Deeper Levels Of Sedation Research Articles

Standing gustatory papillae biopsy procedure for antemortem diagnosis of equine grass sickness.

Diagnosing equine grass sickness (EGS) requires histopathological evidence of chromatolysis and/or neuronal loss in peripheral autonomic ganglia. Previous investigators performed postmortem biopsies of gustatory papillae located on the tongue and found chromatolytic subgemmal neurons in all 13 EGS horses. The present study aimed to design a standardized lingual biopsy sampling method through a transbuccal approach in healthy standing horses and assess the quality of the obtained samples, to allow antemortem diagnosis of EGS in clinical cases. 6 healthy horses. A transbuccal approach was performed bilaterally in 6 healthy standing horses. After having reached a deep level of sedation, horses were placed in stocks and a Günther mouth gag was inserted. Local anesthesia followed by a vertical full thickness incision was performed on both cheeks. Foliate papillae biopsies were carried out using an arthroscopic rongeur inserted through each incision site under oral endoscopic control. Tongue movements were restricted with diazepam. Histological assessment of taste buds and subgemmal plexi neurons was performed using H&E-stained longitudinal sections. The procedure was well tolerated in all horses. Minor complications observed were a transient facial paralysis, some incisional fluid collection, and abscesses. Ten samples (10/12) were suitable for assessment of neuronal perikarya. This procedure was safe for subgemmal plexus biopsy in healthy standing horses. The obtained samples were adequate as long as they were neatly cut lengthwise for inclusion. The technique was also used for 2 clinical cases and revealed the complete absence of neuronal perikarya, confirming chronic EGS.

Success and safety of deep sedation as a primary anaesthetic approach for transvenous lead extraction: a retrospective analysis

There is a rising number in complications associated with more cardiac electrical devices implanted (CIED). Infection and lead dysfunction are reasons to perform transvenous lead extraction. An ideal anaesthetic approach has not been described yet. Most centres use general anaesthesia, but there is a lack in studies looking into deep sedation (DS) as an anaesthetic approach. We report our retrospective experience for a large number of procedures performed with deep sedation as a primary approach. Extraction procedures performed between 2011 and 2018 in our electrophysiology laboratory have been included retrospectively. We began by applying a bolus injection of piritramide followed by midazolam as primary medication and would add etomidate if necessary. For extraction of leads a stepwise approach with careful traction, locking stylets, dilator sheaths, mechanical rotating sheaths and if needed snares and baskets has been used. A total of 780 leads in 463 patients (age 69.9 ± 12.3, 31.3% female) were extracted. Deep sedation was successful in 97.8% of patients. Piritramide was used as the main analgesic medication (98.5%) and midazolam as the main sedative (94.2%). Additional etomidate was administered in 15.1% of cases. In 2.2% of patients a conversion to general anaesthesia was required as adequate level of DS was not achieved before starting the procedure. Sedation related complications occurred in 1.1% (n = 5) of patients without sequalae. Deep sedation with piritramide, midazolam and if needed additional etomidate is a safe and feasible strategy for transvenous lead extraction.

Expert consensus on management of pain, agitation and related issues in adult patients with critical respiratory diseases

