Desired Level Of Sedation Research Articles

Pediatric sedation outside the operating room integrating dexmedetomidine for MRI and CT scan procedures: A systematic review

This systematic review evaluates the efficacy and safety of dexmedetomidine as a sedative for pediatric patients undergoing MRI and CT scans outside the operating room. A comprehensive search of databases, including PubMed, MEDLINE, and Cochrane Library, identified relevant studies. Data on sedation success rates, onset and recovery times, adverse events, dosing, administration, and hemodynamic stability were extracted and analyzed. The results indicate that dexmedetomidine has high sedation success rates and a favorable safety profile, effectively achieving the desired sedation level with minimal adverse events, primarily manageable hemodynamic changes. Onset and recovery times were generally acceptable for clinical practice, and the flexibility in administration routes and dosing highlighted its adaptability to various clinical needs and settings. Overall, dexmedetomidine is a reliable and safe sedative for pediatric patients undergoing MRI and CT scans, offering a balanced profile of efficacy and safety, and its use can be optimized based on clinical context, patient characteristics, and procedural requirements.

Comparing sedation protocols for endoscopic retrograde cholangiopancreatography (ERCP): A retrospective study

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic procedure. Effective sedation is crucial to enhance patient comfort and optimize endoscopist performance. Various sedation protocols, including Propofol and Dexmedetomidine (Pro-Dex), Ketamine and Propofol (Keto-Fol), Propofol and Midazolam (Pro-Mid), and Propofol alone, have been utilized during ERCP. This retrospective study aims to compare the safety and efficacy of these four sedation protocols. MethodsA retrospective analysis was conducted on data from 600 patients who underwent ERCP between 2018 and 2021, with each patient receiving one of the four sedation protocols. Protocol assignment was based on the endoscopist's preference. Data on hemodynamic parameters, sedation level, recovery time, and procedure-related complications were collected. ResultsBaseline data showed no significant differences among the groups pre-procedure. The Pro-Dex group exhibited significantly lower mean total propofol dose, shorter recovery time, and faster achievement of Ramsay Sedation Scale (RSS) score 3–4 compared to the other groups. The Pro-group demonstrated significantly longer hospital stay than the other three groups (median, 4.19 ± 1.1 vs. 3.48 ± 1.2 days in the KP groups, p = 0.042). There were no significant variations in the incidence of respiratory depression, hypotension, or bradycardia among the four groups. Additionally, notable trends were found for hemodynamic measures, total propofol dosage, time to reach the desired level of sedation (as measured by the Ramsay Sedation Scale), and hospital stay based on BMI categories, indicating that higher BMI is linked to more serious outcomes. ConclusionOur retrospective study demonstrates that the Pro-Dex protocol offers superior sedation quality, faster recovery, and fewer complications compared to the other protocols during ERCP. However, the incidence of ERCP-related adverse events did not significantly differ among the four sedation protocols. These findings can aid clinicians in selecting the most appropriate sedation protocol for ERCP, considering patient and endoscopist preferences.

Safety and effcacy of remimazolam tosilate for sedation during combined spinal-epidural anesthesia for orthopedic procedures: a randomized controlled trial

ObjectiveThe objective of this study was to assess the efficacy and safety of Remimazolam in the context of combined spinal-epidural anesthesia for sedation during orthopedic surgery.MethodsThis randomized controlled trial enrolled patients scheduled for orthopedic surgery under combined spinal-epidural anesthesia (N = 80), who were randomly allocated to receive either dexmedetomidine (Group-D) or remimazolam (Group-R). The target sedation range aimed for a Ramsay score of 2–5 or a BIS value of 60–80 to evaluate the effectiveness and safety of remimazolam during sedation.ResultsThe time taken to achieve the desired level of sedation was significantly shorter in the remimazolam group compared to the dexmedetomidine group (3.69 ± 0.75 vs. 9.59 ± 1.03; P < 0.0001). Patients in the remimazolam group exhibited quicker recovery, fewer intraoperative adverse events, more consistent vital signs, and greater satisfaction at various time points throughout the surgery.ConclusionThis preliminary study demonstrates that remimazolam tosilate serves as a safe and effective sedative for orthopedic surgery performed under combined spinal-epidural anesthesia, in comparison with dexmedetomidine.

