Agitation Sedation Research Articles

Dexmedetomidine Nasal Spray on Emergence Agitation After Ear, Nose, and Throat Surgery: Protocol for a Randomized, Double-Blind, Controlled Trial.

Emergence agitation (EA) is a state of psychomotor hyperactivity following general anesthesia and is associated with postoperative complications. Patients undergoing ear, nose, and throat (ENT) surgery are at a high risk for EA. We aim to assess whether preoperative dexmedetomidine nasal spray reduces the occurrence of EA for patients undergoing ENT surgery. This is a protocol for a randomized, double-blind, controlled trial that will include 160 adults scheduled for ENT surgery. Patients will be randomly assigned, in a 1:1 ratio, to receive dexmedetomidine nasal spray (100μg) or a same volume of normal saline approximately 30min before general anesthesia induction. The primary endpoint is the incidence of EA, defined as a Riker sedation agitation scale (RSAS) score ≥5 from discontinuation of sevoflurane until 5min after tracheal extubation. Secondary endpoints include (1) the maximal RSAS score during emergence; (2) the incidence of agitation in the postoperative care unit (PACU); (3) pain at rest and while coughing in the PACU and at 24h postoperatively; (4) postoperative sleep disturbance on the first night after surgery; (5) anxiety within 24h postoperatively; and (6) postoperative delirium during the first 24h after surgery. All analyses will be performed on a modified intention-to-treat basis. For the primary endpoint, subgroup analysis will be conducted on sex, age, and type of surgery. We expect that preoperative dexmedetomidine nasal spray would reduce the incidence of EA after ENT surgery. Our results offer clinical evidence for improving anesthetic care for patients undergoing ENT surgery. Chinese Clinical Trial Registry (Identifier: ChiCTR2400086731).

Electroencephalographic guided propofol-remifentanil TCI anesthesia with and without dexmedetomidine in a geriatric population: electroencephalographic signatures and clinical evaluation.

Elderly and multimorbid patients are at high risk for developing unfavorable postoperative neurocognitive outcomes; however, well-adjusted and EEG-guided anesthesia may help titrate anesthesia and improve postoperative outcomes. Over the last decade, dexmedetomidine has been increasingly used as an adjunct in the perioperative setting. Its synergistic effect with propofol decreases the dose of propofol needed to induce and maintain general anesthesia. In this pilot study, we evaluate two highly standardized anesthetic regimens for their potential to prevent burst suppression and postoperative neurocognitive dysfunction in a high-risk population. Prospective, randomized clinical trial with non-blinded intervention. Operating room and post anesthesia care unit at Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile. 23 patients with scheduled non-neurologic, non-cardiac surgeries with age > 69years and a planned intervention time > 60min. Patients were randomly assigned to receive either a propofol-remifentanil based anesthesia or an anesthetic regimen with dexmedetomidine-propofol-remifentanil. All patients underwent a slow titrated induction, followed by a target controlled infusion (TCI) of propofol and remifentanil (n = 10) or propofol, remifentanil and continuous dexmedetomidine infusion (n = 13). We compared the perioperative EEG signatures, drug-induced changes, and neurocognitive outcomes between two anesthetic regimens in geriatric patients. We conducted a pre- and postoperative Montreal Cognitive Assessment (MoCa) test and measured the level of alertness postoperatively using a sedation agitation scale to assess neurocognitive status. During slow induction, maintenance, and emergence, burst suppression was not observed in either group; however, EEG signatures differed significantly between the two groups. In general, EEG activity in the propofol group was dominated by faster rhythms than in the dexmedetomidine group. Time to responsiveness was not significantly different between the two groups (p = 0.352). Finally, no significant differences were found in postoperative cognitive outcomes evaluated by the MoCa test nor sedation agitation scale up to one hour after extubation. This pilot study demonstrates that the two proposed anesthetic regimens can be safely used to slowly induce anesthesia and avoid EEG burst suppression patterns. Despite the patients being elderly and at high risk, we did not observe postoperative neurocognitive deficits. The reduced alpha power in the dexmedetomidine-treated group was not associated with adverse neurocognitive outcomes.

