, several potential targets for further investigation are identified. Well-powered studies are warranted.

Physical Therapy and Sedation While on Extracorporeal Membrane Oxygenation for COVID-19–Associated Acute Respiratory Distress Syndrome

ObjectivesThis study aimed to determine whether patients on extracorporeal membrane oxygenation (ECMO) with coronavirus disease 2019 (COVID-19) achieved lower rates of physical therapy participation and required more sedation than those on ECMO without COVID-19.DesignRetrospective, observational, matched-cohort study.SettingBicenter academic quaternary medical centers.ParticipantsAll adults on ECMO for severe COVID-19-associated acute respiratory distress syndrome (ARDS) during 2020 and matched (matched 1:1 based on age ± 15 years and medical center) adults on ECMO for ARDS not associated with COVID-19.InterventionsObservational only.Measurements and Main ResultsMeasurements were collected retrospectively during the first 20 days of ECMO support and included daily levels of physical therapy activity, number of daily sedation infusions and doses, and level of sedation and agitation (Richmond Agitation and Sedation Score). During the first 20 days of ECMO support, the 22 patients who were on ECMO for COVID-19–associated ARDS achieved a similar proportion of days with active physical therapy participation while on ECMO compared to matched patients on ECMO for non-COVID-19 ARDS (22.5% v 7.5%, respectively; p value 0.43), a similar proportion of days with Richmond Agitation and Sedation Score ≥-2 while on ECMO (47.5% v 27.5%, respectively; p value 0.065), and a similar proportion of days with chemical paralysis while on ECMO (8.4% v 18.0%, respectively; p value 0.35).ConclusionsThe results of this matched cohort study supported that sedation requirements were not dramatically greater and did not significantly limit early physical therapy for patients who had COVID-19–associated ARDS and were on venovenous extracorporeal membrane oxygenation (VV-ECMO) versus those without COVID-19–associated ARDS who were on VV-ECMO.

Abstracts of the 30th Annual Pediatric Pharmacy Association (PPA) Meeting April 21 to 25, 2021

Abstracts of the 30th Annual Pediatric Pharmacy Association (PPA) Meeting April 21 to 25, 2021

Perioperative dexmedetomidine reduces emergence agitation without increasing the oculocardiac reflex in children: A systematic review and meta-analysis.

Background:Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA incidence without augmenting oculocardiac reflex (OCR) in pediatric patients undergoing strabismus surgery.Methods:We searched PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Cochrane Library to collect the randomized controlled trials (RCTs) investigating the effects of intraoperative DEX in children undergoing strabismus surgery from inception to October 2019. Postoperative Pediatric Agitation and Emergence Delirium (PAED) score, postoperative EA, extubation or laryngeal mask airway (LMA) removal time, postanesthetic care unit (PACU) stay time, OCR, and postoperative vomiting (POV) were evaluated.Results:11 RCTs including 801 patients were included in this study. Compared with control group, intravenous DEX significantly reduced postoperative PAED score (WMD, 3.05; 95% CI: -3.82 to -2.27, P = .017) and incidences of postoperative EA 69% (RR, 0.31; 95% CI: 0.17 to 0.55, P < .00) and POV (RR, 0.28; 95% CI: 0.13 to 0.61, P = .001). Furthermore, the use of DEX significantly delayed extubation or LMA removal time (WMD, 2.11; 95% CI: 0.25 to 3.97, P < .001). No significant difference was found in the incidence of ORC and PACU stay time.Conclusion:Intravenous DEX reduced the incidences of EA without increasing OCR in pediatric patients undergoing strabismus surgery. Meanwhile, DEX infusion decreased the incidence of POV in children.

Investigating the Effects Of Ketofol and the Combination of Remifentanil and Propofol on the Duration of the Convulsion and Haemodynamics of Psychotic Patients in Electroconvulsive Therapy