Comparison of sedation efficacy of intravenous infusion of dexmedetomidine versus propofol in terms of opioid consumption in patients requiring postoperative mechanical ventilation after head and neck onco-surgeries – A randomized prospective study

Abstract Background: The conventional drug regimen of sedation for patients requiring mechanical ventilation in an intensive care unit (ICU) is propofol or midazolam. Dexmedetomidine is a newer drug for sedation with a better clinical profile. We conducted this study to compare the sedative efficacy of dexmedetomidine versus propofol in patients after head and neck cancer surgeries requiring mechanical ventilation. Methods: After ethics committee approval and written informed consent, 80 patients undergoing head and neck onco-surgery were recruited. The patients were randomly allocated to group I [1 mg/kg of bolus propofol over 15 minutes followed by infusion of 1 mg/kg/hour titrated by increasing or decreasing the infusion dose to Ramsay Sedation Score (RSS) 2–4] or group II (a loading dose of dexmedetomidine 1 mcg/kg over 15 minutes followed by a maintenance dose of 0.4 µg/kg/hour titrated to desired sedation level). The RSS, behavioral pain scale (BPS), heart rate, blood pressure, fentanyl consumption, additional sedative agent, extubation time, length of ICU stays, mechanical ventilation duration, side effects, and patient’s satisfaction were noted. Results: Total fentanyl required was 0.56 ± 0.13 µg/kg/hour in group II and 0.58 ± 0.18 µg/kg/hour in group I (P = 0.75). Extubation time, RSS, BPS, patient satisfaction, and ICU duration were similar in both the groups. The incidence of hemodynamic-related adverse effects were 41.67% in group II and 11.11% in group I (P = 0.006). Conclusion: The fentanyl requirement was comparable in both the groups in the postoperative period. Dexmedetomidine was associated with an increased incidence of bradycardia and hypotension as compared to the propofol group. Propofol should be the preferred sedative for postoperative mechanical ventilation after head and neck onco-surgeries.

Dexmedetomidine Versus Midazolam: Does Choice of Sedatives Effect the Duration of Mechanical Ventilation

Objective: To evaluate Dexmedetomidine and Midazolam in mechanical ventilation regarding the extubation time.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Anaesthesia, Combined Military Hospital, Kharian, from May to Dec 2019.&#x0D; Methodology: A total of 88 patients on mechanical ventilator support in ICU were included. In Group-D (Dexmedetomidine), a loading dose of 1 μg/kg Dexmedetomidine over ten minutes was given, and sedation was maintained by continuous infusion at the rate of 0.2–0.6 μg/kg/hr. In Group-M (Midazolam), an intravenous 0.5–1 mg bolus of Midazolam was given over two minutes and maintained by continuous infusion at 10-50 μg /kg/hr; doses were increased incrementally 1–2 mg/hour until desired sedation level was achieved. The Richmond Agitation and Sedation Score assessed the sedation level. The total duration of mechanical ventilation and time from weaning off trial to extubation was recorded.&#x0D; Results: In this study, the mean duration of mechanical ventilation was 63.07±32.07 hours in Group-D versus 86.14±38.96 hours in Group-M (p-value=0.003). The mean extubation time was 25.09±7.33 hours in Group-D versus 30.31±8.37 hours in Group-M (p-value =0.002).&#x0D; Conclusion: This study concluded that Dexmedetomidine is superior Midazolam in providing sedation to mechanically ventilated patients. It reduces the duration of mechanical ventilation and time of extubation.Keywords: Dexmedetomidine, Extubation, Mechanical ventilation, Midazolam, Sedation.

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial.

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children. A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia. Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05). The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high. Chinese Clinical Trial Registry: ChiCTR2000040500.

The effect of melatonin administration on sedation level as adjuvant to propofol in mechanically ventilated traumatic brain injury patients

ABSTRACT Background Melatonin is a pineal gland neuro-hormone influencing the biological regulations of the circadian rhythm. Numerous investigations have revealed variable effects of melatonin in vivo, including anti-inflammatory, antioxidant, sedative, and anxiolytic effects. The effects of using exogenous melatonin as an adjuvant to propofol on the degree of sedation in patients were investigated. Aim We aimed to test the feasibility of melatonin as a sedative agent in traumatic brain injury patients. Methods This research was a double-blinded clinical trial conducted on 38 participants suffering from traumatic brain injuries necessitating sedation and mechanical ventilation. Participants were assigned randomly into two groups. Both groups were sedated by propofol infusion and monitored by bispectral index (BIS). Nineteen patients received 10 mg of melatonin, and 19 patients received a placebo (control). Propofol infusion rate and BIS values were recorded each 30 minutes for 12 hours. Results Exogenous melatonin administration led to a significant decrease in the amount of infused propofol necessary to attain the desired level of sedation. The propofol infusion rates were 4.87 ± 2.91 ml/h in the melatonin group and 6.37 ± 2.87 ml/h in the control group (P- values = 0.001). Conclusion Exogenous melatonin acts as an adjuvant to propofol in sedation, reducing the amount of propofol infusion needed.

