Deeper Levels Of Sedation Research Articles

Evaluation of Nociception Using Quantitative Pupillometry and Skin Conductance in Critically Ill Unconscious Patients: A Pilot Study.

Background: Pain assessment is a challenge in critically ill patients, in particular those who are unable to express movements in reaction to noxious stimuli. The purpose of the study was to compare the pupillary response and skin conductance to pain stimulation in critically ill unconscious patients. Methods: This observational study included adult patients admitted to the intensive care unit (ICU) with acute brain injury (Glasgow Coma Scale < 9 with a motor response < 5) and/or requirements for deep level of sedation. Automated pupillometry (Algiscan, ID-MED, Marseille, France) was used to determine pupillary reflex dilation during tetanic stimulation. The maximum intensity of the stimulation value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception): a pupillary pain index (PPI) score of ≤4 was used to reflect adequate pain control. For skin conductance (SC), the number of SC peaks per second (NSCF) was collected concomitantly to tetanic stimulation. An NSCF of ≤0.07 peak/second was used to reflect adequate pain control. Results: Of the 51 included patients, there were 32 with brain injury and 19 receiving deep sedation. Mean PPI score was 5 (Interquartile Range= 2–7); a total of 28 (55%) patients showed inadequate control of the nociceptive stimulation according to the PPI assessment. Only 15 (29%) patients showed a detectable skin conductance, with NSCF values from 0.07 to 0.47/s. No correlation was found between skin conductance algesimeter (SCA)-derived variables and PPI score or pupillary dilation to pain. Conclusions: Detection of inadequate pain control might vary according to the method used to assess nociception in ICU patients. A poor agreement between quantitative pupillometry and skin conductance was observed.

Uporaba in učinkovitost glasbene terapije v enoti intenzivne terapije

Uvod: Uporaba glasbe v terapevtske namene je neinvazivna intervencija, ki v bolnišničnem okolju lahko ugodno vpliva na pacientovo psihofizično stanje, vendar v vsakdanji obravnavi pacientov ni uveljavljena. Zato je bil namen raziskave preučiti uporabo in učinkovitost glasbene terapije glede na doživljanje bolečine ali stresa pri pacientih, hospitaliziranih v enotah intenzivne terapije.Metode: Izveden je bil sistematični pregled znanstvene literature v mednarodnih podatkovnih bazah: PubMed, CINAHL, Cochrane Library, ScienceDirect, Wiley Online Library z uporabo ključnih besed v angleškem jeziku »music therapy«, »intensive care unit«, »stress«, »anxiety«, »pain« ter upoštevanjem vključitvenihin izključitvenih kriterijev. Potek pregleda literature je prikazan s pomočjo diagrama PRISMA. Kakovost raziskav, vključenih v končno analizo, je bila ocenjena s pomočjo orodja Scottish Intercollegiate Guidelines Network. Rezultati so sintetizirani z uporabo metode analize vsebine.Rezultati: Izmed 749 identificiranih zadetkov je bilo v končno analizo vključenih 13 raziskav. Raziskave kažejo učinkovitost glasbene terapije pri lajšanju bolečin, poglobitvi sedacije, uravnavanju fizioloških parametrov ter zmanjšanju strahu in anksioznosti pri hospitaliziranih pacientih v enotah intenzivne terapije.Diskusija in zaključek: Glasbena terapija je v medsebojnem dopolnjevanju s farmakološkimi ukrepi primerna intervencija za obvladovanje bolečine in stresa. Primanjkuje dokazov o optimalnem trajanju, zvrsti glasbe in načinu izvajanja glasbene terapije za doseganje najboljših rezultatov.

Depth of sedation during drug induced sedation endoscopy monitored by BiSpectral Index® and Cerebral State Index®.