Introduction: Electroconvulsive therapy (ECT) is a method of treatment for patients suffering from depressive disorders, bipolarity, and schizophrenia and is accompanied by hyperdynamic responses. This study aimed to find intravenous anaesthesia with profound effects but fewer side effects. Materials and Methods: This study was an interventional clinical trial, in which 35 patients were categorised into three groups each being treated in three sessions (105 cases in total). Group A received distilled water + propofol 1mg/kg, Group B received remifentanil 1 µg/kg + propofol 1mg/kg and Group C received ketamine + propofol (ketofol) 1 with the dose of 1 mg/kg. Then, the patients were investigated in terms of hemodynamic changes and recovery time in the first 10 min. Results: There were no significant differences in the three groups of the study in terms of the patients' heart rate, blood pressure and oxygen saturation percentage (P = 0.598, P = 0.283 and P = 0.172, respectively). However, there was a significant difference (P = 0.0001) amongst the three groups in terms of recovery time as Group C (ketofol) had the lowest recovery time and Group B (remifentanil + propofol) had the highest recovery time. Moreover, there was a significant difference across the three groups regarding the agitation score showing that sole propofol resulted in the lowest amount of agitation in the three groups (P = 0.026). The highest amount belonged to Group C. Conclusions: The ketofol compound had the lowest recovery time, and the remifentanil + propofol compound had the highest recovery time in ECT candidate patients. Sole propofol caused the lowest amount of agitation and ketofol caused the highest amount of agitation in the patients.

Long-Term Cognitive Outcomes and Sleep in Adults After Extracorporeal Life Support

Objectives:To assess differences in cognitive outcomes and sleep in adult survivors of critical illness, managed with venovenous extracorporeal membrane oxygenation as compared to conventional mechanical ventilation only.Design:Retrospective cohort study linked with data from the COGnitive outcomes and WELLness study.Setting:A multisite study from five adult medical/surgical ICUs in Toronto.Patients:Thirty-three ICU survivors including adult patients who received venovenous extracorporeal membrane oxygenation (n = 11) matched with patients who received mechanical ventilation only (n = 22) using specified covariates (e.g., age).Interventions:None.Measurements and Main Results:Baseline demographics and admission diagnoses were collected at enrollment. Cognitive outcome was evaluated using the Repeatable Battery for the Assessment of Neuropsychologic Status (global cognitive function) and Trail Making Test B (executive function), and sleep variables were estimated using actigraphy. Assessments occurred at 7 days post ICU discharge and again at 6- and 12-month follow-up. No statistically significant difference was seen between patients treated with or without venovenous extracorporeal membrane oxygenation in the mean daily Riker Sedation Agitation Score; however, patients in the venovenous extracorporeal membrane oxygenation group received greater amounts of fentanyl over their ICU stay as compared to patients receiving conventional mechanical ventilation only (p < 0.001). No significant differences were found in performance on either of the cognitive assessment tools, between survivors treated or not with venovenous extracorporeal membrane oxygenation at any of the time points assessed. Total sleep time estimated by actigraphy increased from approximately 6.5 hours in hospital to 7.5 hours at 6-month follow-up in all patients, regardless of treatment type. Total sleep time remained consistent in both groups from 6 to 12 months post ICU discharge.Conclusions:In this small retrospective case series, no significant differences were found in sleep or cognitive outcomes between extracorporeal life support and non–extracorporeal life support survivors. Further, in this hypothesis-generating study, differences in administered sedative doses during the ICU stay seen between the two groups did not impact 6- or 12-month cognitive performance or actigraphy-estimated sleep time.

Effect of ketamine on emergence agitation following septoplasty: a randomized clinical trial

Background and objectivesThe risk of emergence agitation (EA) is high in patients undergoing nasal surgery. The aim of the present study was to investigate the incidence of EA in adults undergoing septoplasty and the effect of ketamine on EA. MethodsIn this randomized study, a total of 102 ASA I–II patients who underwent septoplasty between July 2018 and April 2019 were divided into two groups: ketamine (Group-K, n=52) and saline (Group-S, n=50). After anesthesia induction, Group-K was intravenously administered 20mL of saline containing 1mgkg−1 ketamine, whereas Group-S was administered 20mL of saline. Sedation and agitation scores at emergence from anesthesia, incidence of cough, emergence time, and response to verbal stimuli time were recorded. The sedation/agitation and pain levels were recorded for 30minutes in the recovery unit. ResultsThere was no significant difference between the groups in terms of the incidence of EA (Group-K: 15.4%, Group-S: 24%). The incidence of cough during emergence was higher in Group-S than in Group-K, but the response time to verbal stimuli and emergence time were shorter in Group-S. The sedation and agitation scores were similar after surgery. Pain scores were higher in Group-S at the time of admission to the recovery unit and were similar between groups in the other time points. ConclusionAdministration of 1mgkg−1 ketamine after anesthesia induction does not affect the incidence of EA in patients undergoing septoplasty, but it prolongs the emergence and response time to verbal stimuli and reduces the incidence of cough.