As patients with critical respiratory diseases suffer from the discomfort of disease, frequent medical and nursing procedures, and the noise disturbance of the ICU environment, it is necessary to implement analgesia and sedation to reduce their negative stress and oxygen consumption. Special emphasis will be placed on the clinical practice of analgesia, sedation and rehabilitation in critically ill patients with respiratory diseases, as different pathophysiological features of the respective pulmonary diseases are presented, such as severe asthma and acute exacerbations of chronic obstructive pulmonary disease, as well as the exclusive situations during respiratory therapy, such as recruitment maneuvers, bedside bronchoscopy and operation of extracorporeal membrane oxygenators. To standardize the prevention and management of pain, agitation, delirium, immobility, and sleep disturbance in adult patients with critical respiratory diseases, the Chinese Thoracic Society and Critical Care Medicine Group of Chinese Association of Chest Physicians, Chinese Medical Doctor Association organized pulmonary and critical care experts to discuss 19 important issues and ultimately provided 20 recommendations based on the best available evidence.Assessment, prevention and management of pain should be prioritized before the administration of continuous infused sedatives in all patients with critical respiratory diseases. Bundles that include multiple strategies of non-pharmacological interventions to prevent and manage delirium and sleep disruption are encouraged. For the patients with stable respiratory and hemodynamic status, early mobility and exercise could be safe and beneficial. Respiratory drive control by addressing patient and ventilator factors should be the priority before administration of analog-sedation protocol in the ARDS patients. Deep sedation could be necessary in the early stage of ARDS with high respiratory drive, and during the recruitment maneuver, prone position and measurement of the respiratory mechanics. Maintaining spontaneous breathing with a lower level of sedation is recommended in COPD patients on invasive mechanical ventilation, while a deeper level of sedation, even with a short course of neuromuscular blockade, may be beneficial among severe asthma patients with high peak airway pressure. Pharmacokinetic alterations in patients with critical respiratory diseases during ECMO support are complicated as varied factors are involved, including ECMO circuit factors, drug factors, and patient factors. Therefore, the dosage of analgesics and sedatives should be adjusted according to the target of analog-sedation protocol in the respective disease.

Sedation Practices of Mechanically Ventilated Patients During Critical Care Transport

ObjectiveMechanically ventilated patients who receive deep levels of sedation have high mortality rates, longer lengths of stay, and longer duration of mechanical ventilation in the intensive care unit. Prior literature demonstrated a high frequency of deep sedation across all levels of care. Benzodiazepines have been attributed to similar morbidity and mortality findings. MethodsThis study was a descriptive retrospective review of mechanically ventilated adult critical care transport patients from January 1, 2019, to March 11, 2020. Our primary outcome was the percentage of patients who were deeply sedated at handoff to the receiving facility. Deep sedation was defined as a Richmond Agitation Sedation Scale of −3 to −5. Our secondary outcomes were the percentage of patients who received benzodiazepines; the number of unplanned extubations, crew injuries, and unsafe patient care situations; and the incidence of ventilator dyssynchrony. ResultsFive hundred fifty-three mechanically ventilated patients were transported. Ninety-three patients were excluded because they received paralytics during transport. Four hundred sixty patients were included in the analysis, 422 (91.7%) of whom were deeply sedated. Benzodiazepines were administered to 141 patients (30.6%). There were no differences observed in the secondary outcomes. ConclusionDeep sedation and benzodiazepine administration were frequent during critical care transport of mechanically ventilated patients.

Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams.

Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for healthcare teams and families. Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016. We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019. Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n=5 cases), Chlorpromazine (n=3), Ketamine (n=2) and Propofol (n=2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction. Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.

PHARMACOKINETICS AND PHARMACODYNAMICS OF PROPOFOL AND DEXMEDETOMIDINE DURING ELECTIVE PROCEDURAL SEDATIONS AND CHARACTERISTICS OF THEIR COMBINATION (LITERATURE REVIEW)

In the previous publication, we outlined the general principles of procedural sedation (PS), the depth of suppression of consciousness and spontaneous motor activity, the minimum quantity of patients' pre-procedural examinations and the aspects of informed consent obtaining. The principles of vital signs monitoring, patients' immobilisation, and the detection and treatment of adverse events have been described. A key aspect of the PS is the readiness to ensure patency of the airways and oxygenation at least one level deeper than the existing level of the PS.
 In this publication, attention is focused on the pharmacokinetics and pharmacodynamics of propofol and dexmedetomidine - the main drugs for elective PS and on the combination between them. In a future publication, we plan to characterize other key medications for PS, such as midazolam, ketamine, thiopental, and fentanyl.
 Propofol is a short-track anaesthesia drug, and it was the most widely distributed in the 21st century because after its use patients quickly and fully regain consciousness. At the same time, to achieve the necessary deep level of sedation and prevent unintended movements of the patient, it is often required to use high doses of propofol that can cause clinically significant suppression of the patency of the upper respiratory airways, depth of breathing, and hemodynamic. Therefore, in this publication, we promote the implementation of multimodal sedation and analgesia with the use of moderate doses of several drugs, which allows a significant reduction in the dose of propofol and thus increase the safety of PS. Dexmedetomidine has both sedative and analgesic properties with a minimal effect on the patency of the upper airways and the depth of breathing, thus is the best drug to combine with propofol in PS.
 In children, intranasal administration of dexmedetomidine and midazolam is an important alternative method of premedication, which provides a gentle entry into sedation and prevents the child's stress reactions to the placement of a venous catheter. Although the use of dexmedetomidine in children's practice is still "off-label" and outside the indications approved by the FDA in this publication we provide evidence to justify its safety and effectiveness of its usage in paediatrics PS.