Drug induced sedation endoscopy (DISE) is performed to investigate patterns and sites of obstruction in patients with sleep-disordered breathing (SDB). During DISE the patients are sedated to obtain a muscular relaxation of the upper airway which mimics the relaxation during natural sleep. Different sleep stages are intended to be simulated by drug induced sedation, and it is helpful to measure the depth of sedation. The BiSpectral Index® (BIS) is often used for this procedure. Besides the BIS, other means of sedation depth monitoring exist in anaesthesiology but have not yet been investigated with respect to DISE. Monitoring of the Cerebral State Index® (CSI) is one of these methods. The aim of the study was to compare the BIS and CSI for sedation depth monitoring during DISE. Sixty patients underwent DISE monitored by the BIS and CSI in parallel. The BIS and CSI values were compared using the Bland-Altman analysis. The BIS and CSI values differed during the course of sedation during DISE by a mean of - 6.07. At light sedation (BIS 60-80), lower values by 10 scale points of CSI compared with BIS were detectable. At deeper sedation levels (BIS 40-50), the CSI turned to present equal and even higher values compared with the BIS. Sedation depth measurement during DISE can be performed by the BIS or CSI, but the differences should be interpreted carefully as comparable data for sleep stages in natural sleep are available only for BIS.

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury.

To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI). A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI. A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016. About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p<.001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p<.05). This finding coincided with a reduced level of sedation and a greater level of consciousness. The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation. This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

In Response.

We appreciate the interest of Drs Madhok and Mihm1 in our article2 and their suggestions on how to optimize sedation management in coronavirus disease 2019 (COVID-19) patients. The authors point out the interrelated problems of prolonged mechanical ventilation, choice of sedative drugs, and sedation depth1 that we would like to further address. A recently published analysis from 2 academic hospitals in Boston3—one of the most affected regions in the United States—revealed median duration of invasive mechanical ventilation of 16 days in COVID-19 patients who were successfully extubated. Given these prolonged periods of sedation and immobility, there clearly is a need to implement sedation approaches that would facilitate lung-protective ventilation but that would also limit the rates of oversedation, delirium, sedation-related encephalopathy, and subsequent functional disability in COVID-19 survivors. Older and frail patients are especially susceptible to these adverse outcomes. Propofol, ketamine, dexmedetomidine, and intravenous opioids have been the typical components of the multimodal regimen used across the 10 intensive care units (ICUs) dedicated to treatment of COVID-19 within our institution. This benzodiazepine-free approach has not been uniformly attainable in all patients with COVID-19. The addition of midazolam is typically seen in patients with rising triglyceride levels (due to propofol), rising creatine kinase levels (due to propofol), worsening QT interval prolongation (due to haloperidol, ketamine, azithromycin, and hydroxychloroquine), insufficient sedation depth during paralysis, and in patients with hemodynamic instability. Once introduced, we believe that benzodiazepines should be administered at lowest doses that are sufficient to achieve sedation targets and that allow regular neurologic assessments. Benzodiazepines should also be the first agents discontinued due to their deliriogenic effects and prolonged context-sensitive half time. As mentioned by Drs Madhok and Mihm,1 management of sedation that allows neurologic assessments in patients with COVID-19 is critical given the reports of acute neurologic complications such as cerebrovascular accidents.4 Escalation of the doses of benzodiazepines over the course of the ICU stay without appropriate neuromonitoring in place should be discouraged, and alternative solutions should be sought. It must be emphasized that further deepening the levels of sedation with propofol or benzodiazepines in already adequately sedated patients is unlikely to improve patient-ventilator synchrony, and a bolus dose of neuromuscular blockers might be more appropriate to achieve ventilator synchrony. The use of oral adjuncts (eg, quetiapine, propranolol, clonidine, gabapentin) has been proposed to reduce the doses and side effects of intravenous sedatives and to mitigate shortages of intravenous drugs. In our own experience, utility of these oral agents in critically ill COVID-19 patients has been limited due to high prevalence of ileus,5 intolerance of enteral feeding, and unreliable absorption. We propose that these oral agents might be useful during ventilator and intravenous sedation weaning in patients who manifest signs of withdrawal (hypertension, tachycardia, and delirium), are not on vasopressor support, and in whom bowel function has returned. We have frequently been introducing these enteral agents in patients with COVID-19 who require intermittent or prolonged mechanical ventilation after undergoing a tracheostomy. Finally, we propose that sedation management should be individualized based on respiratory variables. It has been established that COVID-19–induced acute respiratory distress syndrome (ARDS) is a heterogeneous entity.6 While deeper levels of sedation might be indicated in patients with severe hypoxemia and poor lung compliance (eg, during proning, paralysis, high levels of positive end-expiratory pressure [PEEP]), patients with well-preserved compliance might tolerate spontaneous modes of ventilation and lighter sedation levels (eg, dexmedetomidine alone). Bedside assessments of respiratory mechanics might be useful to identify patients with ARDS in whom high respiratory drive and larger tidal volumes are not injurious7 so that they are not exposed to deep sedation and prolonged controlled ventilation unnecessarily. A proactive practice of tailoring sedation and ventilator support might reduce the length of mechanical ventilation and improve long-term outcomes in patients with COVID-19. Dusan Hanidziar, MD, PhDEdward A. Bittner, MD, PhDDepartment of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBoston, Massachusetts[email protected]