A systematic review of the novel applications of cannabinoids in dementia care: food refusal and neuropsychiatric symptoms

<h3>Introduction</h3> In recent years, there has been increased research interest investigating the novel use of cannabinoids in the treatment of patients living with dementia. Early clinical research suggests that cannabinoids may be beneficial in a variety of areas, including pain, sleep, weight loss, and behavioral aggression. In particular, cannabinoids may be especially valuable in dementia care in areas where there are currently limited therapies, including food refusal and neuropsychiatric symptoms (NPS) such as agitation and sleep disruption. Pharmacologic interventions for disordered eating in dementia are limited. And although atypical antipsychotics are commonly used to treat NPS, they are associated with an increased risk of serious adverse events and all-cause mortality in older patients. Thus, this study aims to review the current literature on the potential applications of cannabinoids in the treatment of food refusal and neuropsychiatric symptoms in dementia populations. <h3>Methods</h3> A systematic literature review was performed utilizing six major electronic databases (PubMed, MEDLINE, EMBASE, PsycINFO, Google Scholar, Cochrane CENTRAL) for articles published from database inception to November 2020. Search strings including keywords and Medical Subject Headings (MeSH terms) related to cannabinoids, dementia, food refusal, weight loss, agitation, and neuropsychiatric symptoms were used to identify relevant articles. <h3>Results</h3> A total of 23 relevant articles were identified that examined the use of cannabinoids including tetrahydrocannabinol, dronabinol, and nabilone in dementia patients. Regarding treatment of NPS in dementia, numerous studies found that use of cannabinoids was associated with potential benefits including reduced nighttime motor activity, improved sleep duration, reduced agitation, and lower Neuropsychiatric Inventory scores. With regards to food refusal, multiple articles documented use of cannabinoids being associated with increased percentage of meals consumed, with one crossover placebo-controlled trial finding increased overall body weight in dementia patients on dronabinol. Documented potential side effects include possible worsening of psychosis and anxiety, although overall, the literature appears to show cannabinoids to be generally well-tolerated. <h3>Conclusions</h3> Use of cannabinoids as potential treatments for food refusal and neuropsychiatric symptoms in dementia populations is an ongoing area of research. Completed clinical studies done on the subject to date have been small in scale, but have shown cannabinoids to be relatively well-tolerated and have yielded positive results. Thus, cannabinoids may have potential as a therapeutic intervention in dementia care, and these findings warrant further investigation. <h3>Funding</h3> Not applicable

Feasibility of Intranasal Dexmedetomidine in Treatment of Postoperative Restlessness, Agitation, and Pain in Geriatric Orthopedic Patients.

ObjectiveThe aim of this study was to report preliminary data on the use of intranasal dexmedetomidine to treat postoperative restlessness, agitation, and pain in 23 patients aged > 70 years and undergoing orthopedic surgery.BackgroundPostoperative agitation and delirium are common among older adult patients undergoing orthopedic surgery. Most preparations used to treat agitation and delirium carry a risk for adverse events such as respiratory failure. Moreover, mere opioid therapy may be insufficient in treatment of pain. Dexmedetomidine, an α2-adrenoreceptor agonist with sedative and analgesic properties, has been shown to reduce opioid requirement and reduce postoperative delirium in older adults.MethodsWe studied the use of post-operative intranasal dexmedetomidine in a retrospective study cohort of geriatric patients undergoing orthopedic surgery. Primary outcomes included alterations in heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), peripheral oxygen saturation (SpO2), Modified Richmond Agitation and Sedation Score (mRASS), and opioid consumption following dexmedetomidine administration.ResultsWe identified 23 patients with a mean (SD) age of 79.9 (7.5) years who received dexmedetomidine 100 µg intranasally postoperatively. After dexmedetomidine administration, HR decreased by 10.4 (3.7) beats/min (95% CI 2.9–17.8; p = 0.004) and MAP by 16.2 (4.4) mmHg (95% CI 7.3–25.1; p < 0.001). HR decrease was significant at 2 h and MAP decrease at 1, 2, and 3 h following dexmedetomidine administration. Dexmedetomidine administration was associated with significant reductions in opioid consumption (p < 0.001) and mRASS score (p < 0.001). SpO2 and RR remained unchanged.ConclusionsThese preliminary findings suggest that intranasal dexmedetomidine reduces opioid consumption without causing respiratory depression and may be used to treat postoperative restlessness, agitation, and pain in geriatric patients. However, hemodynamic effects of dexmedetomidine may require close observation for 3 hours following administration in older adult patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40266-021-00846-6.