A prospective, randomized, interventional, comparative study between dexmedetomidine and propofol infusion for monitored anesthesia care during internal jugular vein chemoport insertion

Background: Chemotherapy through peripheral intravenous cannula causes severe thrombophlebitis. Chemoport is a best and favorable alternative for the same. It is done under local infiltration along with monitored anesthesia care with sedation. However, due to the lack of any fixed regimen, overt to under sedation is more common. To maintain an effective, consistent, and continuous level of sedation, we compared dexmedetomidine and propofol infusion in patients requiring monitored anesthesia care (MAC) for chemoport insertion. Methodology: Fifty patients posted for internal jugular vein chemoport insertion were randomly distributed into two groups: the propofol group and dexmedetomidine group. In Group P-injection, propofol infusion started at 125 μg/kg/min. Once observer's OAAS score 3 was achieved, propofol infusion was reduced to 25–75 μg/kg/min, whereas in Group D-Injection, dexmedetomidine bolus infusion was started at 1 μg/kg for 10 min and followed by 0.3–0.7 μg/kg/h and titrated to an OAAS score of 3. Results: OAAS score 3 was achieved significantly earlier in the propofol group as compared to the dexmedetomidine group (3.12 ± 1.7 vs. 8.04 ± 2.07, respectively). We were also able to maintain the desired sedation level throughout the procedure. Satisfaction scores in both the groups were comparable and patients in both the groups were hemodynamically stable throughout the procedure. Conclusion: In the current study, we found that propofol infusion was better regarding early onset and maintenance of OAAS score 3 with no requirement of rescue sedation during the procedure. The hemodynamic parameters and satisfaction scores were comparable in both groups. Hence, we suggest the use of injection propofol infusion for MAC under sedation in a patient requiring internal jugular vein chemoport insertion when compared to dexmedetomidine.

Communication on analgesia and sedation: parents’ opinions in six pediatric ICU in northern Italy

Abstract Introduction Communication between healthcare professionals and parents regarding analgesic and sedative treatments for seriously ill children is challenging. Although appropriate information may help parents during admission to the pediatric intensive care unit (PICU), some areas of communication may be missed. Objectives To explore and describe the opinions of parents of children admitted to PICU about analgosedation, information received about it and its potential adverse effects, and suggestions for improving the comfort of hospitalized children. Methods Parents’ opinions were collected in six PICUs in northern Italy. Parents of children who were hospitalized for more than 48 hours and required analgesia and sedation were asked to provide opinions on the quality of information with respect to the treatments used, possible short- and long-term sequelae, satisfaction with efficacy, environmental factors perceived as disturbing, and suggestions for improving children’s comfort. Results Forty-eight parents participated. Information about analgosedation was rated, as was its effectiveness. Parents pointed out some interesting suggestions to improve their children’s comfort during their hospitalization in PICU. On the other hand, it was found that information about possible complications, withdrawal syndrome, delirium, or difficulties in obtaining the desired level of sedation was often provided poorly or inadequately. In addition, wide differences were found between centres, particularly with regard to analgosedation side effects and withdrawal syndrome. Conclusions Parents should receive early explanations of these potential complications. Even considering the limited number of participating PICUs, distributed exclusively in northern Italy, and the small number of participants, this is the first data collection focused on communication between health professionals and parents of children undergoing analgosedation treatment in pediatric intensive care units. Key messages • This is the first data collection focused on communication between health professionals and parents of children undergoing analgosedation treatment in pediatric intensive care units. • Information about possible complications, withdrawal syndrome, delirium, or difficulties in obtaining the desired level of sedation was often provided poorly or inadequately.