The efficacy of dexmedetomidine and propofol for sedation in endoscopic ultrasonography: A comparative study

Background: Efficacy and safety of dexmedetomidine as a sedative agent has not been studied in a procedure such as endoscopic ultrasound (EUS) where propofol is being used extensively to provide a deep level of sedation. The present study was conducted to compare the efficacy of dexmedetomidine and propofol to achieve adequate sedation levels in patients undergoing EUS.Methods: Sixty patients scheduled for EUS under sedation for the diagnostic and therapeutic purpose were randomly divided into two groups. Thirty patients in Group D received dexmedetomidine while 30 Group P patients received propofol. The recovery from sedation was assessed using the modified Aldrete's score. Once the modified Aldrete's score of 10/10 was achieved, the patients' perception regarding the pain was assessed using the Visual Analog Scale (VAS) score. Primary outcome measures were VAS score and vital parameters, whereas secondary outcome measures were gag reflex and recovery from sedation using the modified Aldrete's score. Comparison of quantitative and qualitative variables between the groups was done using unpaired Student's t-test and Chi-square test or Fisher's exact test, respectively.Results: The absence of gag reflex was significantly higher in patients who received dexmedetomidine. Dexmedetomidine was found to have greater hemodynamic stability compared with propofol-treated patients. Dexmedetomidine achieved similar levels of sedation to propofol, although with a slower onset of sedation.Conclusions: The use of dexmedetomidine was associated with greater hemodynamic stability and absence of gag reflex.

Opioid and Benzodiazepine Requirements in Obese Adult Patients Receiving Extracorporeal Membrane Oxygenation.

Background: The use of extracorporeal membrane oxygenation (ECMO) sometimes requires deep levels of sedation (Richmond Agitation Sedation Scale [RASS] -5) in patients with acute respiratory distress syndrome (ARDS). The role of obesity in opioid and sedative requirements remains unclear in patients receiving ECMO. Objective: This study sought to determine whether obesity increases midazolam and opioid requirements in patients receiving venovenous (vv)-ECMO up to the first 7 days after initiation. Methods: This was a retrospective cohort study of adult patients with ARDS managed with vv-ECMO. Results: The obese (n = 38) and nonobese (n = 43) groups had similar baseline characteristics. Fentanyl equivalents were significantly higher on day 3 in the obese group (P = 0.02) despite similar RASS scores with no differences in midazolam requirements. There were no differences in duration of ECMO, length of stay, or mortality. Conclusion and Relevance: Daily midazolam requirements were not significantly different, and opioid requirements were only significantly higher in the obese group on day 3 despite similar levels of sedation. The impact of obesity with the addition of ECMO and how to adapt doses of medications remains elusive.

Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation

PurposeTo characterize monitoring of pain, agitation, and delirium; investigate opioid and sedative choices; and describe prevention and treatment of delirium in adults receiving venovenous extracorporeal membrane oxygenation (vv-ECMO) for respiratory failure. Materials and methodsInternational, cross-sectional survey distributed January 2018 to members of the Society of Critical Care Medicine. ResultsRespondents were predominately physicians (58%) from North America (89%). Fentanyl (77%) and hydromorphone (48%) were the most common intravenous opioids used to manage pain. A deep level of sedation was targeted in the first 24-h after initiation of vv-ECMO 64% of the time. When deep sedation was targeted, propofol (70%) and benzodiazepines (41%) were the most common sedatives. The most common sedatives for light sedation were dexmedetomidine (45%) and propofol (39%). Delirium prevention included avoidance of benzodiazepines (73%), whereas the most common treatment strategy was scheduled atypical antipsychotics (83%). Centers that extubated patients during vv-ECMO used dexmedetomidine as the second preferred sedative as compared to benzodiazepines at non-extubating centers (p = 0.04). ConclusionsMost respondents use validated scales and protocols to assess and manage pain, agitation/sedation, and delirium. The majority of respondents reported targeting a deep level of sedation with propofol being used for both deep and light levels of sedation.