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

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

Assessment of Amnesic Effect and the Depth of Hypnosis During Therapeutic Inhalation of Xenon-Oxygen Mixture

The current literature lacks data on the incidence of intraoperative awakening during xenon anesthesia. This could be due to amnesia preventing memories of the intraoperative awakening.The objective: to determine the concentration of xenon in the xenon-oxygen mixture, which causes amnesia for events during inhalation in 100% of patients, and to make correlations with the depth of hypnosis as per Kugler scale.Subjects and Methods: 34 patients with chronic neurogenic pain who received 111 20-minute inhalations with concentration of xenon up to 50% were included in the study. Amnesia evaluation, EEG monitoring, and pain assessment on a visual analog scale (VAS) were performed.Results. Amnesic effect developed in 100% of patients at xenon concentration of 45%. On inhalation of xenon at concentrations of up to 50%, EEG changes did not exceed D1 grade on Kugler scale. The decrease in bispectral index (BIS) did not reach the level of deep sedation (Me 96.2%) at xenon concentration of 50%. The decrease in pain on VAS was approximately 60%.Conclusions. Xenon inhalations cause transient congradic amnesia at concentrations of 45% or more. The accuracy of the BIS monitoring readings may be reduced when using xenon in a monovariant. Inhalations of xenon-oxygen mixture in concentrations up to 50% showed good analgesic properties in the framework of combined therapy of chronic pain syndrome.

Clinical Nurse Specialist Practice: Impact on Improving Sedation Practice in Critical Care.

Prolonged mechanical ventilation results from deeper levels of sedation. This may lead to impaired respiratory muscle functioning that develops into pneumonia, increases antibiotic use, increases delirium risk, and increases length of hospitalization. A trauma and surgical intensive care unit interdisciplinary team conducted a quality improvement project to lighten sedation levels and shorten mechanical ventilation time. The project included multimodal elements to improve sedation practice. Standardizing the spontaneous awakening trial algorithm, creation of electronic health record tools, integration of sedation practices into daily rounds, and focused education for nursing were implemented in April 2021 through October 2021. A reduction of median hours spent on mechanical ventilation was achieved. Mechanical ventilation hours decreased from 77 to 70. Richmond Agitation Sedation Scale levels improved from a median of -2 to -1, and daily spontaneous awakening trials increased from 10% to 27% completed. The quality improvement project demonstrated that, with increased daily spontaneous awakening trials and lighter sedation levels, the time patients spent on mechanical ventilation was shortened. There was no increase to self-extubation with lighter sedations levels. Shorter time on mechanical ventilation can reduce patient harm risks.

Early spontaneous breathing for acute respiratory distress syndrome in individuals with COVID-19.