Management of Agitation, Delirium, and Catatonia in Intubated COVID-19 Patients: A Case Series &amp; Rationale for Valproate Sodium Use During Extubation

The complete spectrum of neuropsychiatric effects of SARS-CoV-2 acute respiratory distress syndrome has yet to be fully appreciated, particularly in intubated patients. Manifestations including delirium and catatonia need to be considered in intubated COVID-19 patients. Medications known to exhibit neuroprotective effects, like valproate, can assist in agitation related to sedative withdrawal during extubation. This case series reports on the management of agitation, delirium, and catatonia in COVID-19 patients during and after extubation efforts. We present three cases in which Psychiatry was consulted for agitation in intubated COVID-19 patients. These patients were managed for severe agitation during weaning from extubation as well as for subsequent psychiatric challenges, including catatonia. Patient 1: 26-year-old female with bipolar I with psychotic features who was admitted for acute hypoxic respiratory failure from COVID-19 pneumonia. After an emergency C-section at 31 weeks’ gestation, she was intubated for 9 days and started on valproate 250 mg BID for agitation. She was extubated successfully and discharged home. Patient 2: 42-year-old female with bipolar I and PTSD who was intubated following COVID-19-related acute hypoxic respiratory failure. She received valproate 250mg BID and was extubated successfully. She became catatonic when home quetiapine was resumed and recovered following quetiapine discontinuation and lorazepam. She was discharged on valproic acid and alprazolam. Patient 3: 23-year-old female with bipolar I with psychotic features who was admitted for COVID-19 acute hypoxic respiratory failure and intubated. She received valproate 250 mg BID and was extubated successfully. She became catatonic when risperidone was re-initiated, but recovered following risperidone discontinuation and addition of lorazepam, gabapentin, and duloxetine. Quetiapine was added before discharge. Valproate was effective for managing delirium and agitation during extubation, as evidenced by normalizing Richmond Agitation and Sedation Scale scores. Additionally, valproate aided in managing catatonia post-extubation. This case series reports on the management of agitation in COVID-19 patients during extubation efforts with valproate sodium, due to its ability to manage delirium and catatonia. Valproate is known to exhibit neuroprotective effects, which possibly explains successful management of agitation during the extubation process.

Apathy and agitation in institutionalized older adults: an empirically derived classification.

Apathy and agitation are often recognized as the most problematic behavioural and psychological symptoms in care settings. In this study, we analyze the relationship between apathy and agitation symptoms other and their relationship with demographic, cognitive, and neuropsychiatric variables and psychotropic medication use. A retrospective study was conducted at a gerontological care centre in Láncara, Spain. Participants were 196 residents of the gerontological care centre, including 143 with a diagnosis of dementia. Apathy and agitation were assessed with the Apathy Scale for Institutionalized Patients with Dementia, Nursing Home version, and the Spanish version of the Cohen-Mansfield Agitation Inventory, respectively. Two-stage hierarchical cluster analysis (hierarchical cluster analysis in a first exploratory stage and K-means clustering to obtain the final solution in the second stage) was conducted to assign residents to different groups based on apathy and agitation scores. In cluster 1, a certain level of apathy, the highest levels of agitation, and the most frequent intake of atypical antipsychotics and clomethiazole were observed. The highest levels of apathy and the most frequent intake of memantine were seen in cluster 2. The lowest levels of agitation and apathy and the highest levels of cognitive performance were found in cluster 3. In this study, subjects with dementia were in a state of high agitation and eventual apathy, had low cognitive status, and were very old. Patients with this profile require well-designed non-pharmacological interventions.