Efficacy and cost savings with the use of a\xa0minimal sedation / anxiolysis protocol for intra-articular corticosteroid injections in children with juvenile idiopathic arthritis: a retrospective review of prospectively collected data

BackgroundIntra-articular corticosteroid injections (IACI) are frequently used in the treatment of juvenile idiopathic arthritis. There is a paucity of evidence-based research describing methods of pain and anxiety control for this procedure. IACI were mostly performed under general anesthesia for children younger than 13 years old in our institution as of 2014. We started to integrate sedation services more commonly in our institution with the minimal sedation/anxiolysis (MSA) protocol outlined as an alternative to general anesthesia for IACI in 2015. The purpose of this study was to evaluate the effectiveness and cost savings of a minimal sedation protocol for intra-articular corticosteroid injections in juvenile idiopathic arthritis patients after instituting this protocol at our institution.MethodsThe MSA protocol included nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention. A retrospective review of prospectively collected data was performed on a total of 80 consecutive patients with juvenile idiopathic arthritis who underwent joint injections using the protocol.ResultsThe procedure was successfully completed in greater than 95% of the patients. The median pain score (measured on a verbal numeric scale of 0–10) reported by the patient was 1 (IQR 0–2.5), by the parent 1 (IQR 0–2), by the rheumatologist 1 (IQR 0–1), and by the sedationist 1 (IQR 0–1). Degree of motion during the procedure was reported by the rheumatologist and the sedationist as none in 68% of the patients, mild in 36% and moderate in 6%. Patient, parent, rheumatologist and sedationist rated satisfaction as very high in the vast majority (94%). Emesis was reported in only 2 (2.5%) patients, no significant adverse events were reported, and no patients progressed to a deeper level of sedation than intended. Financial analysis revealed a 33% cost reduction compared with the use of general anesthesia in the operating room.ConclusionsA minimal sedation/anxiolysis protocol (including nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention), provides safe and effective analgesia for intra-articular corticosteroid injection in a subset of patients with juvenile idiopathic arthritis and offers a lower cost alternative to general anesthesia.

Efficacy, safety and satisfaction of sedation-analgesia in Spanish emergency departments

ObjectivesTo offer analgesia and sedation should be a priority in paediatric emergency departments. The aim of this study was to determine the effectiveness and safety of the sedation-analgesia procedure, as well as the satisfaction of the doctors, patients and parents. MethodsA multicentre, observational, and prospective analytical study was conducted on the sedation-analgesia procedure performed on children younger than 18 years old in 18 paediatric emergency departments in Spain from February 2015 until January 2016. ResultsA total of 658 procedures were recorded. The effectiveness was good in 483 cases (76.1%; 95% CI: 72.7–79.4%), partial in 138 (21.7%; 95% CI: 18.5–24.9%), and poor in 14 (2.2%; 95% CI: 1.1–3.4). The effectiveness was better when the doctor in charge was an emergency paediatrician (OR: 3.14; 95% CI: 1.10–8.95), and when a deeper level of sedation was achieved (OR: 2.37; 95% CI: 1.68–3.35). Fifty two children (8.4%) developed adverse drug reactions, more usually gastrointestinal, neurological or respiratory ones (89.9% were resolved in <2h). One patient was intubated. The older child and a deeper level of sedation were found to be independent risk factors for adverse reactions (OR: 1.18; 95% CI: 1.09–1.28 and OR: 1.86; 95% CI: 1.22–2.83, respectively). Thirteen children (5%) developed late adverse drug reactions, more commonly, dizziness and nauseas. A combination of midazolam/ketamine had been used in all the cases (RR: 24.46; 95% CI: 11.78–50.76). The perceived satisfaction level (0–10) was obtained from 604 doctors (mean: 8.54; SD: 1.95), 526 parents (mean: 8.86; SD: 1.49), and 402 children (mean: 8.78; SD: 1.70). ConclusionsThe sedation-analgesia procedure performed in paediatric emergency departments by trained paediatricians seems to be useful, effective and safe, as well as satisfactory for all participants.

