Bolus Dose Of Propofol Research Articles

Use of dexmedetomidine for fast-track anesthesia in noncomplex pediatric cardiac surgery

Introduction Fast-track anesthesia technique is now an important aspect for reducing or eliminating the adverse effects of prolonged postoperative ventilation together with reducing ICU and hospital length of stay. This study was conducted to evaluate the effect of using dexmedetomidine as an adjuvant drug for fast-track technique in pediatric cardiac surgery. Patients and methods Sixty patients of both sexes with ages ranging from 1 to 12 years indicated for correction of noncomplex congenital heart diseases with cardiopulmonary bypass (CPB) were included in this study. After standard inhalational induction using sevoflurane for all patients, they were randomly classified into two groups of 30 each. In the dexmedetomidine group (group D), the patients received an initial bolus dose of dexmedetomidine (0.4 mg/kg) over 10 min, followed by continuous infusion of 0.5 mg/kg/h until the end of CPB. In the propofol group (group P) the patients received an initial bolus dose of propofol (2 mg/kg) over 30 s, followed by infusion at rate of 0.5 mg/kg/min until the end of CPB. Results There were significant differences between the two groups ( P Conclusion Dexmedetomidine helps in fast-track anesthesia in pediatric cardiac surgery and has many desirable effects that encourage its use in the perioperative period.

Severe opioid withdrawal syndrome after a single dose of nalmefene

Case 1 A 43-year-old man was brought by ambulance to the emergency department (ED) with severe agitation and clinical signs of severe opioid withdrawal approximately 2 h after a single dose of nalmefene (Selincro®, Lundbeck (Switzerland)) for his alcohol dependence. His medical history included paranoid schizophrenia, depression, and alcohol and codeine dependence. He consumed up to two bottles of Makatussin®Hustentropfen (GebropharmaAG, Liestal, Switzerland), a codeine-containing cough medicine, per day (equivalent to 636 mg codeine base per day). The psychiatrist who prescribed the nalmefene was unaware of the extent of the patient’s codeine abuse. The patient needed high bolus doses of midazolam (cumulative dose 25 mg, commenced in the community prior to transfer to the ED), morphine (10 mg), and propofol (40 mg) to treat the agitation. He was transferred to the intensive care unit (ICU) for further monitoring and treatment, where he received midazolam, propofol, morphine, and clonidine by continuous intravenous infusion. After the first 12 h, it was possible to withdraw clonidine and propofol; however, midazolam and morphine were continued for a further 48 h. Attempts to stop the medication before this point resulted in reemergence of the opioid withdrawal symptoms. After 3 days of ICU treatment, we were able to transfer the patient to psychiatric inpatient services.

A Pilot Study of Cerebral and Hemodynamic Changes During Sedation with Low Dose of Thiopental Sodium or Propofol in Patients with Acute Brain Injury.

One of the most important therapeutic maneuvers in head injury patients is to maintain Intracranial Pressure (ICP) and Cerebral Perfusion Pressure (CPP) within normal levels. To compare the effects of low dose of thiopental sodium and propofol on reducing ICP and CPP in patients with head injury that scheduled for neurosurgical interventions. Using a randomized, crossover pilot study, we enrolled patients with head injury that scheduled for neurosurgical interventions admitted to ICU unit of a teaching hospital during 2010 to 2011. In this pilot study, patients randomized into two equal groups. The first group received bolus injection of thiopental sodium 2 mg/kg and a maintenance dose of 2 mg/kg/h and the second group was given a bolus dose of propofol 0.5 mg/kg followed by propofol infusion 20 μg/kg/min. All of patients were given dexamethasone 8 mg at time of catheter insertion. ICP measurement catheter was inserted for each patient and ICP, CPP, SPO2 and MAP were recorded hourly for a period of 6 hours. There was no significant difference in sex and age between the two study groups (p>0.05). The mean ICP, CPP, SPO2 and arterial blood pressure were found to be similar with no significant difference between both groups (p>0.05). Both propofol and thiopental sodium were equally effective in monitoring and maintaining CPP and MAP and eventually an ideal SPO2.