Effect of three modalities on emergence agitation among post-traumatic stress disorder patients undergoing laparoscopy: a randomized controlled study

Background and aimEmergence agitation (EA) after general anesthesia is common in patients with post-traumatic stress disorder (PTSD). Due to the recent worldwide events such as the Covid-19 pandemic and wars, PTSD is not rare. Accordingly, a reliable, cost-effective anesthetic protocol to lower the incidence of EA is crucial. Therefore, we aimed to compare three different interventions for avoiding EA in PTSD patients undergoing gynecological laparoscopic surgery. Participants were divided into four groups: 1: performing pre-operative relaxation techniques (deep breathing exercise and progressive muscle relaxation [PMR]); 2: administrating intra-operative Ketamine; 3: applying both previously mentioned strategies and 4 as controls.MethodsThis study was carried out on 144 adult women scheduled for gynecological laparoscopy, randomly allocated into four groups: three intervention groups and a control group (36 each). Women aged 18-45 years old, with a diagnosis of PTSD were included in the study. Patients with a positive history of major neurological, cardiovascular, metabolic, respiratory, or renal disease were excluded. Any patient who reported the use of psychiatric drugs were also excluded from the study. Data was analyzed using IBM SPSS Statistics software version 26. Kolmogorov- Smirnov was used to verify the normality of the distribution of variables. Odds ratio was calculated to clarify the strength and direction of the association between intervention groups and control. Data was deemed significant at a p-value ≤0.05.ResultsHeart rate (HR) and Mean Arterial Blood Pressure (MABP) intra-operative and post-operative till 24 hours were significantly lower in groups 1, 2, and 3 compared to group 4 (p<0.001). There was a significant statistical difference in the intraoperative HR percentage decrease. MABP percentage decrease post-operative was higher in all the intervention groups with no statistically significant difference, except for group 1 compared to group 4, which was statistically significant (12.28 ± 11.77 and 6.10 ± 7.24, p=0.025). Visual Analogue Scale measurements were significantly less in the intervention groups 1, 2, and 3 compared to group 4. On Riker sedation–agitation scores, group 1 was 85 times more likely to be non-agitated (85 (15.938 – 453.307), p<0.001), group 2 was 175 times more likely to be non-agitated (175 (19.932–1536.448), p<0.001) and group 3 was protected against agitation.ConclusionPre-operative relaxation techniques (breathing exercises and PMR) significantly lowered HR, MABP, VAS score, and EA than controls. These effects were not significantly different from intra-operative ketamine injection or the combination of both (relaxation techniques and ketamine). We recommend routine pre-operative screening for PTSD and the application of relaxation techniques (breathing exercises and PMR) in the pre-operative preparation protocol of PTSD-positive cases as well as routine practical application of preoperative relaxation techniques. Further studies on using pre-operative relaxation techniques in general could be cost-effective.

Effects of dexmedetomidine combined with etomidate on postoperative cognitive function in older patients undergoing total intravenous anaesthesia: a randomized, double-blind, controlled trial

BackgroundEtomidate has been advocated for anesthesia in older and critically ill patients because of its hemodynamic stability. Clinical studies have shown that dexmedetomidine has neuroprotective and anti-inflammatory properties and improves postoperative cognitive dysfunction in older patients. The present study was to evaluate the effects of the combination of etomidate and dexmedetomidine with different anaesthesia time on postoperative cognitive function in older patients.MethodsA total of 132 older patients undergoing ureteroscopic holmium laser lithotripsy were randomly divided into EN group and ED group equally. Patients whose surgery time was less than or equal to 1 h in each group were allocated to short-time surgery group (EN1 group and ED1 group), and whose surgery time was more than 1h were allocated to long-term surgery group (EN2 group and ED2 group). The primary outcome was the score of the Mini-Mental State Examination. The secondary outcomes were State-Trait Anxiety Inventory scores, Riker sedation agitation scores, Zung Self-Rating Depression Scale scores, the memory span for Arabic numerals, the plasma concentrations of S-100 calcium-binding protein B and neuron specific enolase, the time to spontaneous respiration, recovery, and extubation.ResultsThe MMSE scores at t2-3 were higher in ED1 and ED2 groups than in EN1 and EN2 groups (p<0.05). Compared with ED1 and ED2 groups, the ZSDS scores, the S-AI scores and the T-AI scores at t1-2 were higher in EN1 and EN2 groups (p<0.05), respectively. The recalled Arabic numbers at t1-3 were higher in ED2 group than in EN2 group (p<0.05). The plasma concentration of S-100β at t1-2 in EN1 group and t1-3 in EN2 group were higher than that in ED1 and ED2 groups (p<0.05), respectively. Compared with ED1 and ED2 groups, the plasma concentrations of NSE were higher at t1-3 in EN1 group and t1-4 in EN2 group (p<0.05), respectively.ConclusionThe administration of dexmedetomidine could improve postoperative cognitive dysfunction, emergence agitation, depression and anxiety, attenuate the plasma concentrations of S-100β and NSE in older patients undergoing total intravenous anaesthesia with etomidate.Trial registrationRegistration number: ChiCTR1800015421, Date: 29/03/2018.