Comparison between Diazepam and Midazolam as Premedicant to Reduce Anxiety in Patients underwent Elective Surgery Under General Anaesthesia

Background: The majority of patients admitted to hospital for elective surgery experience anxiety preoperatively which can adversely influence the surgical procedure as well as the patient’s recovery. Reduction of anxiety and fear at preoperative period in patients of elective surgery is essential for surgical preparation. Benzodiazepines are the most commonly used drugs for this purpose. The purpose of the study to evaluate the comparative efficacy of Diazepam and Midazolam regarding onset, duration and degree of antianxiety, sedation and amnesia during surgery under general anaesthesia. Materials and methods: The study was carried out in series of 60 consequetive, unselected patients, aged 18-60 years, admitted for the elective surgery under General Anaesthesia, in Combined Military Hospital (CMH) Chattogram during the period September 2019 to February 2020. Patients receiving diazepam or midazolam as preoperative medication were taken. Anxiety was scored using VAS, sedation was scored by using Ramsay Sedation scale and anterograde amnesia by asking preoperative events after 24 hours. Results: While evaluating mean anxiety reduction only, mean reduction is greater in the diazepam group compared to that of midazolam. Desired sedation level was less achieved with midazolam. In the diazepam group, greater number of patients could not recall preoperative events. Conclusion: The standard administration of diazepam before procedure provides patients with a moderate reduction of periprocedural anxiety. Routinely, administration of midazolam has a limited effects on the reduction of anxiety. Additionally, premedication of midazolam is associated with a high incidence of adverse effects. Therefore, this study does not support the routine use of midazolam as premedication to reduce anxiety. IAHS Medical Journal Vol 5(1), June 2022; 65-69

Comparison of intranasal and nebulized dexmedetomidine for premedication in pediatric patients: A non-inferiority randomized controlled trial.

Dexmedetomidine is a highly selective α-2 adrenoreceptor agonist and has been found to be an effective premedication agent when administered via the intranasal route. We aimed to compare the efficacy of dexmedetomidine premedication administered via intranasal route and through nebulization in pediatric patients. This non-inferiority randomized controlled trial was conducted after getting approval from institutes ethics committee and informed written parental consent. Sixty-four children aged 2-8 years scheduled for elective surgery under general anesthesia were enrolled and were divided into two groups. Group I (Intranasal, n = 33) received 2 mcg/kg dexmedetomidine via intranasal route and group N (Nebulized, n = 31) received 2 mcg/kg dexmedetomidine through nebulization. The primary outcome was number of patients with satisfactory sedation 30 minutes after premedication at separation from parent. The secondary outcome included ease of medication acceptance, anxiety at parental separation, acceptance of anesthesia mask, perioperative hemodynamics, emergence agitation during recovery and adverse effects. Data collected was analyzed using Chi-square test, Student "t" test and Mann-Whitney U test with the help of SPSS 22. A one tailed P value < 0.025 was considered significant. Demographic profile was comparable between groups. On arrival in OR 27 (81.8%) patients in group I and 21 (67.7%) patients in group N had satisfactory sedation score (P = 0.19). The median (IQR) sedation score was comparable between group I and group N (P = 0.057). Patients in Group I showed significantly better medication and mask acceptance scores (P < 0.0001, P = 0.001 respectively), parental separation anxiety score (P < 0.0001) and emergence agitation score (P = 0.001). There were no significant differences in hemodynamic parameters and adverse effects between the groups. Although nebulized dexmedetomidine is non-inferior to intranasal dexmedetomidine in providing desired level of sedation but intranasal administration had better acceptance of medication and anesthesia mask with lesser anxiety at parental separation and postoperative emergence agitation.

Comparison of the Effects of Oral Midazolam and Intranasal Dexmedetomidine on Preoperative Sedation and Anesthesia Induction in Children Undergoing Surgeries.