A randomized controlled trial of oral chloral hydrate vs intranasal dexmedetomidine plus buccal midazolam for auditory brainstem response testing in children

Moderate to deep sedation is required for an auditory brainstem response test when high-intensity stimulation is used. Chloral hydrate is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric non-painful procedural sedations. The aim of this study was to compare the sedation success rate after oral chloral hydrate at 50mgkg-1 and intranasal dexmedetomidine at 3μgkg-1 plus buccal midazolam at 0.1mgkg-1 for an auditory brainstem response test. Children who required an auditory brainstem response test were recruited and randomly assigned to receive oral chloral hydrate at 50mgkg-1 and intranasal placebo, or intranasal dexmedetomidine at 3μgkg-1 with buccal midazolam 0.1mgkg-1 . The primary outcome was the rate of successful sedation for auditory brainstem response tests. Fifty-seven out of 82 (69.5%) were successfully sedated after chloral hydrate, while 70 out of 78 (89.7%) children were successfully sedated with dexmedetomidine plus midazolam combination, with the odd ratio (95% CI) for successful sedation between dexmedetomidine plus midazolam combination and chloral hydrate estimated to be 3.84 (1.61-9.16), P=0.002. Dexmedetomidine plus midazolam was associated with quicker onset with median onset time 15 (IQR 11.0-19.8) for dexmedetomidine plus midazolam and 20 (IQR 15.0-27.0) for chloral hydrate respectively, with difference between median (95% CI) of 5 [3-8], P<0.0001). The behavior observed during drug administration of intranasal dexmedetomidine and buccal midazolam was better that of the children who had oral chloral hydrate. No children required oxygen therapy or medical intervention for hemodynamic disturbances in this study and the incidence of hypotension and bradycardia was similar. Intranasal dexmedetomidine plus buccal midazolam was associated with higher sedation success with deeper level of sedation, with similar discharge time and adverse event rate when compared to chloral hydrate.

PSY140 - DEXMEDETOMIDINE UTILISATION STUDY IN THE INTENSIVE CARE UNIT

To describe the patterns of dexmedetomidine use in the Intensive Care Unit (ICU) in a tertiary hospital and the impact of pharmacy intervention on it. Prospective four-month study (October 2017-January 2018). There was a greater use of dexmedetomidine in November so pharmacists encouraged physicians to consider protocols before prescribing. Dexmedetomidine 1mg/10 ml vial is administered as a solution (4 mcg/ml) by intravenous perfusion at dose range: 0.2-1.4 mcg/kg/hour. Data collected: treatment days with dexmedetomidine or sedative drugs combination, oral clonidine consumption, dexmedetomidine solution used (ml/day), infusion rates used (milliliters/h), RASS level and vials dispensed/month. Thirty-one patients received dexmedetomidine. Median duration of treatment was 1.8 days(maximum 8 days). Two patients(6.5%) received the combination formed by Remifentanil+Propofol+Midazolam+Dexmedetomidine, although it was less than 24 hours. Average dexmedetomidine solution administered/patient: 175 ml/day(48-672); average dexmedetomidine infusion rate: 9.9 ml/h(2-28). RASS level was not recorded any time during dexmedetomidine treatment in 13 patients (41.9%). Seven patients(22.6%) registered a RASS value lower than -3, two of them received treatment with dexmedetomidine during 6 and 7 days of respectively. Dexmedetomidine consumption in ICU was 26, 114, 91 and 76 vials for each month of this study. In three patients(9.7%) dexmedetomidine was replaced by clonidine when possible (clonidine was not prescribed in the first two months; in December and in January it was dispensed 91 and 48 tablets respectively). During the study, two cases of incorrect use were detected(6.5%). Dexmedetomidine consumption has been clearly reduced since the intervention halfway through the study period, and the use of clonidine was favored in its place. In most cases the use of dexmedetomidine was indicated and correctly justified. The importance in these cases lies in the need to establish maximum times from which the combination of dexmedetomidine should not be overcome with several sedatives for own use in deep sedation levels.