Analgosedation Management in the Intensive Care Unit: A Narrative Systematic Review

Background: Intensive care unit (ICU) patients' pain and sedation management is a significant nursing challenge. Sedatives and muscle relaxants administration has been long used for improving patients' comfort and tolerance to mechanical ventilation. This practice led to an increase in adverse ICU outcomes in terms of health status, hospitalization stay, infections, and mortality. The use of appropriate ICU pain and sedation assessment tools is limited. Methods: We conducted a narrative literature systematic review (from 2010 to 2022) whose primary aims were to analyze the analgosedation definition and identify ICU patients’ pain, agitation, and sedation assessment tools; secondary aims were to explore analgesia and sedation pharmacological and non-pharmacological treatments and nurses’ perceptions and attitudes regarding analgosedation issues. Results: We retrieved 45 eligible articles. Analgosedation foresees early pain management - using pharmacological and non-pharmacological approaches and then, if necessary, implementing adequate sedation. Recommended assessment tools are the Behavioral Pain Scale (BPS) and the Critical Care Observational Tool (CPOT) for pain assessment, the Richmond Agitation Sedation Scale (RASS), and the Sedation Agitation Scale (SAS) for sedation assessment. Guidelines and specific protocols recommend both pharmacological and non-pharmacological approaches. Health professionals report mainly barriers (lack of adherence to guidelines and protocols, workload, reduced awareness, and own perceptions) to analgosedation correct application. The implementation of ICU analgosedation strategies requires continuous health professionals’ commitment and collaboration and valid assessment tools use. Conclusion: ICU analgosedation management (pain control first, and then sedation if necessary) is limited due to health professionals' knowledge gaps, inappropriate use of assessment tools, guidelines, and specific protocols. Recommended assessment tools are the BPS and CPOT for pain assessment and the RASS and SAS for sedation assessment. Interventions to improve ICU analgosedation awareness and practice include training events, the use and consultation of literature guidelines, and the use of validated assessment tools.

A retrospective analysis of the incidence and determinants of self-extubation in a tertiary care surgical intensive care unit

Background &amp; Objective: Self-extubation is reported as one of the most common adverse events in the adult intensive care units worldwide. We aimed to find out the incidence and determinants of self-extubation in surgical intensive care unit of our tertiary care hospital. Methodology: It was retrospective analysis of the data acquired from the hospital databases, about the patients who self-extubated during admission to surgical intensive care unit (SICU) of Aga Khan University Hospital, Karachi, Pakistan, during six calendar years, from January 01, 2010, through December 31, 2016. Data collection form was used to collect personal details, drugs used for sedation, sedation agitation score, pain score, nurse-patient ratio and the use of any restraint at the time of extubation. SPSS was used to analyze data applying the central limit theorem to calculate the mean and standard deviation for quantitative variables and the Chi-square test was conducted using a P &lt; 0.05 for qualitative variables. Multivariate logistic regression analysis was performed to identify the independent risk factors for self-extubation Results: A total of 618 patients were admitted to the SICU who required mechanical ventilation during the study period. An overall 2.1% incidence of self-extubation was calculated with a documented thirteen self-extubation episodes. The mean age of patients was 38.46 ± 16.97 y with majority of them being males. Most, 9 (69.2%), of the patients were not restrained at the time of self-extubation. Nurse to patient ratio was 1:1. Majority of patients 7 (53.8%) were not on any sedative drug infusion and the mean sedation agitation score at that time was 4.46 ± 2.02 while mean pain score was 5.31 ± 2.72. Reintubation was performed in 10 (76.9%) of the patients, who had self-extubated. Conclusion: This study revealed that the incidence of self-extubation was 2.1% in SICU and there was strong correlation between absent physical restraint and self-extubation incidence during the weaning period. Key words: Mechanical ventilation; Reintubation; Self-extubation; Sedation; Surgical Intensive Care Unit; Tertiary Care Hospital Ali MA, Rashid S, Siddiqui KM, Yousuf MS. A retrospective analysis of the incidence and determinants of self-extubation in a tertiary care surgical intensive care unit. Anaesth. pain intensive care 2023;27(3):260−263; DOI: 10.35975/apic.v27i3.2231 Received: October 03, 2022; Reviewed: April 04, 2023; Accepted: April 19, 2023

Effect of a repeated verbal reminder of orientation on emergence agitation after general anaesthesia for minimally invasive abdominal surgery: a randomised controlled trial