Acute respiratory distress syndrome (ARDS) represents the most severe course of COVID-19 (caused by the SARS-CoV-2 virus), usually resulting in a prolonged stay in an intensive care unit (ICU) and high mortality rates. Despite the fact that most affected individuals need invasive mechanical ventilation (IMV), evidence on specific ventilation strategies for ARDS caused by COVID-19 is scarce. Spontaneous breathing during IMV is part of a therapeutic concept comprising light levels of sedation and the avoidance of neuromuscular blocking agents (NMBA). This approach is potentially associated with both advantages (e.g. a preserved diaphragmatic motility and an optimised ventilation-perfusion ratio of the ventilated lung), as well as risks (e.g. a higher rate of ventilator-induced lung injury or a worsening of pulmonary oedema due to increases in transpulmonary pressure). As a consequence, spontaneous breathing in people with COVID-19-ARDS who are receiving IMV is subject to an ongoing debate amongst intensivists. To assess the benefits and harms of early spontaneous breathing activity in invasively ventilated people with COVID-19 with ARDS compared to ventilation strategies that avoid spontaneous breathing. We searched the Cochrane COVID-19 Study Register (which includes CENTRAL, PubMed, Embase, Clinical Trials.gov WHO ICTRP, and medRxiv) and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies from their inception to 2 March 2022. Eligible study designs comprised randomised controlled trials (RCTs) that evaluated spontaneous breathing in participants with COVID-19-related ARDS compared to ventilation strategies that avoided spontaneous breathing (e.g. using NMBA or deep sedation levels). Additionally, we considered controlled before-after studies, interrupted time series with comparison group, prospective cohort studies and retrospective cohort studies. For these non-RCT studies, we considered a minimum total number of 50 participants to be compared as necessary for inclusion. Prioritised outcomes were all-cause mortality, clinical improvement or worsening, quality of life, rate of (serious) adverse events and rate of pneumothorax. Additional outcomes were need for tracheostomy, duration of ICU length of stay and duration of hospitalisation. We followed the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently screened all studies at the title/abstract and full-text screening stage. We also planned to conduct data extraction and risk of bias assessment in duplicate. We planned to conduct meta-analysis for each prioritised outcome, as well as subgroup analyses of mortality regarding severity of oxygenation impairment and duration of ARDS. In addition, we planned to perform sensitivity analyses for studies at high risk of bias, studies using NMBA in addition to deep sedation level to avoid spontaneous breathing and a comparison of preprints versus peer-reviewed articles. We planned to assess the certainty of evidence using the GRADE approach. We identified no eligible studies for this review. We found no direct evidence on whether early spontaneous breathing in SARS-CoV-2-induced ARDS is beneficial or detrimental to this particular group of patients. RCTs comparing early spontaneous breathing with ventilatory strategies not allowing for spontaneous breathing in SARS-CoV-2-induced ARDS are necessary to determine its value within the treatment of severely ill people with COVID-19. Additionally, studies should aim to clarify whether treatment effects differ between people with SARS-CoV-2-induced ARDS and people with non-SARS-CoV-2-induced ARDS.

The Efficacy and Complications of Deep Sedation in Pediatric Dental Patients: A Retrospective Cohort Study.

Background Dental anxiety in children is a common problem. Currently, many of dental procedures are performed under sedation. Different methods of sedation have been employed for this purpose. Compared to adults, children usually need a deeper sedation level. The aim of this retrospective study is to assess the efficacy and complication of deep sedation in pediatric dental patients. Method This study was performed on 250 ASA (American Society of Anesthesiologists) I, II children undergoing deep sedation during the dental procedures. After the administration of oral midazolam as premedication, the monitoring process started. The patients that received the sedation dose of propofol and oxygen through nasal cannula during the procedure were carefully monitored for the purpose of evaluating hemodynamic and respiratory complications. The mean procedure and recovery time, postoperative nausea and vomiting (PONV), and success rate were further studied. Result The average age of the patients was 3.7. 32% of the patients were females, and 68% of them were males. Laryngospasm that occurred in 5 cases was resolved immediately by using positive pressure ventilation. Mild hypoxia was observed in 17 cases which were immediately managed by a bag-valve-mask ventilation. No cases of hemodynamic complications and PONV were reported. The mean length of the procedure was 57 minutes, and the mean length of recovery was 16 minutes. The success rate of this method was estimated to be 99.6%. Conclusion Deep sedation with propofol is a suitable technique with a high success rate for dental procedures in children. It was also concluded that in pediatric dental procedures, the presence of a skilled anesthetist and the implementation of a close monitoring process are required.