A child with difficult airway for magnetic resonance imaging: Is dexmedetomidine useful?

Sir, Magnetic resonance imaging (MRI) poses challenges to the anaesthesiologists in providing adequate sedation without compromising the patient's airway or haemodynamics and ensuring rapid recovery. The additional challenges posed by remote locations make the highest level of vigilance essential during MRI study. Dexmedetomidine has been used as a sole agent or in combination with other drugs for sedation in radiology set up.[1,2] Seven-month-old male child, weighing 7 kg, with history of swelling in the floor of mouth was referred to our hospital for MRI scanning. On detailed history, the swelling was present since birth and was increasing in size. There was no feeding difficulty but sleep was disturbed. On examination, a 4 cm × 4 cm swelling completely pushing tongue to one side was seen [Figure 1a]. Rest of the clinical examination was normal. Need for Intensive Care Unit stay was explained to relatives. Equipment for difficult airway was kept ready. Plan was to sedate the child in the preparation room. All monitors (electrocardiogram [ECG], pulse oximetry, end-tidal CO2 [ETCO2]) were attached. In the MRI room, MRI-compatible anaesthesia workstation and multiparameter monitor were kept ready. Intravenous (i.v.) cannula was secured and glycopyrrolate 0.05 mg administered. Dexmedetomidine 7 µg was administered over 10 min as infusion. Sedation was assessed using Ramsay sedation score. Ketamine 10 mg i.v. was given as supplemental sedation after completion of dexmedetomidine infusion to achieve Ramsay sedation score of 6. Then patient was transferred to MRI table and all monitors (ECG, pulse oximetry, ETCO2) were attached. Stable capnogram was established before proceeding to scan. Oxygen supplementation was given with nasal cannula (2 L/min). Continuous monitoring of vital parameters was done. Procedure lasted for 45 min. No episode of apnoea, desaturation and bradycardia was noted. The child was immobile throughout the MRI scanning. After the procedure, the patient was transferred to recovery room and monitored till recovery. MRI imaging confirmed the extent of swelling, and the tumour was compressing trachea [Figure 1b]. Figure 1 (a) Large tumour in oral cavity pushing tongue; (b) magnetic resonance imaging scan showing tumour compressing trachea Dexmedetomidine is useful for paediatric sedation in many clinical situations. It is associated with rapid onset and offset and a natural, sleep-like state with minimal effect on respiration. During MRI, the patient needs to be still for good-quality image. Paediatric patients need sedation and sometimes general anaesthesia for MRI. Many drugs such as chloral hydrate, phenobarbital, ketamine, midazolam and propofol have been used in MRI setting.[1] Dexmedetomidine alone has been used for sedation in MRI suite with more than 90% success.[3] These studies noted no apnoea or respiratory depression with high dose of dexmedetomidine. As dexmedetomidine single dose gives adequate sedation for 45–60 min, MRI can be done without need for supplemental sedation. In a study comparing dexmedetomidine plus single bolus dose of midazolam and propofol, dexmedetomidine provided satisfactory condition for MRI and respiratory incidences were similar to the propofol group.[2] In another study of dexmedetomidine versus midazolam,[4] the quality of MRI was better with dexmedetomidine and need for rescue medication was less. Comparison of intramuscular (i.m.) ketamine, i.m. dexmedetomidine, and dexmedetomidine–ketamine combination showed that the combination was superior with regard to onset, haemodynamic and respiratory stability.[5] Quality of MRI and radiologist satisfaction regarding image quality was better in dexmedetomidine–ketamine combination group. The combination of dexmedetomidine and ketamine is useful as the risk of apnoea is minimal with this combination. In a case series of trisomy 21 patients for MRI, dexmedetomidine–ketamine combination provided effective sedation without haemodynamic and respiratory compromise.[6] We conclude that dexmedetomidine and ketamine combination is an option to manage children with difficult airway for sedation in MRI suite.

Pediatric procedural sedation with propofol using a higher initial bolus dose.

We sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed. This was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale. Eight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to <90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm. A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

346 Ultrasound Measurement of Inferior Vena Cava Collapse Predicts Propofol-Induced Hypotension

Propofol is frequently used for deep sedation. Hypotension from propofol is a commonly observed side effect but there are no reliable methods to determine which patients are at risk for propofol-induced hypotension. Bedside ultrasound, widely available in emergency department (EDs), has been used to estimate volume status by visualization of inferior vena cava (IVC) collapse. We hypothesized that an IVC collapse index (IVC-CI) of 50% or greater will predict hypotension in patients receiving a bolus dose of intravenous propofol.

Bispectral Index Guided Sedation in Congenital Pain Insensitivity Syndrome.

Bispectral Index Guided Sedation in Congenital Pain Insensitivity Syndrome.

Comparing the Effects of Oral Clonidine Premedication With Intraoperative Dexmedetomidine Infusion on Anesthetic Requirement and Recovery From Anesthesia in Patients Undergoing Major Spine Surgery

Clonidine, an α2 agonist, has been used in anesthesia for many years to provide sedation, anxiolysis, analgesia, controlled hypotension, and to provide opioid-sparing anesthesia. Recently, there has been a great interest in using the newer α2 agonist, dexmedetomidine, because of its more selectivity toward α2 adrenoreceptors. We compared the effects of clonidine with dexmedetomidine on anesthetic requirement and recovery from anesthesia. Seventy-four patients undergoing major spine surgery were randomly allocated to receive either oral clonidine premedication followed by an intraoperative saline infusion (group A) or placebo premedication followed by dexmedetomidine infusion in the intraoperative period (group B). Standard anesthesia protocols were followed for induction and maintenance. Heart rate, blood pressure, and end-tidal concentrations of isoflurane were noted every 15 minutes after proning. Hypertensive responses were treated with bolus doses of propofol and fentanyl. Hypotensive episodes were treated with bolus doses of ephedrine or phenylephrine. Primary outcomes were the comparisons of the effect of these 2 drugs on anesthetic requirement and recovery from anesthesia. Secondary outcomes were the comparisons of the hemodynamic response, intraoperative analgesic requirement, and blood loss during surgery. Demographic data, duration of surgery, total dose of fentanyl and propofol requirement, blood loss, and the recovery time were comparable between the 2 groups. Both drugs reduced the isoflurane requirement during surgery. However, the reduction was more and statistically significant with dexmedetomidine compared with clonidine group at 1 and 2 hours after proning (P=0.001, 0.039 at 1 and 2 h). Both drugs are equally effective in controlling the hemodynamics, and the number of episodes of hypotension, hypertension, and bradycardia were comparable between the 2 groups. Both clonidine and dexmedetomidine have anesthetic-sparing effect; however, it was more with dexmedetomidine than with clonidine. Recovery from isoflurane anesthesia was similar between both groups. Both are equally effective in controlling the hemodynamic response and reducing the blood loss during spine surgery.

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine

OBJECTIVE:Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy.MATERIALS AND METHODS:Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated.RESULTS:The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K.CONCLUSION:Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period.

A randomized trial evaluating low doses of propofol infusion after intravenous ketamine for ambulatory pediatric magnetic resonance imaging.

Objective:Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following sedation with propofol infusion dose of 100, 75 and 50 mcg/kg/min given after a bolus dose of ketamine and propofol.Materials and Methods:One hundred children of American Society of Anesthesiologists status 1/2, aged 6 months to 8 years, scheduled for elective MRI were enrolled and randomized to three groups to receive propofol infusion of 100, 75 or 50 mcg/kg/min (Groups A, B, and C, respectively). After premedicating children with midazolam 0.05 mg/kg intravenous (i.v.), sedation was induced with bolus dose of ketamine and propofol (1 mg/kg each) and the propofol infusion was connected. During the scan, heart rate, noninvasive blood pressure, respiratory rate, and oxygen saturation were monitored.Results:The primary outcome that is, discharge time was shortest for Group C (44.06 ± 18.64 min) and longest for Group A (60.00 ± 18.66 min), the difference being statistically and clinically significant. The secondary outcomes that is, additional propofol boluses, scan quality and awakening time were comparable for the three groups. The systolic blood pressure at 20, 25 and 30 min was significantly lower in Groups A and B compared with Group C. The incidence of sedation related adverse events was highest in Group A and least in Group C.Conclusion:After a bolus dose of ketamine and propofol (1 mg/kg each), propofol infusion of 50 mcg/kg/min provided sedation with shortest discharge time for MRI in children premedicated with midazolam 0.05 mg/kg i.v. It also enabled stable hemodynamics with less adverse events.