BackgroundAn orientation strategy providing repeated verbal reminders of time, place, and person has been widely used for the non-pharmacological management of delirium. We hypothesised that using this strategy could reduce emergence agitation and improve recovery profiles. MethodsThis prospective observer-blinded RCT included male and female patients aged 18–70 yr undergoing minimally invasive abdominal surgery. During emergence from general anaesthesia, subjects in the orientation group (n=57) were provided a repeated reminder, including orientation: ‘(Patient's name), you are now recovering from general anaesthesia after surgery at Seoul National University Hospital, open your eyes!’ via noise-cancelling headphones, whereas those in the control group (n=57) only heard their name: ‘(Patient's name), open your eyes!‘. The primary outcome was the incidence of emergence agitation (Riker sedation agitation scale [SAS] ≥5). The incidence of dangerous agitation (SAS=7), maximal SAS score in the operating room, and recovery profile until 24 h postoperatively were evaluated as secondary outcomes. ResultsThe incidence of emergence agitation in the operating room was significantly lower in the orientation group than in the control group (16/57 [28.1%] vs 38/57 [66.7%]; relative risk [95% confidence interval], 0.5 [0.3–0.7]; P<0.001). The incidence of dangerous agitation (0 [0.0%] vs 10 [17.5%], P=0.001) and the median maximal SAS score (4 [4–5] vs 5 [4–6], P<0.001) were also lower in the orientation group. Secondary outcomes, other than agitation-related variables, were comparable between the two groups. ConclusionsRepeated verbal stimulation of orientation may serve as a simple and easily applicable strategy to reduce emergence agitation after general anaesthesia. Clinical trial registrationNCT05105178.

753: EVALUATION OF SEDATIVE AND ANALGESIC PRACTICES AND OUTCOMES IN MECHANICALLY VENTILATED PATIENTS

Introduction: Sedative and analgesic agents are used for patient comfort during mechanical ventilation (MV) but can cause deleterious effects such as prolonged MV and delirium. Maintaining light sedation and performing daily awakening trials (DATs) can reduce untoward effects. We assessed the relationship between sedative and analgesic dose and 28-day MV-free survival in medical ICU (MICU), surgical ICU (SICU), and cardiac (CICU) patients, hypothesizing that higher doses would be associated with lower 28-day MV-free survival. Methods: In this single-center retrospective study, MICU, SICU, and CICU patients admitted to a tertiary care hospital from 1/1/21-6/30/21 and on MV admitted for 1-7 days were randomly selected if their goal Sedation Agitation Scale (SAS) score was 3-4. Baseline demographics and clinical characteristics were collected. The primary outcome was correlation between average sedative or analgesic dose and 28-day MV-free survival. Secondary outcomes included time at goal SAS score, DAT completion, and deep sedation (SAS < 3) within 48 hours of intubation. The primary outcome was evaluated using linear regression; secondary outcomes were assessed with descriptive statistics. Results: 411 subjects, including 99 MICU, 54 SICU, and 27 CICU patients, were evaluated. 53% were male and the median age and weight were 66.5 years (IQR, 56-77) and 84 kg (IQR 70-100), respectively. 8% of MICU patients but no SICU or CICU patients had Covid-19. A history of chronic opioid use was most common in MICU and SICU patients (19% and 17%, respectively) and CICU patients most often had a history of chronic kidney disease (33%). Doses of dexmedetomidine, propofol, midazolam, and fentanyl demonstrated poor correlation with 28-day MV-free survival among all patients, with R-squared values of 0.002, 0.06, 0.01, and 0.1, respectively. The association of sedative dose was strongest for midazolam in MICU patients, with each 1mg/hr increase corresponding to a 0.6 day reduction in 28-day MV-free survival. SAS scores were 3-4 70% of the time, SATs were completed in 73% of appropriate cases, and 57% of patients were deeply sedated within 48 hours of intubation. Conclusions: In this regression analysis, sedative and analgesic doses were not associated with 28-day MV-free survival in a mixed critically ill population.