The development of facility standards for common outpatient procedures and implications for the context of abortion

BackgroundIn recent years, an increasing number of states have enacted laws that impose specific requirements for facilities in which abortions are performed. In this study, we sought to understand the processes used to develop facility standards in the context of other, less politically charged areas of health care and consider implications for the context of abortion.MethodsWe conducted key informant interviews with 20 clinicians and accreditation professionals involved in facility standards development for common outpatient procedures (endoscopy, gynecology, oral surgery, plastic surgery). We examined the motivations for and processes used in facility standards development, use of scientific evidence in standards development, and decision-making in the absence of evidence. Interview data were thematically coded and analyzed using an iterative approach.ResultsIn contrast to U.S. state laws that target abortion facilities, standards for other outpatient procedures are commonly set by committees of clinicians organized by professional associations or accreditation organizations. These committees seek to establish standards that ensure patient safety without placing unnecessary burden on clinicians in practice. They aim to create evidence-based standards but can be hampered by lack of relevant research. In the absence of research evidence, committees rely on their clinical expertise and sense of best practices in decision-making. According to respondents, considerations of potential harm (e.g., deeper levels of sedation, invasiveness), rather than the specific procedure, should prompt additional requirements.ConclusionsIf facility standards in the context of abortion were developed through processes similar to other outpatient procedures, 1) professionals who perform the procedure would be involved in standards development and 2) in the absence of clear research evidence, the expertise of clinicians, and the guidelines and standards of other organizations, are used to describe a best practice standard of care.

Effect of dexmedetomidine infusion on hemodynamic responses in microsurgery of larynx.

Background and Aims:Microlaryngeal surgery is a frequently performed ear, nose, and throat procedure used to diagnose and treat laryngeal disorders. Suspension laryngoscopy causes prolonged stimulation of the deep pressure receptors of the larynx leading to adverse circulatory responses and consequently cardiac complications. In this study, dexmedetomidine infusion was used to assess its effectiveness for attenuation of this hemodynamic stress response.Material and Methods:Sixty patients undergoing elective microlaryngeal surgery randomly received either dexmedetomidine 1 μg/kg over 10 min followed by continuous infusion of 0.5 μg/kg (Group D) or normal saline infusion at the same rate (Group P) till the end of surgery. Anesthesia in all patients was induced with propofol, succinylcholine to facilitate endotracheal intubation after premedication with fentanyl 2 μg/kg and glycopyrrolate. Intraoperative, vital parameters were maintained within 20% of baseline with rescue analgesic fentanyl 1 μg/kg and subsequently with propofol boluses up to 1 mg/kg. The percentage of patients and the total amount of intraoperative fentanyl and propofol required in each group were recorded. Sedation score at 10 minutes postextubation was assessed by Ramsay sedation score.Results:Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group P (P > 0.05). The percentage of patients requiring rescue fentanyl and propofol was higher in Group P than Group D (36.6% and 30% vs. 6.6% and 3.3% P = 0.01). Recovery scores were better in dexmedetomidine group.Conclusion:Dexmedetomidine infusion attenuates the hemodynamic stress response during laryngoscopy, intubation, and microlaryngeal surgery and is associated better recovery profile.