Total intravenous propofol and remifentanil versus balanced anesthesia with sevoflurane and remifentanil for pediatric lower abdominal surgery

Background This study aimed to evaluate and compare the induction, the maintenance, hemodynamic responses and the recovery profile of propofol-remifentanil combination (total intravenous anesthesia) and sevoflurane-remifentanil under the Bispectral index for pediatric patients undergoing short lower abdominal surgery. Materials and methods Sixty ASA physical status I and II patients aged 3-10 years scheduled for elective lower abdominal procedure were assigned to receive either the propofol and remifentanil combination (group P/R = 30 patients) or sevoflurane and remifentanil (group S/R = 30 patients) under Bispectral index monitoring. In both groups, anesthesia was started with remifentanil infusion (0.5 μg/kg/min) for 2 min. In the P/R group, a bolus dose of propofol 2 mg/kg was given, and then the infusion was started (7.5 mg/kg/h) and reduced gradually to 3 mg/kg/h. In the S/R group, sevoflurane 2 vol% in 100% O 2 was added and increased gradually to 8 vol%, and then reduced to 4, 3, 2 vol%. Results Induction of anesthesia was rapid in the P/R group (2.3 ± 0.7 min) compared with the S/R group (2.6 ± 1.3 min). Hypotension occurred after induction 10% in the P/R group versus 30% in the S/R group. Bradycardia was a defining feature in the P/R group only. Group P/R achieved rapid extubation in 12 min and was transferred to the postanesthesia care unit, in 17 min compared with 15 and 20 min, respectively, in the S/R group. Conclusion This study indicates that the propofol-remifentanil combination is superior to the sevoflurane-remifentanil combination, with faster induction and recovery, although both techniques are considered to be safe and effective for providing anesthesia to pediatric patients.

Effect of repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia

Background: Succinylcholine-induced fasciculations and myalgia are common and troublesome for the patients. A few studies have used propofol to minimize succinylcholine-induced fasciculations and myalgia, but none of these have used a repeat bolus dose. Materials and Methods: A prospective, randomized, double blind study was designed to assess the effect of a repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia. Ninety adult patients scheduled for elective surgery under general anesthesia were selected by computer-generated random numbers and allocated to one of the three equal groups randomly. Anesthesia was induced with intravenous injection of propofol 2 mg/kg, followed by administration of succinylcholine 1.5 mg/kg. Immediately after the injection of succinylcholine a repeat bolus of propofol was given as per group. Group I: No repeat dose of propofol; Group II: Repeat propofol bolus of 0.5 mg/kg body weight; Group III: Repeat propofol bolus of 1.0 mg/kg body weight. Muscle fasciculations were observed and graded as nil (0), mild (1), moderate (2), or severe (3). Postoperative myalgia were assessed every 6 hourly for 24 h and then at 48 h and graded as nil (I), mild (II), moderate (III), or severe (IV). Results: The overall incidence of muscle fasciculations was 73 and 33% in Groups II and III, respectively as against 90% in Group I. The incidence of postoperative myalgia was highest (86.67%) in Group I and lowest in Group III (60.0%). Conclusion: The technique of giving repeat bolus dose of propofol immediately after succinylcholine not only decreases the incidence and severity of fasciculations and postoperative myalgia, but also provides hemodynamic stability and satisfactory grade of relaxation for intubation.

Comparing the effects of three different additional doses of propofol infusion on intubation condition and hemodynamic changes during general anesthesia under elective surgery: A randomized, placebo-controlled, double blind clinical trial.