Emergence delirium after intracranial neurosurgery- a prospective cohort study

ObjectivesThe primary objective of this study was to estimate the incidence of emergence delirium (ED) including hypo- and hyperactive ED, after intracranial neurosurgery. Secondary objective was to identify perioperative risk factors of ED in these patients. MethodsThis prospective observational study was conducted at an academic neurosciences hospital. All consecutive adult patients (age ≥ 18 years) with a preoperative Glasgow Coma Scale score of 15 undergoing elective intracranial surgery under general anesthesia during the six-month period from October 2020 to March 2021 were included in this study. Perioperative patient data were collected till one hour after surgery. ED was defined as per Riker’s sedation agitation score (SAS) as hyperactive ED when SAS was >4 and hypo active ED when SAS was <4 on a 1 to 7 scale. ResultsData of 320 patients were analyzed in this study. The overall incidence of ED was 22 % (71/320), with incidence of hyperactive ED of 4.3 % (n = 14) and hypoactive ED of 18 % (n = 57). The risk factors for ED were preoperative delirium (odds ratio [OR], 95 % confidence interval [CI] and p value of 4.41, 1.3–15.19, and 0.002), education level (OR = 2.21, [0.98–4.94], p = 0.05), minimum alveolar concentration of inhalational anesthetic (OR = 1.47, [1.17–1.88], p = 0.002), postoperative nausea and vomiting (OR = 4.56, [2.04–10.32], p = 0.001), and body weight (OR = 1.69, [1.1–2.68], p = 0.02). Hyperactive ED was predicted by preoperative delirium (OR = 5.28, [1.12–21.21], p = 0.024) and low education level (OR = 4.35, [1.2–17.04], p = 0.027). ConclusionsAtleast one in five patients undergoing brain surgery under anesthesia develop ED. Addressing modifiable risk factors might reduce ED.

Jinekolojik Cerrahide Taze Gaz Akımının Derlenme Ajitasyonu Üzerine Etkileri: Klinik Bir Çalışma

ABSTRACT Objective: This prospective study aimed to determine whether low flow anesthesia (LFA) has an effect on emergence agitation in women who underwent laparotomic gynecologic surgeries. Method: Sixty four female patients were enrolled in this prospective randomized study. The patients were randomly allocated into two groups: Group 2 and Group 0.5. The fresh gas flow (FGF) rate was set at 4 L min-1 in both groups, initially. When all patients reached 1 minimum alveolar concentration of sevoflurane, the FGF rate was reduced to 2 L min-1 in Group 2 and 0.5 L min-1 in Group 0.5. For Group 0.5, vapor was closed 15 minutes before the end of surgery, while it was closed at the end of the operation for Group 2. At the end of the surgery, the FGF rate was increased to 4 L min-1. Emergence agitation was assessed using the Riker Sedation Agitation Scale (SAS) in the post-anesthesia care unit at 5, 10, 20 and 30th minutes. Results: Emergence agitation was observed in 5 patients, no significant difference was found between two groups. For all evaluation times, number of patients with SAS=4 was significantly higher in Group 0.5, while the number of patients with SAS&lt;4 was significantly higher in Group 2 (p&lt;0.05). Conclusion: The number of patients who are calm and cooperative was higher in LFA. Keywords: Emergence agitation, general anesthesia, fresh gas flow

Systematic review and meta-analysis of the correlation between bispectral index (BIS) and clinical sedation scales: Toward defining the role of BIS in critically ill patients.

The bispectral index (BIS) is an attractive approach for monitoring level of consciousness in critically ill patients, particularly during paralysis, when commonly used sedation scales cannot be used. As a first step toward establishing the utility of BIS during paralysis, this review examines the strength of correlation between BIS and clinical sedation scales in a broad population of non-paralyzed, critically ill adults. We included studies evaluating the strength of correlation between concurrent assessments of BIS and Richmond Agitation Sedation Scale (RASS), Ramsay Sedation Scale (RSS), or Sedation Agitation Scale (SAS) in critically ill adult patients. Studies involving assessment of depth sedation periperative or procedural time periods, and those reporting BIS and sedation scale assessments conducted >5min apart or while neuromuscular blocking agents (NMBA) were administered, were excluded. Data were abstracted on sedation scale, correlation coefficients, setting, patient characteristics, and BIS assessment characteristics that could impact the quality of the studies. Twenty-four studies which enrolled 1235 patients met inclusion criteria. The correlation between BIS and RASS, RSS, and SAS overall was 0.68 (95% confidence interval, 0.61-0.74, Ƭ2 = 0.06 I2 = 71.26%). Subgroup analysis by sedation scale indicated that the correlation between BIS and RASS, RSS, and SAS were 0.66 (95% confidence interval 0.58-0.73, Ƭ2 = 0.01 I2 = 30.20%), 0.76 (95% confidence interval 0.69-0.82, Ƭ2 = 0.04 I2 = 67.15%), and 0.53 (95% confidence interval 0.42-0.63, Ƭ2 = 0.01 I2 = 26.59%), respectively. Factors associated with significant heterogeneity included comparator clinical sedation scale, neurologic injury, and the type of intensive care unit (ICU) population. BIS demonstrated moderate to strong correlation with clinical sedation scales in adult ICU patients, providing preliminary evidence for the validity of BIS as a measure of sedation intensity when clinical scales cannot be used. Future studies should determine whether BIS monitoring is safe and effective in improving outcomes in patients receiving NMBA treatment.