An Easy Way for Percutaneous Nephrolithotomy Using Mixed Sedative Agents

Objective: We recorded the data of patients performing Percutaneous Nephro-lithotomy (PCNL) under combined spinal anesthesia with sedative mixtures of Ketamine-Propofol (KP) or Fentanyl-Propofol (FP). Background: The PCNL is usually done under General anesthesia (GA); combining spinal anesthesia with a mixture of sedative drugs has shown to provide an optimum intra and post-operative analgesic and sedative response without side effects. Patients and Methods: 100 healthy patients were enrolled for PCNL, after stabilization of the sensory block of spinal anesthesia patients were randomized into two groups; Group KP received 1 mg/Kg Ketamine and 1 mg/Kg Propofol diluted in 20 ml syringe given over 30 seconds and Group FP received 1 mic/Kg Fentanyl and 1 mg/Kg Propofol diluted in 20 ml syringe over 30 seconds; both groups will receive increment doses if the patient suffers from anxiety, pain or discomfort. Perioperative Hemodynamic data (HR, SBP, DBP, RR, and SpO2) were recorded; PACU stay time and post operative analgesia time were analyzed. Results: Sedative mixtures of FP and KP provided remarkably deep sedation levels for PCNL procedures under spinal anesthesia. Respiratory depression, hypotension and bradycardia were the major side effects reported in FP group which had mean decrease in RR of 4.63 breath/min (27.49%) with mean 3.77% drop in SpO2 levels. KP group produced significant increase in HR about 7 beats/min without reported side effects. Conclusion: Various sedation techniques may be applicable for PCNL procedures with routine premedication, mixtures of fentanyl-Propofol or Ketamine-Propofol could be used, and KP has advantages of stable hemodynamics, prolonged analgesic response intra and post-operatively with no appreciable side effects and more effective method of sedative mixture.

The Influence of Sedation Level Guided by Bispectral Index on Therapeutic Effects for Patients with Severe Traumatic Brain Injury.

Sedation therapy is vital for treating severe traumatic brain injury (TBI). Yet, types of sedation assessment tools and sedation levels that are suitable for sedation treatment have not been investigated. To investigate the influence of different sedation levels guided by the Bispectral Index (BIS) on the therapeutic effects for severe TBI. According to inclusion, exclusion, and rejection criteria, 35 patients were prospectively included and divided into Richmond Agitation Sedation Scale (RASS), BIS(I), and BIS(II) groups. The RASS group was controlled the level of sedation to within -2 or -3, and the BIS(I) and (II) groups within the range of 40-50 and 50-60, respectively. In addition to clinical data, RASS, BIS, and intracranial pressure (ICP) values were collected. RASS and ICP variability were introduced to investigate the different of sedative control effect with or without BIS monitor, and the control effect of ICP between different sedation levels. Statistical analysis was performed to estimate the effectiveness of different sedation levels guided by BIS in sedation treatment within 72 hours. There were no significant differences in demographics among the 3 groups. RASS variability of the BIS(I) and (II) groups was significantly lower than that of the RASS group (P < 0.05), and in the BIS(I) group it was insignificantly lower than in the BIS(II) group. The ICP of the BIS(I) and (II) groups declined to <13.5 mm Hg significantly earlier than that of the RASS group (P < 0.05), and the difference between BIS(I) and (II) was insignificant. ICP variability of RASS group was higher than those of the BIS(I) and (II) groups (P < 0.05), and ICP variability of the BIS(I) group was significantly lower than that of the BIS(II) group (P < 0.05). Differences in days in the neurosurgery intensive care unit and outcomes among the 3 groups were insignificant. BIS is more reliable than RASS for maintaining a stable sedation status and ICP. Deeper sedation levels (BIS 40-50) cause ICP to decrease more quickly, with lower ICP variability.

Nurse-driven analgesia and sedation in pediatric patients with univentricular hearts requiring extracorporeal life support after first-stage palliation surgery: A pilot study.

Few data are available regarding requirements of sedation and analgesia in children during extracorporeal life support. The aim of this study was to evaluate if children with functionally univentricular hearts on extracorporeal life support after first-stage palliation surgery have higher requirement of analgesics and sedatives compared with children without extracorporeal life support using a goal-directed nurse-driven analgesia and sedation protocol. This prospective observational matched case-control pilot study was conducted at a cardiac pediatric intensive care unit of a tertiary referral center. Seventeen patients with functionally univentricular hearts including hypoplastic left heart syndrome who were on extracorporeal life support after first-stage palliation surgery were enrolled from July 2012 to January 2017. Seventeen matched patients served as controls. Doses of morphine, midazolam, clonidine, and muscle relaxants as well as sedation scores (COMFORT behavior scale and the nurse interpretation of sedation scale) were assessed according to a nurse-driven protocol every 8 hours up to 120 hours after first-stage palliation surgery. Sedation scores were equal in the extracorporeal life support group and in the control group at most points in time. There was no significant difference in cumulative doses of morphine and midazolam. However, children of the extracorporeal life support group received higher doses of midazolam and morphine at some points in time. A nurse-driven protocol for analgesia and sedation of children with extracorporeal life support is feasible. Patients with extracorporeal life support do not need deeper sedation levels and have not higher cumulative sedation requirements than children without extracorporeal life support.