Background:Laryngoscopy and endotracheal intubation can induce unfavorable hemodynamic changes as propofol itself can induce hypotension. The aim of this study was to compare the effects of three different additional doses of propofol infusion on intubation conditions and hemodynamic changes occurred after intubation.Materials and Methods:This double-blinded prospective study was performed on 140 patients aged 18-60 who received different additional doses of propofol and were randomly allocated into 4 groups as follows: A: Received additional dose of propofol 0.5 mg/kg infused after an initial dose 1.5 mg/kg. B: Received additional dose of propofol 1 mg/kg infused after an initial dose 1 mg/kg. C: Received additional dose of propofol 1.5 mg/kg after an initial dose 1 mg/kg. D: Received propofol 2 mg/kg as a bolus with no additional dose.Results:Intubation conditions were acceptable in 91.4% of Group A patients, 94.2% of Group B patients, 97.1% of Group C patients and 68.5% of Group D patients. There were no significant differences in the mean of heart rate between four groups at any time before and after laryngoscopy. Mean arterial pressure (MAP) 3 min after laryngoscopy was significantly lower in Group D versus Group A (P = 0.015) while MAP was not different at any time between other groups.Conclusion:Infusion of propofol 1.5 mg/kg added to initial bolus dose of propofol 1 mg/kg improves intubation conditions significantly without inducing hemodynamic changes.

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Introduction: There are concerns that fluid abstinence prior to sedation may put patients at risk for hypotension during sedation. This risk may be increased in children. Methods: This study is a retrospective chart review of 263 children who received intravenous (IV) Propofol by bolus then continuous infusion to complete magnetic resonance imaging from June 2011 through May 2013. All patients were instructed to take nothing by mouth as directed by the American Society of Anesthesiologists preoperative fasting guideline. Actual time of abstinence was documented prior to initiation of sedation. Study data included patient characteristics (gender, age, and weight), propofol bolus dose and infusion rate and hemodynamic parameters were measured at baseline and 5 minute intervals for the sedation duration which is routine per policy. IV fluid received was also recorded. Total and percent maximum decrease in systolic blood pressure (SBP) and mean arterial pressure (MAP) relative to baseline were calculated. Max SBP and MAP decreases were also dichotomized at 25 SBP units (SBPdrop25) and 20% MAP (pctMAPdrop20). Associations of hemodynamic changes with fluid abstinence and other patient characteristics were explored with linear correlation and logistic regression analyses. Results: Mean fluid abstinence time was 538.4 +/- 294.0 minutes, propofol bolus dose 2.4 +/- 0.9 mg/kg, propofol infusion rate dose 160.1 +/- 29.3 g/kg/min, and duration 51.6 +/- 24.8 minutes. Duration of procedure, baseline SBP and MAP were significantly correlated with blood pressure decreases but not with fluid abstinences time. Fluid abstinence time was not significantly correlated with maximum SBP decrease (r = 0.02, p = .727) or maximum percent MAP decrease (r = 0.08, p = .20). Logistic regression showed no significant relationships between fluid abstinence time and SBPdrop25 (O.R. 1.0, 95% C.I. 1.00 – 1.01) or pctMAPdrop20 (O.R. 1.0, 95% C.I. 1.00 – 1.01). Conclusions: In our study duration of fluid abstinence prior to sedation with Propofol is not independently associated with hemodynamic changes in children.