COMPARISON OF INTRANASAL DEXMEDETOMIDINE V/S MIDAZOLAM AS A PREMEDICATION IN CHIDREN WITH CONGENITAL HEART DISEASE UNDERGOING CARDIAC SURGERY

Background: The intranasal route is a reliable way to administer preanaesthetics and sedatives to children. The aim of present study was to compare the anxiolytic and sedative effects of intranasal dexemedetomidine and midazolam as a premedication in children with congenital heart disease undergoing cardiac surgery.. Patients and Methods: Fifty chidrens 2-12 years of age group of either sex with congenital heart disease undergoing cardiac surgery were randomly allocated into two groups. Group A-(n=25) - received intranasal dexmedetomidine as premedication.(0.1 µg/kg diluted in 2ml NS ) Group B- (n=25)- received intranasal midazolam as premedication. (0.2 mg/kg diluted in 2ml NS) Heart rate, mean arterial blood pressure and oxygen saturation were monitored upto30 minute after drug administration. The sedation score, anxiety score and child separation score were recorded until the child taken to the OR. The postoperative agitation score was also observed. Results and Conclusion: Premedication with intranasal dexmedetomidine attained significant and satisfactory sedation with better parental separation and lower anxiety levels without any adverse effects as compared with intranasal midazolam in children with congenital heart disease undergoing cardiac surgery.

Effect of dexmedetomidine on perioperative hemodynamics and organ protection in children with congenital heart disease: A randomized controlled trial.

Background:This study aimed to investigate the effects of dexmedetomidine (Dex) on hemodynamics and organ protection in congenital heart disease (CHD) children who underwent open-heart surgery under cryogenic cardiopulmonary bypass.Methods:Ninety children were randomly allocated to group C (0.9% saline 0.2 μg/kg/hour), group D1 (Dex 0.2 μg/kg/hour), and group D2 (Dex 0.4 μg/kg/hour) (n = 30 per group). All participants received fentanyl, propofol and 1% sevoflurane for anesthesia induction. Hemodynamic data were measured from T0 (before the induction) to T7 (30 minutes after extubation). The difference of arterial internal jugular vein bulbar oxygen difference and cerebral oxygen extraction ratio were calculated according to Fick formula. Enzyme-linked immunosorbent assay was performed to detect the serum myocardial, brain and kidney injury markers. The incidence of acute kidney injury (AKI) was calculated by serum creatinine level. Tracheal extubation time, postoperative pain score and emergence agitation score were also recorded.Results:Compared with group C, group D1, and D2 exhibited reduction in hemodynamic parameters, myocardial and brain injury indicators, and tracheal extubation time. There were no significant differences in blood urea nitrogen and neutrophil gelatinase-associated lipocalin or incidence of AKI among the 3 groups. Besides, the incidence of tachycardia, nausea, vomiting and moderate agitation, and the FLACC scale in group D1 and D2 were lower than those in group C. Moreover, Dex 0.4 g/kg/hour could further reduce the dosage of fentanyl and dopamine compared with Dex 0.2 g/kg/hour.Conclusions:Dex anesthesia can effectively maintain hemodynamic stability and diminish organ injuries in CHD children.

Comparative study of hemodynamic effects, quality of extubation and emergence - agitation response of the patients with dexmedetomidine versus lignocaine during and following the endotracheal extubation

Background: Endotracheal extubation is the translaryngeal removal of a tube from the trachea via the nose or mouth. It is associated with hemodynamic changes because of reflex sympathetic discharge caused by epipharyngeal and laryngopharyngeal stimulation. Various drugs and techniques have been tried to attenuate the airway and stress responses during tracheal extubation. In present study, we have compared the effects of dexmedetomidine and intravenous lignocaine on the hemodynamic and recovery profiles during endotracheal extubation. Material and Methods: Present study was prospective randomised comparative study, conducted in patients from age group of 18-45 years, ASA grade I/II, scheduled for elective abdominal surgeries. The patients were categorised into two different groups using the sealed envelope method as Group D and group L. Results: In present study, patients were divided in following 2 groups with 50 patients in each group as group D (Dexmedetomidine) and group L (Lignocaine). Age, gender, mean BMI were comparable in both groups and difference was not significant statistically. The difference between mean heart rate, systolic BP, diastolic BP and mean arterial BP during extubation, after extubation at 1, 3, 5, 10, 15, 20, 25, 30 minutes in dexmedetomidine group and lignocaine group was statistically significant. In Dexmedetomidine group, 12% of the patients had no cough during extubation, 72% of the patients had smooth extubation with minimal cough while in Lignocaine group, 22% of the patients had smooth extubation with minimal cough, 74 % of the patients had moderate cough during extubation. Statistical analysis of the Emergence agitation score shows better results in group D. Conclusion: Administration of Dexmedetomidine before tracheal extubation was more effective in maintaining the hemodynamic stability, facilitated smooth tracheal extubation and had a better quality of recovery as compared to Lignocaine.