A double-blind randomised placebo-controlled trial of percutaneous coronary intervention for the relief of stable angina without antianginal medications: design and rationale of the ORBITA-2 trial.

Percutaneous coronary intervention (PCI) is frequently performed for stable angina. However, the first blinded trial, ORBITA, did not show a placebo-controlled increment in exercise time in patients with single-vessel disease, at 6 weeks, on maximal antianginal therapy. ORBITA-2 will assess the placebo-controlled efficacy of PCI on angina frequency in patients with single- or multivessel disease, at 12 weeks, on no antianginal therapy. ORBITA-2 is a double-blind placebo-controlled trial randomising participants with (i) angina at presentation, (ii) documented angina during the 2-week pre-randomisation symptom assessment phase, (iii) objective evidence of ischaemia, (iv) single- or multivessel disease, and (v) clinical eligibility for PCI. At enrolment, antianginals will be stopped, and angina questionnaires completed. Participants will record their symptoms on a smartphone application daily throughout the trial and will undergo exercise treadmill testing and stress echocardiography at pre-randomisation. They will then undergo coronary angiography with unblinded invasive physiology assessment. Eligible participants will then be sedated to a deep level of conscious sedation and randomised 1:1 between PCI and placebo. After the 12-week blinded follow-up period, they will return for questionnaires, exercise testing and stress echocardiography assessment. If angina becomes intolerable, antianginals will be introduced using a prespecified medication protocol. The primary outcome is an angina symptom score using an ordinal clinical outcome scale for angina. Secondary outcomes include exercise treadmill time, angina frequency, angina severity and quality of life. Trial registration: ClinicalTrials.gov: NCT03742050.

Impact of Target-Controlled Infusion (TCI) of Propofol on State- and Response-Entropy and Sedation Depth During Flexible Bronchoscopy

Background: The increasing use of flexible bronchoscopy for diagnostic and interventional purposes requires further knowledge on feasible sedation regimens. We investigated the potential benefit of Target- Controlled Infusion (TCI) of propofol on sedation depth. Methods: Fifty-four patients scheduled for elective flexible bronchoscopy were allocated to receive propofol sedation using either intermittent boluses or Target Controlled Infusion (TCI). Endpoints included Entropy monitoring to evaluate sedation depth, sedation quality and the total amount of propofol. Results: There were no significant differences between both cohorts regarding the number of adverse sedation-related events. The mean applied dose of propofol was significantly higher in the Target-Controlled Infusion group (405±249 mg vs. 324±94 mg, p=0.015). Until patients reached loss of consciousness (LOC), State Entropy (SE) and Response Entropy (RE) levels were comparable among both sedation regimens. During the procedure, both parameters decreased to significantly lower levels in the TCI-cohort (SE: 77.7±13.2 vs. 88.8±8.6 (p=0.002) and RE: 69±12.6 vs. 79±8.7 (p=0.005)). Examination conditions, as rated by proceduralists and assisting nurses, were superior in the TCI-cohort. In addition, restraining measurements, due to uncontrolled movement during the examination needed to be applied more often to patients in the bolus cohort (body restraint: 26 (96%) vs. 18 (67%), p=0.005). Conclusion: Target-Controlled Infusion of propofol complies with the requirements of flexible bronchoscopy by providing a deep and steady level of sedation without impairing patient’s safety. In addition, there is evidence that overall sedation quality is superior, both for bronchoscopist and assisting staff.