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Introduction: The administration of the bolus injection of propofol is frequently associated with significant and often distressing pain. This pain is magnified in children. The objective of this prospective randomized study was to assess differences in pain experience with propofol injection in two different intravenous (IV) sites (antecubital fossa vs. dorsum of hand), in children with the goal of identifying the preferred site for propofol administration. Methods: A total of 136 children, 1-18 years old assessed as American Society of Anesthesiologist (ASA) class I–II undergoing sedation with propofol for magnetic resonance imaging (MRI) during January 2013 to July 2013, were placed into two groups by IV site. Initial IV site attempted was randomized by day of the week. Pain was assessed by independent of the study nurses using the 10 point Face, Activity, Cry and Consolability (FLACC) scale during injection. FLACC scores were assessed three times, in pre-sedation before entering the MRI suit, in the MRI machine room presedation and upon administration of the bolus dose of propofol. Chi square and t-tests were used to assess differences in patient characteristics comparing the two IV site groups. Group differences in FLACC scores in all 3 instances were evaluated with Wilcoxon Signed Ranks and Wilcoxon Rank Sums tests. Results: The sample included 72 females and 64 males. Mean age was 77.2 +/- 39.5 months and weight 26.9 +/- 16.3 kg. Groups were not significantly different in gender allocation, mean age or weight. Admission and MRI room FLACC scores were not statistically significant by IV site. However, in response to propofol administration, FLACC scores for the hand IV site (median = 5, mean =4.93) were significantly higher than for the antecubital site (median =3, mean=3.34) (p-0.004). Conclusions: Our findings demonstrated the pain experience during propofol administration in antecubital fossa veins is significantly less than dorsum of the hand. We suggest that all effort should be made to use this IV access site.

English

BACKGROUND AND OBJECTIVES: ERCP is a routinely carried out diagnostic and/or therapeutic procedure. It is a distressing procedure in awake patients. These patients require sedation mainly to minimize their anxiety and analgesics to alleviate pain and discomfort thereby enhancing patient's cooperation throughout the procedure 1 . Propofol has been traditionally used. Dexmedetomidine, a novel selective α2 agonist is known to produce sedation without compromising hemodynamic stability or causing respiratory depression. Objective of this study was to compare Propofol-Fentanyl combination with Dexmedetomidine-Fentanyl combination for providing satisfactory procedural sedation during ERCP. METHODS: 70 patients undergoing elective ERCP were divided into 2 groups of 35 each. Dexmedetomidine group patients received Fentanyl 1µg/kg and a loading dose of Dexmedetomidine1µg/kg over 10 minutes followed by a maintenance dose of 0.5 µg/kg/hr intravenously. Propofol Group patients received Fentanyl 1µg/kg and a loading dose of Propofol infused at 0.5mg/kg over 10 min followed by a maintenance dose of 2 mg/kg/hr intravenously. If patients showed signs of insufficient sedation as measured by Richmond Agitation Sedation Scale (RASS) they were supplemented with rescue Propofol bolus doses of 0.5 mg/kg. Sedation score and vitals were assessed every 5 minutes till the end of the procedure and every 5 minutes for 15 minutes during recovery. RESULTS: At the end of 15 minutes (pre-procedure), RASS in Dexmedetomidine group was -2.89±0.71 and RASS in the Propofol group was -3.31±0.53. Propofol group achieved the desired targeted RASS of more than -3 at 15 minutes. 22% of patients in Dexmedetomidine group and 2.8% of the patients in the Propofol group did not achieve RASS of -3 even after 15 minutes of infusion. Mean RASS over entire ERCP in Dexmedetomidine group was - 3.18±.41 and in the Propofol group was -3.31±.39. Mean RASS over entire ERCP in Dexmedetomidine group was lesser than Propofol but there was no statistically significant difference (p=0.134) CONCLUSION: The combination of Propofol with Fentanyl achieved better overall conditions for ERCP compared to the combination of Dexmedetomidine with Fentanyl.

Entropy correlates with Richmond Agitation Sedation Scale in mechanically ventilated critically ill patients