Background and Purpose: Premedication with either oral midazolam or intranasal dexmedetomidine prior to surgery remains less than ideal. The aim of this study was to investigate whether the combination of those two drug regimens would have any beneficial effects on the preoperative sedation and the children’s compliance during anesthesia inhalation induction. Experimental Approach: One hundred thirty-eight children aged 2–6 years were randomly allocated into three groups: Group M with oral midazolam 0.5 mg kg−1, Group D with intranasal dexmedetomidine 2 μg kg−1, and Group M + D with intranasal dexmedetomidine 1 μg kg−1 plus oral midazolam 0.5 mg kg−1. The primary outcome was the children’s compliance during inhalation induction with sevoflurane. The secondary outcomes included the preoperative sedative effects, behavior scores, parental separation anxiety scores, and the postoperative incidence of emergence agitation and recovery time. Results: Subjects in Group M + D showed higher satisfaction scores of compliance (p = 0.0049) and mask acceptance (MAS) (p = 0.0049) during anesthesia inhalation induction. Subjects in Group M + D had a significantly shorter time than those in Groups M and D to achieve the desired sedation level (p < 0.001) and remained at a higher sedation score in the holding area and up to the anesthesia induction after drug administration (p < 0.001). Conclusion and Implications: We conclude that pediatric patients premedicated with intranasal dexmedetomidine 1 μg kg−1 plus oral midazolam 0.5 mg kg−1 had significantly improved anesthesia induction compliance, and quicker onset to achieve and maintain a satisfactory level of sedation than those premedicated separately with two drugs. Therefore, the combined premed regimen is a greater choice when we are expecting a higher quality of sedation and a smoother anesthesia induction in children undergoing the surgeries.

Personalized sedation goal for agitated delirium in patients with cancer: Balancing comfort and communication.

Agitated delirium is common and highly distressing. Medications are often needed to reduce agitation, but it is unclear what the desired level of sedation is. This study assessed personalized sedation goals (PSGs) and their predictors for patients in a delirium clinical trial and in clinical vignettes. This was a preplanned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated delirium. At the baseline, caregivers and nurses were independently asked to select the PSG for the trial patient from 5 choices corresponding to Richmond Agitation Sedation Scale (RASS) scores of 0 or higher (no sedation), -1 to -2, -3, -4, and -5 (deep sedation). Respondents also selected a PSG for 6 vignettes that differed by the level of agitation, ability to communicate, and survival. Forty-two caregivers and 39 nurses answered questions regarding PSGs. For the trial patient, caregivers preferred RASS scores of -1 to -2 most often (36%), whereas nurses preferred an RASS score of -3 most often (51 %). Caregivers were significantly more likely than nurses to choose lighter sedation (odds ratio [OR], 4.8; P = .01) despite reporting greater delirium-related distress (P = .0006). Patients were undersedated 33% to 53% of the time and oversedated 0% to 15% of the time according to the PSG response criteria. In the case vignettes, deeper sedation was preferred by nurses (P < .0001) and for patients who were unable to communicate (OR, 3.1-4.4; P < .0001) and had a shorter life expectancy (OR, 1.7; P = .002). Caregivers often preferred lighter sedation than nurses. Many patients were undersedated in comparison with caregivers' PSGs, and this highlights room for improvement. In the last days of life, many patients with cancer develop delirium and become restless/agitated; this can be highly distressing. Caregivers and physicians alike are often concerned about the use of sedatives for agitated delirium and try to find a balance between maximizing comfort and maintaining communication. This study examined the concept of a personalized sedation goal for setting an individualized target for the level of sedation. Caregivers often preferred lighter sedation than nurses. Many patients were undersedated in comparison with caregivers' stated goals, and this highlights room for improvement.

The Effect of Preoperative Anxiety and Pain Sensitivity on Preoperative Hemodynamics, Propofol Consumption, and Postoperative Recovery and Pain in Endoscopic Ultrasonography.

IntroductionThe present study investigates how preoperative anxiety and pain sensitivity affect the consumption of anesthetics, time elapsed until the desired sedation level is achieved, preoperative hemodynamics, postoperative recovery time, and postoperative pain.MethodsThe present study includes 80 ASA 1–2 patients aged between 20 and 65 who were scheduled for endoscopic ultrasonography (EUS) under sedation. Patients were instructed to fill out the Spielberger State-Trait Anxiety Inventory (STAI) and Pain Sensitivity Questionnaire (PSQ) before the procedure. For sedation, 0.03 mg kg−1 intravenous midazolam, 1 mg kg−1 lidocaine, 1 µ kg−1 fentanyl, and then a bolus dose of 1 mg kg−1 propofol were infused over a period of 60 s. The time elapsed until the bispectral index (BIS) value reached 75 was recorded. For anesthesia maintenance, 2 mg kg−1 h−1 propofol infusion was administered. In the case of sedation failure, an additional dose of 0.1 mg kg−1 propofol (IV) was administered to ensure sedation depth with a BIS level of 65–75, and the propofol infusion was halted once the BIS value dropped below 65.ResultsSTAI-S and STAI-T scores were significantly positively correlated with PSQ minor pain and PSQ total scores. The time elapsed until reaching a BIS level of 75, propofol infusion dose used during sedation, and the need for additional doses of propofol, heart rate (HR), and duration of post-anesthesia care unit stay were significantly positively correlated with both preoperative anxiety and preoperative pain sensitivity. In terms of postoperative pain, the visual analog scale (VAS) at 1 h was more highly correlated with STAI-S and STAI-T than with PSQ. The VAS 2 h was only correlated with STAI-S and STAI-T.ConclusionThe significant linear correlation between preoperative anxiety and pain sensitivity and anesthesia need can facilitate better preoperative management by predicting individual anesthetic consumption.Trial RegistrationThe study was registered with the number NCT03114735 on ClinicalTrials.gov.