Predicting Receipt and Types of Occupational Therapy Services for Patients with Arousal Deficits in the Neuro Critical Care Unit

Occupational therapy has been identified as a required service in the neuro critical care unit (NCCU), however who receives occupational therapy services and what services they receive are not well understood. We sought to determine if arousal deficits impacted patients’ likelihood to receive an occupational therapy evaluation or specific types of occupational therapy interventions in the NCCU. When compared to patients without arousal deficits, patients who were experiencing agitation or light sedation, but not deep sedation, were more likely to receive occupational therapy interventions in the therapeutic activities category. Arousal deficits were not associated with receipt of occupational therapy services or occupational therapy interventions in the self-care or therapeutic exercise categories. Determining predictors of occupational therapy services will help ensure the timely delivery of services by improving the allocation of resources and identifying potential gaps in care.

Effect Evaluation of Dexmedetomidine Intravenous Anesthesia on Postoperative Agitation in Patients with Craniocerebral Injury by Magnetic Resonance Imaging Based on Sparse Reconstruction Algorithm.

The effect of dexmedetomidine on postoperative agitation of patients with craniocerebral injury was investigated based on magnetic resonance imaging (MRI) with the sparse reconstruction algorithm. Sixty patients with craniocerebral injury who underwent tracheal intubation and craniotomy hematoma removal under general anesthesia in hospital were selected as the research objects. Patients were randomly and averagely divided into the normal saline group (group A) and the dexmedetomidine (DEX) group (group B). DEX was added to patients in group A during anesthesia. Other operations in group B were the same as those in group A, where DEX needed to be used was replaced by an equal amount of the normal saline. All patients received the MRI examination, and the images were processed by using the sparse reconstruction algorithm. After the surgery, some indexes, such as hemodynamics (mean arterial pressure (MAP) and hear rate (HR)), the Riker sedation agitation score, the Ramsay sedation score, and the visual analogue scale (VAS) score were recorded and compared. The results showed that the MRI image quality processed by sparse reconstruction algorithm was observably improved. After reconstruction, the sharpness of the image was significantly improved, and the distinction between lesions and tissues was also increased. The Riker sedation agitation score and the incidence of agitation in group A were greatly lower than those in group B (16% VS 76%, P < 0.05). The Ramsay sedation score of group A was manifestly higher than that of group B. The cases of postoperative nausea, vomiting, chills, delirium, and bradycardia in group A were 2, 1, 1, 0, and 1, respectively. The cases of postoperative nausea, vomiting, chills, delirium, and bradycardia in group B were 3, 9, 6, 5, and 0, respectively. The cases of chills and delirium in group A were observably less than those in group B (P < 0.05). In conclusion, based on the sparse reconstruction algorithm, the MRI technology and DEX had high adoption value in preventing postoperative agitation of patients with craniocerebral injury. Compared with group B, the hemodynamics of patients in group A was more stable.

Use of Levomepromazine for the Treatment of Emergence Agitation in Patients Receiving Mechanical Ventilation for SARS-CoV-2 Related Acute Respiratory Distress Syndrome

Purpose: To report our experience with the use of Levomepromazine (LMZ) for the treatment of delirium in patients treated for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Methods: Retrospective series of patients admitted to the Intensive Care Unit (ICU) of a non-academic hospital and who requiring invasive mechanical ventilation for the treatment of ARDS due to SARS-CoV-2. Infection was confirmed by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) testing, and patients presented delirium after withdrawal of neuromuscular blockade or sedation lightening treated with LMZ on top of other treatment. Results: Out of 34 ARDS patients admitted from 22 March 2020 to 23 January 2021, 11 (32.3%) died before neuromuscular blockade withdrawal, and of the remaining 23, 16 were treated with LMZ. The median time to initiation of LMZ was 6 days (interquartile, 5 to 8) from the start of sedation, and median duration of LMZ treatment was 5 (1 to 28) days. Median sedation score (as assessed by the Sedation Agitation Scale (SAS)) was 2 (1-4) at initiation and 3 (2-4) at discontinuation of LMZ, while median analgesia scores (Behavioral Pain Scale (BPS)) were respectively 3 (3-5) and 4 (3-5). Of the 16 patients treated with LMZ, 12 were weaned from mechanical ventilation immediately following discontinuation, without recurrence of delirium. No adverse effects related to LMZ use were observed. The 4 patients who could not be weaned from mechanical ventilation following LMZ required new neuromuscular blockade. Conclusions: Based on this retrospective series, LMZ seems to be useful for the management of delirium occurring after withdrawal of neuromuscular blockade or lightening of sedation in patients with ARDS due to SARS-CoV-2.