Sedation is routinely used in intensive care units. However due to absence of objective scoring systems like Bispectral Index and entropy our ability to regulate the degree of sedation is limited. This deficiency is further highlighted by the fact that agitation scores used in intensive care units (ICU) have no role in paralyzed patients. The present study compares entropy as a sedation scoring modality with Richmond Agitation Sedation Scale (RASS) in mechanically ventilated, critically ill patients in an ICU. Twenty-seven, mechanically ventilated, critically ill patients of either sex, 16-65 years of age, were studied over a period of 24 h. They received a standard sedation regimen consisting of a bolus dose of propofol 0.5 mg/kg and fentanyl 1 lg/kg followed by infusions of propofol and fentanyl ranging from 1.5 to 5 mg/kg/h and 0.5 to 2.0 lg/kg/h, respectively. Clinically relevant values of RASS for optimal ICU sedation (between 0 and -3) in non-paralyzed patients were compared to corresponding entropy values, to find if any significant correlation exists between the two. These entropy measurements were obtained using the Datex-Ohmeda-M-EntropyTM module. This module is presently not approved by Food and Drug Administration (FDA) for monitoring sedation in ICU. A total of 527 readings were obtained. There was a statistically significant correlation between the state entropy (SE) and RASS [Spearman's rho/rs = 0.334, p\0.0001]; response entropy (RE) and RASS [Spearman's rho/rs = 0.341, p\0.0001]). For adequate sedation as judged by a RASS value of 0 to -3, the mean SE was 57.86 ± 16.50 and RE was 67.75 ± 15.65. The present study illustrates that entropy correlates with RASS (between scores 0 and -3) when assessing the level of sedation in mechanically ventilated critically ill patients.

Patient-Controlled Sedation in Orthopedic Surgery Under Regional Anesthesia: A New Approach in Procedural Sedation

Background and objectives: Regional anesthesia is a commonly used technique in orthopedic procedures. Sedation should reduce the patient's anxiety and fear while increasing regional anesthesia quality. This study evaluated the hemodynamic changes, level of sedation, both patients’ and surgeons’ levels of satisfaction and potential side effects in patient-controlled sedation using propofol. MethodsThis randomized clinical trial studied sixty ASA physical class I-III patients scheduled for total knee replacement surgery under combined spinal-epidural anesthesia. Patients in Group P (n = 30) received propofol via a patient-controlled analgesia device with the following settings: intravenous propofol bolus dose 400μg.kg_1, 5-minute lockout interval and no basal infusion. In Group S, we infused saline 150 using the same settings. To determine the level of sedation, we used BIS and Observer's Assessment of Alertness/Sedation Scale. For all patients, we recorded the number of requests. As the final evaluation, we scored surgeons’ and patients’ satisfaction on 4-point scales. ResultsBoth BIS values and OAA/S scores were lower in Group P than in Group S. Patients’ satisfaction was higher in Group P, although there was no significant difference with respect to surgeons’ satisfaction between the groups. The number of requests for sedation was significantly higher in Group S. However, most requests were considered unsuccessful. ConclusionThis study suggests that patient-controlled sedation with propofol can be used efficiently in orthopedic procedures.

Sex Difference in Formation of Propofol Metabolites: A Replication Study

Women recover faster from propofol anaesthesia and have been described to have a higher incidence of awareness during surgery, compared to men - an effect that may be inherent in sex differences in propofol metabolism. In an observational study, 98 ASA I-II patients treated with continuous propofol infusion were recruited. The associations between sex and CYP2B6 and UGT1A9 polymorphisms with dose- and weight-adjusted area under the total plasma level time curves (AUC) for propofol, and its metabolites propofol glucuronide (PG), 4-hydroxypropofol (OHP) and hydroxyl glucuronide metabolites 4-hydroxypropofol-1-O-β-D-glucuronide (Q1G) and 4-hydroxypropofol-4-O-β-D-glucuronide (Q4G), were analysed. Significantly higher AUC of PG (1.3 times, p=0.03), Q1G (2.9 times, p<0.001), Q4G (2.4 times, p<0.01) and OHP (4.6 times, p=0.01) were found in women (n=53) than in men (n=45) after intravenous infusion of propofol using target-controlled infusion system. There was, however, no significant impact of gene polymorphisms on propofol biotransformation. The results, which are supported by a previous pilot study using a propofol bolus dose, suggest that, compared to men, more rapid propofol metabolism may occur in women - a factor that may contribute to the mentioned differences in the efficacy of propofol anaesthesia between male and female patients.

Pentax-AWS video laryngoscope for tracheal intubation in a patient with Klippel-Feil syndrome

Pentax-AWS video laryngoscope for tracheal intubation in a patient with Klippel-Feil syndrome