COMPARATIVE CHARACTERISTICS OF DEXDOR AND DIPRIVAN FOR SEDATION IN UROLOGICAL OPERATIONS UNDER SPINAL ANESTHESIA

Currently, anesthesiologists-resuscitators have a large number of sedatives (hypnotics, general anesthetics, anxiolytics), but many of them, in addition to the main action, give a number of side effects or do not provide optimal sedation. On the other hand, there are new modern drugs for sedation, thus, the need to correct existing regimens of sedative therapy is quite timely and necessary. The aim of the study was to examine the advantages and disadvantages of different sedation methods in patients with urological profile operated under spinal anesthesia. 80 patients (54 men and 26 women) who underwent urological surgery under balanced anesthesia (spinal anesthesia in combination with drug sedation) were examined. Patients were randomly divided into two groups. Group 1 (n = 40) – sedation with dexdor, group 2 (n = 40) – sedation with diprivan. The level of sedation was assessed using the RAMSEY scale, the degree of post-anesthesia recovery on the Bidway five-point scale, and anesthesia satisfaction was assessed using the Lowa Satisfaction with Anesthesia Scale (ISAS). The degree of hemodynamic disorders was determined by continuous monitoring of heart rate, blood pressure and ECG. The normality of the distribution was checked using the Shapiro–Wilk method. The Mann–Whitney test was used to assess the statistical significance of the difference between the two independent groups. Results. The study showed that a deeper level of sedation during surgery was observed in the second group (sedation with diprivan). In this group, postoperative drowsiness was also higher both during the first 15 minutes and 30 minutes after surgery. Despite the fact that patients receiving dexdor had more superficial sedation, they generally showed significantly higher overall satisfaction with anesthesia. The study proved the effectiveness and safety of both drugs for sedation in urological patients under spinal anesthesia. However, a number of important advantages of dexdor were found as compared to diprivan. Dexdor, due to its ability to cause mild to moderate sedation, allows the patient to contact staff, almost does not suppress respiration, lets the patient feel comfortable and causes sufficient retrograde amnesia.

Comparison of nebulized fentanyl, midazolam, and dexmedetomidine as a sedative premedication in outpatient pediatric dental surgeries

Background The preoperative time is traumatic for young children undergoing surgery. Parental separation and needle injection increase preoperative anxiety. Preoperative sedation in children is usually administered via the rectal, oral sublingual, and intranasal routes with different degrees of patient acceptance. Nebulized drug is an alternative method of sedation that is relatively easy to set up. Materials and Methods Thirty nine pediatric patients (2–6) years old scheduled for outpatient dental surgeries were randomly allocated in three groups (13 patients each); group (F) received nebulized fentanyl 2 μg/kg 30 min before surgery, group (M) received nebulized midazolam 0.2 mg/kg 30 min before surgery and group (D) received nebulized dexmedetomidine 2 μg/kg 30 min before surgery. The outcome measures included onset of sedation, parental separation, tolerance to mask induction, reaction to intravenous cannulation and preoperative hemodynamic changes (systolic blood pressure, diastolic blood pressure and heart rate). Results Children who received nebulized fentanyl and nebulized midazolam had early onset of sedation as compared to dexmedetomidine. In child-parent separation, quality of induction was better with fentanyl and dexmedetomidine as compared to midazolam. Intravenous cannulation score was best achieved with fentanyl as premedication. Conclusion Nebulized fentanyl in a dose of 2 μg/kg is better than nebulized midazolam 0.2 mg/kg and nebulized dexmedetomidine 2 μg/kg as far as premedication is concerned because of its early onset of action, deeper levels of sedation, easy child-parent separation and shorter duration of action.