Effect of music therapy on infants who underwent mechanical ventilation after cardiac surgery.

To investigate the effect of music therapy on infants who underwent mechanical ventilation after cardiac surgery. A prospective randomized controlled study was conducted in a provincial hospital in southeast China. The subjects were randomly divided into the music therapy (MT) group and the control group. Both groups were given standardized sedation treatment and routine nursing. Infants in the MT group received 60 min of MT three times a day. The sedation medication, Richmond sedation agitation scale (RASS) score, incidence of delirium, mechanical ventilation duration, length of cardiac intensive care unit (CICU) stay, restraint belt use time, and successful ventilation withdrawal rate were collected. Infants in the control group had a higher total amount of on-demand midazolam (p = .039). Infants in the MT group had a significantly lower incidence of delirium, shorter mechanical ventilation duration, and restraint band use time (p = .047, p = .046, and p = .038, respectively). Although infants in the MT group had a higher success rate of ventilation withdrawal, lower RASS scores, and shorter ICU stay, the difference was not statistically significant (p = .427, p = .585, and p = .068, respectively). MT in the ICU can reduce the use of on-demand sedative drugs, shorten mechanical ventilation, and reduce the occurrence of delirium in infants who underwent mechanical ventilation after cardiac surgery. MT is a safe and reliable treatment and worthy of clinical application.

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.

Butorphanol versus Propofol in Patients Undergoing Noninvasive Ventilation: A Prospective Observational Study

BackgroundThe present study aimed to explore sedation management in agitated patients who suffered from acute respiratory failure (ARF) and were treated with noninvasive ventilation (NIV).Patients and MethodsWe divided 118 patients undergoing NIV treatment with butorphanol or propofol into two groups: group B (n = 57, butorphanol was initiated at the rate of 0.12 µg/kg/min as a continuous intravenous infusion and then titrated by 0.06 µg/kg/min every half an hour, group P (n = 61, propofol was initiated at the rate of 5 µg/kg/min as a continuous intravenous infusion and then titrated by 1.5 µg/kg/min every half an hour). Score of Sedation Agitation Scale (SAS) in the two groups was maintained between 3 and 4. Medications including sedative, analgesic, and antipsychotic, NIV intolerance score, SAS score, visual analog scale (VAS), medication use and adverse events were recorded repeatedly.ResultsPatients receiving butorphanol required significantly less total amount of fentanyl than patients receiving propofol during NIV to maintain the target VAS [0 (0–0) µg vs 150 (50–200) µg, P< 0.005]. Hemodynamic stability during NIV showed it was better kept in patients treated with butorphanol.ConclusionButorphanol not only decreased the requirements of fentanyl but also enhanced hemodynamic stability in agitated patients suffering from ARF receiving NIV.Trial RegistrationRegistered at http://www.chictr.org.cn/ (ChiCTR1800015534).

Impact of Intraoperative Dexmedetomidine versus Remifentanil on Recovery Characteristics following Laparoscopic Sleeve Gastrectomy.

To evaluate the impact of intraoperative dexmedetomidine versus remifentanil on postoperative pain; and enhanced recovery profile in patients scheduled for laparoscopic sleeve gastrectomy (LSG). Clinical observational double-blind pilot study. King Khalid University Hospital, affiliated with King Saud University, Riyadh, Saudi Arabia, from December 2019 to March 2020. Forty adult patients with body mass index (BMI) >35 Kg/m2were divided into two equal groups: group dexmedetomidine (D) and group remifentanil (R). In the post-anaesthesia care unit (PACU) and for 24 hours in the ward, the patients were assessed for pain score and other recovery characteristics. In the PACU, the mean values of numerical rating scale (NRS) were 4.26±1.97 vs. 4.15±1.9 and morphine consumption median values were 4 vs. 1 mg in groups D and R, respectively (p >0.05). The number of patients who developed shivering were 0 vs. 6 in groups D and R, respectively (p <0.05). Sedation agitation scale (SAS) median values were 4 vs. 4 (p <0.05), postoperative nausea and vomiting (PONV) frequency was 1 vs. 6 (p >0.05) in groups D and R, respectively. The length of hospital stay (LOS) median values were 1 vs. 1 day in groups D and R, respectively (p >0.05). Better enhanced recovery profile after LSG supports the use of intraoperative infusion of dexmedetomidine as an anaesthetic adjuvant versus remifentanil. Key Words: Dexmedetomidine, Remifentanil, Enhanced recovery after surgery (ERAS); Bariatric surgery.

Procedural sedation – a patient’s whim or a necessity?