Intranasal midazolam for the sedation of geriatric patients with care-resistant behaviour during essential dental treatment: An observational study.

ObjectivesTo describe the efficacy and safety of intranasal midazolam for sedation during essential dental treatment of geriatric patients with major neurocognitive disorder (MND) and care‐resistant behaviour (CRB).BackgroundDental treatment is often impossible in geriatric MND patients with CRB. Intranasal midazolam may provide a non‐invasive sedation method, but there is currently no information on its use in geriatric patients.MethodsIn this observational study, we included geriatric patients with severe MND and CRB needing urgent dental treatment. Each patient received 5 mg midazolam intranasally. Agitation/sedation levels, heart rate, respiration rate and oxygen saturation were recorded at 5‐minute intervals.ResultsThirty two patients were included. Mean age was 84 (±7) years. Mean (SD) time to treatment start was 13 (±5) minutes, and mean time to maximum sedation 17 (±11) minutes. Sedation was sufficient to enable dental treatment to be completed in 31 (97%) patients. Anxiolysis/light sedation occurred in 16 (50%) patients, and moderate to deep sedation occurred in 16 (50%) patients. No patients suffered from apnoea, although 3 patients required a chin‐lift manoeuvre. Hypoxaemia occurred in 1 of these patients and in 2 other patients without airway obstruction. All patients recovered uneventfully. In a regression model, age, weight and other sedative medication use were found not to be associated with maximum sedation depth.ConclusionsOf 5 mg intranasal midazolam facilitates treatment of geriatric patients with MND in the comfort of their own environment. More information is needed to guide titration to balance the desired sedation level and patient safety.

Comparison of the efficacy of ketamine– propofol versus sodium thiopental–fentanyl in sedation: a randomised clinical trial

BackgroundMany sedative regimens have been studied with controversial efficiencies. This study tried to assess the desirable and adverse effects of sodium thiopental–fentanyl (TF) with ketamine–propofol (KP) for procedural sedation and...

Intramuscular dexmedetomidine and oral chloral hydrate for pediatric sedation for electroencephalography: A propensity score-matched analysis.

Intramuscular dexmedetomidine can be used for pediatric sedation without requiring intravenous access and has advantages for electroencephalography by inducing natural sleep pathway, but only a limited number of studies compared the efficacy of intramuscular dexmedetomidine with oral chloral hydrate. To compare the efficacy and safety of intramuscular dexmedetomidine and oral chloral hydrate used for sedation during electroencephalography in pediatric patients. We reviewed the medical records of pediatric patients who underwent sedation for electroencephalography between January 2015 and December 2016. Initial doses of dexmedetomidine and chloral hydrate were 3mcg/kg and 50mg/kg, respectively; second doses (1mcg/kg and 50mg/kg, respectively) were administered if adequate sedation was not achieved. Demographic data, time of sedative administration, time of sedation and awakening, and time of arrival at recovery room and discharge were analyzed. Out of a total of 1239 patients, 125 patients had received dexmedetomidine and 1114 had received chloral hydrate. After 1:1 propensity score matching, the dexmedetomidine and chloral hydrate groups each had 118 patients. Testing completion rate with a single dose of medication was higher in the dexmedetomidine group (91.5% vs 71.2%; mean difference [95% CI] 20.3 [10.8-29.9]; P<.0001; Pearson chi-square value=16.09). Sedation onset time was shorter in the dexmedetomidine group as well (16.6±13.0minutes vs 41.5±26.8minutes; mean difference [95% CI] 24.8 [19.1-30.6]; P<.0001; T=8.27). On the contrary, the duration of recovery was longer in the dexmedetomidine group (35.5±40.2minutes vs 18.5±30.7minutes; mean difference [95% CI] 18.6 [8.8-28.5]; P=.0002; T=-2.82). Total residence time was not significantly different between the two groups (125.8±40.6minutes vs 122.1±42.2minutes, mean difference [95% CI] 5.21 [6.1-16.5], P=.3665T=0.04). Intramuscular dexmedetomidine showed higher sedation success rate and shorter time to achieving the desired sedation level compared with oral chloral hydrate and thus may be an effective alternative for oral chloral hydrate in pediatric patients requiring sedation for electroencephalography.