Safety of deep sedation in the endoscopy suite.

As the complexity of endoscopic procedures increases, the use of propofol and the desire for deep sedation are becoming more common in the endoscopy suite. This review explores sedation depth, agents used for sedation, recommended monitoring, and adverse event risks that occur during sedation for endoscopy. The sedation provider for endoscopy varies by practice location and with regulatory requirements. As increasingly deep levels of sedation are used in this setting, the need for all providers to have training in the ability to rescue patients from sedation-related side effects is paramount. Propofol has an important role for prolonged and uncomfortable endoscopic interventions and has a strong safety record in the endoscopy suite. Vital signs monitoring is recommended during all endoscopy sedation, and there is emerging interest in advanced monitoring (e.g., capnography, processed electroencephalogram, respiratory monitoring) in this setting. The reported rate of adverse events during endoscopy sedation varies widely; however, advanced age and increasing American Society of Anesthesiologists physical status score are consistently associated with increased risk. Whether anesthesiologist-administered sedation is safer than non-anesthesiologist-administered sedation remains controversial. This review provides some guidance to providers who administer sedation in the endoscopy suite and is intended to improve the safety of patients. The recommendations are based on best available evidence and expert opinion.

Could Greater Depth of ED Sedation Be Associated with Worse Outcome

Deeper sedation levels within the first 48 hours of intensive care unit admission have been associated with longer duration of mechanical ventilation

Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial

Transversus abdominis plane (TAP) block and local anesthetic wound infiltration provide analgesia after cesarean delivery. Studies comparing the 2 techniques are scarce, with conflicting results. This double-blind, randomized controlled trial aimed to compare bilateral ultrasound-guided TAP block with single-shot local anesthetic wound infiltration for analgesia after cesarean delivery performed under spinal anesthesia. We hypothesized that the TAP block would decrease postoperative cumulative fentanyl consumption at 24 hours. Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies undergoing elective cesarean delivery under spinal anesthesia. Exclusion criteria were: <19 years of age or >40 years of age; height <150 cm, weight <60 kg, body mass index ≥40 kg/m; contraindications to spinal anesthesia; history of recent opioid exposure; hypersensitivity to any of the drugs used in the study; significant cardiovascular, renal, or hepatic disease; and known fetal abnormalities. Eighty subjects were randomly allocated to 2 equal groups. In the infiltration group, participants received 15 mL of bupivacaine 0.25% in each side of the surgical wound (total 30 mL); and in the TAP group, participants received 20 mL of bupivacaine 0.25% bilaterally in the TAP block (total 40 mL). The TAP block and wound infiltration were performed by the primary investigator and the operating obstetrician, respectively. All participants received postoperative standard analgesia (ketorolac and paracetamol) and intravenous fentanyl via patient-controlled analgesia. Patients and outcome assessors were blinded to the study group. The primary outcome was the cumulative fentanyl consumption at 24 hours. Secondary outcomes were the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, the incidence of side effects (nausea and vomiting and pruritis), and patient satisfaction. Data from 78 patients (39 patients in each group) were analyzed. The mean ± SD of cumulative fentanyl consumption at 24 hours was 157.4 ± 63.4 μg in the infiltration group and 153.3 ± 68.3 μg in the TAP group (difference in means [95% confidence interval] is 4.1 [-25.6 to 33.8] μg; P = .8). There were no significant differences between the 2 groups in the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, and patient satisfaction. The incidence of side effects (nausea and vomiting and pruritis) was low in the 2 groups. TAP block and wound infiltration did not significantly differ regarding postoperative fentanyl consumption, pain scores, and patient satisfaction in parturients undergoing cesarean delivery under spinal anesthesia.