Background. Procedural sedation (PS) is a condition that allows patients to avoid discomfort when undergoing certain painful manipulations on the background of stable hemodynamics and respiration and maintaining the ability to respond adequately to verbal commands or tactile stimulation. PS is most often used in dentistry, maxillofacial surgery, endoscopy, ophthalmology, otorhinolaryngology.&#x0D; Objective. Describe the main features of the PS.&#x0D; Materials and methods. Analysis of literature data on this topic.&#x0D; Results and discussion. Risk groups during PS include patients with cardiovascular decompensation, morbid obesity, obstructive sleep apnea, grade III-IV chronic renal failure, liver decompensation, as well as age over 70. The conditions for safe PS are as follows: all medical staff are trained to provide cardiorespiratory resuscitation; there is a constant quick access to resuscitation equipment; a routine pre-procedure assessment of the patient’s condition (especially the upper respiratory tract) was carried out; pre-procedure fasting was prescribed; careful monitoring of the patient’s condition is provided. The main scales for sedation assessment include Ramsay Sedation Scale, Sedation Agitation Scale, Motor Activity Assessment Scale, Vancouver Interactive and Calmness Scale, Richmond Agitation-Sedation Scale, Adaptation to Intensive Care Environment, Minnesota Sedation Assessment Tool. Midazolam, propofol, dexmedetomidine can be used for PS. Minimal sedation (anxiolysis) is a medical condition in which the patient responds normally to voice commands. Cognitive function and coordination in this condition may be impaired, however, cardiorespiratory function remains unchanged. Such sedation is prescribed in traumatology, maxillofacial surgery, urology, gynecology, plastic surgery. Moderate sedation is a medical suppression of consciousness in which the patient responds to voice commands accompanied by light tactile stimulation. Adequate respiration and functioning of the cardiovascular system is maintained. Diazepam/sibazone, midazolam, dexmedetomidine are prescribed for this purpose. The latter is recommended for fiber-optic intubation in a state of complete consciousness. The dangers of PS include passive aspiration and ventilation disorders, which leads to hypoxia and hypercapnia. Caution should be taken with propofol due to the possible development of respiratory depression and hemodynamics, pain in the vein during administration. Dexmedetomidine does not cause respiratory depression, however, this does not eliminate the need for monitoring.&#x0D; Conclusions. 1. Adequate sedation during surgery is a logical component of the intervention if the regional methods of anesthesia are applicated. 2. Sedation outside the operating room will account for more and more of the use of anesthetics. 3. There is a need for clear regulation of PS. 4. When choosing a drug one should take into account the purpose of its administration, curability of complications, comfort and safety of the patient.

Effects of Additional Intraoperative Administration of Sufentanil on Postoperative Pain, Stress and Inflammatory Responses in Patients Undergoing Laparoscopic Myomectomy: A Double-Blind, Randomized, Placebo-Controlled Trial.

PurposeAlthough pain after laparoscopic surgery is assumed to be minor, many women still suffer from unexpected postoperative pain. Thus, we aimed to assess whether additional intraoperative administration of sufentanil could help to improve postoperative pain and related agitation, stress, and inflammation response in patients undergoing laparoscopic myomectomy.Patients and MethodsForty female patients with uterine myoma scheduled for laparoscopic myomectomy under general anesthesia were randomized to receive sufentanil (group T, n=20) or normal saline (group C, n=20) 1h before the end of the surgery. The postoperative pain, agitation, stress, inflammation, and adverse effects were measured.ResultsAs the primary outcome, the visual analog scale (VAS) pain score was significantly reduced in group T as compared with group C at each measured time point in a post-anesthesia care unit (PACU), VAS 5 min (31.5 ± 2.7 vs 40.6 ± 5.6) (P<0.001), VAS 30 min (36.5 ± 4.5 vs 46.0 ± 2.9) (P<0.001), VAS 1h (37.8 ± 4.0 vs 48.6 ± 5.5) (P<0.001). The secondary outcomes, including the sedation agitation scale (SAS) scores, plasma concentrations of epinephrine and norepinephrine, and the levels of plasma interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-α) in group T were remarkably lower than those in group C (P < 0.001). The cough cases in group T also showed a significant reduction in comparison with group C (P < 0.05). In addition, the anesthetic recovery time, including the spontaneous breathing recovery time and extubation time, were not significantly different between the two groups, as were the cases of respiratory depression and postoperative delirium (P > 0.05).ConclusionFor patients undergoing laparoscopic myomectomy, administration of sufentanil 1 h before the end of surgery shows excellent analgesic and sedative effects, alleviated postoperative stress and inflammatory responses, reduced incidence of cough, without prolonging anesthetic recovery time and increasing adverse reactions.