Analysis on the Anesthesia Effects of Sevoflurane and Propofol on Laparoscopic Cholecystectomy

To compare the anesthesia effects of propofol and sevoflurane in laparoscopic cholecystectomy. 60 patients with laparoscopic cholecystectomy in our hospital from January 2019 to June 2020 were randomly divided into control group and observation group, 30 cases in each group. The control group was given total intravenous anesthesia (continuous infusion of propofol 6-8 mg/kg/h during operation), while the observation group was given intravenous inhalation combined anesthesia (continuous inhalation of 1-2.5 % sevoflurane during operation). The vital signs, anesthesia time, recovery time and extubation time of the two groups after induction and at the end of operation were compared and the occurrence of agitation during anesthesia recovery period was recorded The changes of heart rate and blood pressure before and after agitation were analyzed. The results showed that there was no significant difference in anesthesia time, recovery time and extubation time between the two groups (p>0.05); there was no significant difference in body temperature, oxygen saturation, mean arterial pressure and heart rate between the two groups after induction and at the end of operation (p>0.05); compared with the control group, the average agitation score of the observation group was significantly higher and the difference was statistically significant (p<0.05). There were 6 cases of restlessness in the control group (6/30) and 14 cases of restlessness in the observation group (14/30), the difference between the two groups was statistically significant (p<0.05); before and after the emergence of restlessness, the blood pressure fluctuation rate and heart rate fluctuation rate changed significantly and the blood oxygen saturation decreased, with significant difference (p<0.05). Sevoflurane inhalation anesthesia is more prone to emergence agitation than propofol intravenous infusion anesthesia. Intravenous anesthesia and inhalation anesthesia have their own advantages. If we fully grasp and make use of their characteristics in our work, we will make the patients wake up more smoothly and the anesthesia work more efficiently.

Evaluation of Effect of Preoperative Oral Carbohydrate on the Perioperative Agitation in Pediatrics Undergoing Elective Herniorrhaphy; A Doubl-Blind Randomized Clinical Trial

Background The aim of this study was to evaluate the effect of preoperative oral carbohydrate on the perioperative agitation in pediatrics with elective herniorrhaphy. Materials and Methods In this randomized clinical trial study, 120 pediatrics, 6 months to 10 years-old who underwent elective herniorrhaphy were admitted. Sixty pediatrics in the intervention group received 5 ml/kg of 20% dextrose solution manufactured by Samen Company as carbohydrate beverage exactly 2 hours before surgery and the control group (n=60) received distilled water. The perioperative agitation score was calculated as follows. Score 1: quiet, silent child, score 2: mild but agitated, score 3: medium aggression, and score 4: severe agitation measured before surgery, at recovery, 5, 15 and 30 minutes after intervention. Also, the incidence of nausea and vomiting was recorded in each group. Results Of the 60 pediatrics in the intervention group, 54 patients were quiet and silent at the time of entry into the operating room, and 6 patients had mild agitation; in the control group, 7 patients were quiet and silent, 41 patients were mild but agitated, and 12 were moderate. There was a significant difference in agitation between the two groups (P = 0.001). Five minutes after surgery, 54 patients scored 1, 6 patients scored 2 in the control group, 27 patients scored 1 and 33 patients scored 2. There was a significant difference between agitations of children 5 minutes after intervention in the two groups. Conclusion Five ml/kg of 20% dextrose solution as carbohydrate beverage exactly 2 hours before anesthesia may lead to parental satisfaction and improvement in positive behavior of pediatrics at anesthesia induction and wake up from anesthesia.