Sedation in the intensive care unit

Introduction. Sedation is the reduction of irritability or agitation by the use of certain drugs mostly to facilitate therapeutic or diagnostic procedures. Scales for evaluation of the depth of sedation. Riker Sedation-Agitation Scale and Richmond Agitation-Sedation Scale are the most commonly used scales. Drugs. Sedation is generally produced by using medications from the group of opioids, benzodiazepines, intravenous and inhalation general anesthetic agents, neuroleptics, phenothiazines, ?-agonists and barbiturates. Adverse effects of sedatives. Sedation is often associated with hypotension, prolonged mechanical ventilation and longer time on respiratory support, higher frequency of delirium, immunosuppression, deep vein thrombosis, increased risk for development of nosocomial pneumonia, all of which leads to the prolonged recovery time. Conclusion. Sedatives currently used in intensive care units are widely used, but they have limitations. The goal is to get the desired level of sedation with as few side effects as possible.

Safety and efficacy of a cardiologist-only approach to deep sedation for electrical cardioversion.

Electrical cardioversion is still the preferred method to restore sinus rhythm in patients with atrial fibrillation. The main disadvantage is that electrical cardioversion requires deep sedation, generally administered by anaesthesiologists, for safety concern. An exclusively cardiologic management of deep sedation should have the advantage to reduce resources and time consumed. All consecutive patients admitted to our division with persistent atrial fibrillation or atrial flutter to undergo elective electrical cardioversion from June 2002 to December 2016 were included. The sedation protocol was managed only by cardiologists and involved the administration of a 5-mg bolus of midazolam, followed by increasing doses of propofol to achieve the desired sedation level. Exclusion criteria were strictly observed. Complications were recorded. A retrospective analysis on a deidentified database has been performed. A total of 1188 electrical cardioversions were scheduled in our centre. A total of 1195 patients were scheduled in our centre, of whom 1188 met inclusion criteria. Electrical cardioversion was performed in 1073 cases (90.3%). Electrical cardioversion was successful in restoring sinus rhythm in 1030 (96.0%) patients. Immediate recurrence of atrial fibrillation occurred in 89 patients (8.3%). 99/1073 (9.22%) patients underwent trans-oesophagel echocardiography before cardioversion. Deep sedation, according to our protocol, was effective in 100% of cases. Midazolam was administered at a dosage of 5 mg to all patients, while propofol was administered at a dosage ranging from 20 to 80 mg (25.1 ± 11.0 mg SD). No anaesthesia-related complications were observed, neither significant respiratory depression requiring intubation nor anaesthesiologist support. The exclusively cardiological procedure of deep sedation seems to be safe and effective.

Population pharmacokinetics of remifentanil in critically ill patients receiving extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is associated with pharmacokinetic (PK) changes of drugs. It presents considerable challenges to providing optimal dosing regimens for patients receiving ECMO. We aimed to describe the population PK of remifentanil in critically ill adult patients receiving venoartrial extracorporeal membrane oxygenation (VA-ECMO) and to identify determinants associated with altered remifentanil concentrations. The population PK model of remifentanil was developed using nonlinear mixed effects modelling (NONMEM). Fifteen adult patients who received a continuous infusion of remifentanil during VA-ECMO participated in the study. The PK of remifentanil was best described by a one-compartment model with additive and proportional residual errors. Remifentanil concentrations were affected by sex and ECMO pump speed. The final PK model included the effect of sex and ECMO pump speed on clearance is developed as followed: clearance (L/h) = 366 × 0.502sex × (ECMO pump speed/2350)2.04 and volume (L) = 41. Remifentanil volume and clearance were increased in adult patients on VA-ECMO compared with previously reported patients not on ECMO. We suggest that clinicians should consider an increased remifentanil dosing to achieve the desired level of sedation and provide a dosing regimen according to sex and ECMO pump speed.