A CASE OF PROPOFOL-RELATED INFUSION SYNDROME IN SARS-COV-2

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Propofol-related infusion syndrome (PRIS) is a rare and serious effect of propofol infusion for sedation in critically ill patients. Though there has been an association seen with higher doses of propofol and prolonged infusion times, usually greater than 24 to 48 hours. CASE PRESENTATION: We present a case of an 86-year-old man with history of bradycardia and an implanted permanent pacemaker who was admitted for acute hypoxic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. Throughout hospital stay, this patient had progressively increasing oxygen requirements with appropriate escalation in level of care to the ICU. Due to increasing hypoxia despite non-invasive ventilation, the patient was intubated on day 4 of hospitalization, placed on vasopressors and started on sedation, which included continuous propofol infusion. On day 6 of hospitalization, the patient developed worsening hypotension requiring increased levels of sedation and significant lab abnormalities compared to labs collected the day prior. The patient was noted to have elevated potassium to 5.8 mmol/L, creatinine elevation to 2.41 mg/dL from 1.36 mg/dL, and elevated AST of 184 U/L and ALT of 95 U/L from normal levels. Lactate was 4.5, and creatinine kinase was 1317. Six hours later, repeat liver function tests revealed AST of 2078 U/L and ALT of 966 U/L. In the setting of sudden onset rhabdomyolysis, acute kidney injury, and lactic acidosis, there was concern for PRIS and propofol was discontinued. After extended discussion with the family, aggressive measures including dialysis were declined, and patient died. Of interest, the patient's pacemaker likely prevented the patient from developing bradycardia, classically seen in PRIS. DISCUSSION: Challenges with sedation of intubated patients with SARS-CoV-2 have been clinically observed and deeper sedation levels have been required to promote ventilator synchrony. Propofol continues to be a first-line sedative in critically ill patients, including SARS-CoV-2 patients. These patients require sedation higher infusion rates compared and are therefore at higher risk. Our patient was maintained on 20mcg/kg/min for 27 hours, then subsequently on 45 mcg/kg/min for 34 hours thereafter. Therefore, our patient was at increased risk of PRIS given propofol infusion at high doses was maintained for longer than 24 hours. Moreover, the concurrent use of vasopressors placed him at increased risk. CONCLUSIONS: Although propofol is recommended as a first-line anesthetic agent in critically ill patients with SARS-CoV-2 requiring sedation, the multiorgan failure resulting from PRIS is potentially fatal. Early recognition is crucial for management, which includes discontinuing propofol infusion and hemodialysis if indicated. REFERENCE #1: Hanidziar D, Bittner EA. Sedation of Mechanically Ventilated COVID-19 Patients: Challenges and Special Considerations. Anesth Analg. 2020;131(1):e40-e41. doi:10.1213/ANE.0000000000004887 REFERENCE #2: Payen JF, Chanques G, Futier E, Velly L, Jaber S, Constantin JM. Sedation for critically ill patients with COVID-19: Which specificities? One size does not fit all. Anaesth Crit Care Pain Med. 2020;39(3):341-343. doi:10.1016/j.accpm.2020.04.010 REFERENCE #3: Yamamoto K. Risk of propofol use for sedation in COVID-19 patient. Anaesthesiology Intensive Therapy. 2020;52(4):354-355. doi:10.5114/ait.2020.100477. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response

Selection strategy for sedation depth in critically ill patients on mechanical ventilation

BackgroundAnalgesia and sedation therapy are commonly used for critically ill patients, especially mechanically ventilated patients. From the initial nonsedation programs to deep sedation and then to on-demand sedation, the understanding of sedation therapy continues to deepen. However, according to different patient’s condition, understanding the individual patient’s depth of sedation needs remains unclear.MethodsThe public open source critical illness database Medical Information Mart for Intensive Care III was used in this study. Latent profile analysis was used as a clustering method to classify mechanically ventilated patients based on 36 variables. Principal component analysis dimensionality reduction was used to select the most influential variables. The ROC curve was used to evaluate the classification accuracy of the model.ResultsBased on 36 characteristic variables, we divided patients undergoing mechanical ventilation and sedation and analgesia into two categories with different mortality rates, then further reduced the dimensionality of the data and obtained the 9 variables that had the greatest impact on classification, most of which were ventilator parameters. According to the Richmond-ASS scores, the two phenotypes of patients had different degrees of sedation and analgesia, and the corresponding ventilator parameters were also significantly different. We divided the validation cohort into three different levels of sedation, revealing that patients with high ventilator conditions needed a deeper level of sedation, while patients with low ventilator conditions required reduction in the depth of sedation as soon as possible to promote recovery and avoid reinjury.ConclusionThrough latent profile analysis and dimensionality reduction, we divided patients treated with mechanical ventilation and sedation and analgesia into two categories with different mortalities and obtained 9 variables that had the greatest impact on classification, which revealed that the depth of sedation was limited by the condition of the respiratory system.

Patient-Level Barriers and Facilitators to Early Mobilization and the Relationship With Physical Disability Post–Intensive Care

Background Early mobilization (EM) is associated with reduced physical disability post–intensive care (PD PIC). Yet, contextual factors facilitate or impede delivery of EM in the intensive care unit (ICU). Only 45% of ICUs in the United States routinely practice EM despite its recognized benefits. Objectives To analyze the evidence on the relationship between critical care EM, PD PIC, and personal (patient-level) factors, using the theoretical lens of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). Method The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the World Health Organization ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized. Results Early mobilization delivery was influenced by personal factors. Deeper sedation level, the presence of delirium, higher patient acuity, the presence of medical devices, and patient weight were identified barriers to EM delivery. Patient engagement in EM was associated with improved delivery. Patients who enjoyed rehabilitation were more likely to demonstrate improvement in functional impairment than those who did not enjoy rehabilitation. Discussion Early mobilization is associated with reduced PD PIC, yet numerous contextual factors affect the delivery of EM in the ICU. Further study of patient-level factors and EM must explore the relationship between patient engagement, baseline demographics, and functional status at ICU admission, patient-level considerations for decisions to mobilize, and EM in the ICU. This research is critical to improving the delivery of EM in the ICU and reducing PD PIC.

Dexmedetomidine as an adjunctive analgaesic in the perioperative setting: A review of the literature.

Though arguably past the initial phase of the opioid epidemic, opioid-sparing or opioid-eliminating pain management regimens remain beneficial for patients and practitioners alike. Providing adequate analgaesia without relying on opioids is especially advantageous in the operative setting, as patients may be able to recover without deep levels of sedation or the need for a high amount of opioid medications. Despite being used primarily as a sedative over the past 20 years, dexmedetomidine, a centrally acting alpha2-agonist, possesses analgaesic properties, though its use has been limited by its well-described cardiovascular suppressive effects. The objective of this review was to determine the efficacy and safety of adjunctive dexmedetomidine for the purposes of analgaesia in the perioperative setting.

A randomised study of comfort during bronchoscopy comparing conscious sedation and anaesthetist-controlled general anaesthesia, including the utility of bispectral index monitoring.

BackgroundThe difference in patient comfort with conscious sedation versus general anaesthesia for bronchoscopy has not been adequately assessed in a randomised trial. This study aimed to assess if patient comfort during bronchoscopy with conscious sedation is noninferior to general anaesthesia.Methods96 subjects were randomised to receive conscious sedation or general anaesthesia for bronchoscopy. The primary outcome was subject comfort. Secondary outcomes included willingness to undergo a repeat procedure if necessary and level of sedation assessed clinically and by bispectral index (BIS) monitoring.ResultsThere was no significant difference between subject comfort scores (difference −0.01, 95% CI −0.63–0.61 on a 10-point scale; p=0.97) or willingness to undergo a repeat procedure (97.7% versus 91.8%, 95% CI −4.8–15.5%; p=0.37). Deeper levels of sedation in the general anaesthesia cohort was confirmed with both clinical and BIS monitoring. There was no significant difference in diagnostic accuracy (conscious sedation 93.9%, 95% CI 80.4–98.3% versus general anaesthesia 86.5%, 95% CI 72.0–94.1%; p=0.43). There were more complications (29.6%, 95% CI 18.2–44.2% versus 6.1%, 95% CI 2.1–16.5%; p<0.01) in the general anaesthesia group. There was no relationship between high BIS scores and subject discomfort. BIS levels <40 during a procedure were associated with increased complications.ConclusionConscious sedation is not inferior to general anaesthesia in providing patient comfort during bronchoscopy, despite lighter sedation, and is associated with fewer complications and comparable diagnostic accuracy. BIS monitoring may have a role in preventing complications associated with deeper sedation.