A randomized trial comparing physostigmine vs lorazepam for treatment of antimuscarinic (anticholinergic) toxidrome

Background Toxicity from antimuscarinic agents precipitates a constellation of signs and symptoms; two of the most significant are agitation and delirium. Benzodiazepines are commonly used for treatment; physostigmine is also effective but is underutilized due to concerns for safety and short duration of action. The objective of this study was to compare lorazepam to physostigmine for the treatment of antimuscarinic delirium and agitation. Methods This was a blinded, randomized clinical trial in patients presenting for antimuscarinic toxidrome. Inclusion criteria were: ≥10–<18 years old, at least one central and two peripheral antimuscarinic symptoms, delirium and moderate agitation. Subjects were randomized to either (1) lorazepam bolus (0.05 mg/kg) followed by a 4-h normal saline infusion, or (2) physostigmine 0.02 mg/kg bolus followed by a 4-h physostigmine infusion (0.02 mg/kg/h). Primary outcomes were the control of delirium and agitation after bolus and during the infusion. Results Ten (53%) subjects were enrolled in the lorazepam arm, 9 (47%) in the physostigmine arm. Diphenhydramine was the most common agent ingested (16, 84%). Fewer patients receiving physostigmine had delirium after the initial bolus (44% vs 100%, p = 0.01) and at the 4th hour of infusion (22% vs 100%, p < 0.001) compared to patients who received lorazepam. There was a significant decrease in agitation scores in the physostigmine arm compared to the lorazepam arm after the initial bolus (89% vs 30%, p = 0.02), but no difference at the 4th hour of infusion (p > 0.99). There were no seizures, bradycardia, bronchorrhea, bronchospasm, intubation, or cardiac dysrhythmias. Conclusion Physostigmine was superior to lorazepam in controlling antimuscarinic delirium and agitation after bolus dosing, and control of delirium after a 4-h infusion. There were no serious adverse events in either treatment arm. Physostigmine bolus and infusion should be considered in adolescent patients with significant delirium and agitation from antimuscarinic agents

A Quality Improvement Intervention to Reduce Postoperative Opiate Use in Neonates.

Opiate use in neonates can affect clinical outcomes after surgery and may alter future neurodevelopment. We implemented a multimodal opioid reduction strategy in our NICU for infants undergoing nonemergent gastrointestinal surgery. After multiple stakeholder's meetings, our opioid reduction intervention included giving neonates postoperative standing intravenous acetaminophen every 6 hours for 48 hours, a standardized postsurgical sign-out with the NICU team in which pain control was directly addressed, and a series of postsurgical pain education seminars with NICU providers. To assess the impact of our quality improvement project, we used process control charts to investigate trends in postoperative opioid use in our preintervention (January 2012 to April 2016) and postintervention (May 2016 to September 2019) cohorts. A total of 77 infants were included in the study (40 in the preintervention cohort and 37 in the postintervention cohort). Patient characteristics were equivalent. The intervention significantly reduced the trend in postoperative morphine equivalents (median: 7.96 mg/kg in preintervention cohort versus 0.095 mg/kg in postintervention cohort; P < .0001). The Neonatal Pain, Agitation, and Sedation Scale pain scores and safety profiles were equivalent in both groups. The intervention was also associated with a 24-hour reduction in postoperative ventilation time (P < .048) and a 7-day reduction in the use of total parenteral nutrition (P < .017). Standing intravenous acetaminophen coupled with provider education can successfully reduce opioid use in postsurgical neonates. Given the concern for opioid exposure in neonatal neurodevelopment as well as clinical benefits of reduced opioids, similar strategies for opioid reduction may prove useful at other institutions.

Safety of Oral Midazolam as a Perioperative Anxiolytic for Outpatient Dermatologic Procedures.

Perioperative anxiety can negatively impact patient satisfaction and can complicate outpatient dermatologic procedures. Evaluate adverse events associated with oral midazolam as a perioperative anxiolytic during dermatologic surgery and assess whether an enhanced monitoring approach is associated with an increased detection rate. Five hundred cases (250 before and after change in monitoring) where patients were administered oral midazolam between July 2015 and May 2017 were retrospectively reviewed. The number of procedures, type of procedures, dose in milligrams, number of doses, major and minor adverse events, and vital signs were recorded. The difference in number of treatment sites, types of procedures, and total dose administered was not significant. There were minor but significant differences in the mean change in blood pressure, heart rate, respiratory rate, and Richmond Agitation and Sedation Scale score before and after the procedure but not oxygen saturation. These vital sign changes were not clinically significant. There were zero major adverse events in both groups. There were 2 patients who became transiently hypoxic. Oral midazolam administration was not associated with major adverse events including in the more intensively monitored group. This supports its use as an anxiolytic for outpatient dermatologic procedures.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist