Duration Of Sedation Research Articles

Practice-Pattern Variation in Sedation of Neurotrauma Patients in the Intensive Care Unit: An International Survey.

Background: Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery.

Clonazepam Versus Diazepam as Sedative in Elective Caesarean Section Under Spinal Anaesthesia

Background: Regional anaesthesia has become an important anaesthetic technique now a days. The use of spinal anaesthesia is often limited by the unwillingness of patients to remain awake during surgery. Pharmacologically induced tranquility improves acceptance of regional technique. This study compares Clonazepam and Diazepam in terms of onset and recovery of sedation, haemodynamic effects and adverse effects of both the drugs during elective caesarian section under spinal anaesthesia. Materials and methods: This randomized clinical trial included 60 ASA (American Society of Anaesthesiologists) grade I patients between age 20-40 years undergoing elective Caesarean sections under spinal anaesthesia during the period of January 2022 to June 2022. Patients were randomly allocated to one of two groups: Clonazepam group (Group C, n=30), who received Clonazepam in a single dose of 0.015mg/kg and Diazepam group (Group D, n=30), who received Diazepam in a single dose of 0.15mg/kg. Results: There was no significant difference of mean blood pressure and mean heart rate between the two groups (p>0.05). Time of onset and duration of sedation was comparable between the two groups (p value 0.759 and 0.652 respectively). Percentage of patient satisfaction was comparable between the two groups(80% vs 86.66%, p value 0.841). Incidence of pain in arm during drug administration was significantly more in Diazepam group (10% vs 100%, p<0.001). Conclusion: Both Clonazepam and Diazepam have satisfactory haemodynamic stability and sedation characteristic in single dose technique during spinal anaesthesia for caesarean section. IAHS Medical Journal Vol 5(2), Dec 2022; 20-24

Use of midazolam and butorphanol to sedate harbor seal pups (Phoca vitulina) undergoing rehabilitation

AbstractBetween 2012 and 2022, the Vancouver Aquarium Marine Mammal Rescue Centre sedated 110 harbor seal pups for physical examinations, diagnostic procedures, or treatment. A sedation protocol of butorphanol and midazolam (0.1–0.2 mg/kg each) was administered via a single i.v. injection in 171 procedures. Of these, 21 pups were anesthetized only with the injectables, while supplemental isoflurane inhalation anesthesia by mask was provided during 58 procedures; 92 other animals required intubation for respiratory support due to apnea or to achieve a deeper plane of anesthesia to facilitate more invasive procedures. Of the 171 sedations, five were euthanized due to poor prognosis and six failed to recover. Maximum sedation, sufficient for intended procedure or anesthesia induction, was achieved within a mean of 8.5 ± 5.8 min for i.v. injection (n = 133). Sedation duration (drug administration to full recovery) without supplemental inhalation anesthesia had a mean of 30.2 min and ranged from 14 to 52 min (n = 13). When used in stabilized young harbor seals, administration of injectable butorphanol and midazolam proved to be an effective protocol to obtain safe and reliable sedation for physical examination, minimally invasive diagnostic procedures, or as a premedication for general anesthesia.

Comparison between Effects of Ketofol and Dexmedetomidine as Sedative in Elective Caesarean Section under Subarachnoid Anaesthesia

Background: Regional anaesthesia has become an important anaesthetic technique now a days. The use of spinal(subarachnoid) anaesthesia is often limited by the unwillingness of patients to remain awake during surgery.Pharmacologically induced tranquility improves acceptance of regional technique. Objective: This study compares Ketofol (Ketamine + Propofol) and Dexmedetomidine in terms of onset and recovery ofsedation, haemodynamic effects, respiratory effects and adverse effects of both the drugs during elective Caesariansection under spinal anaesthesia. Materials and Methods: This randomized clinical trial included 60 ASA (American Society of Anaesthesiologists)grade I and II patients between age 20-40 years undergoing elective Caesarean sections under Subarachnoidanaesthesia during the period January 2022 to June 2022. Patients were randomly allocatedto one of two groups:Ketofol group (Group KP, n=30), who received Ketofol in a single dose of 0.5mg/kg (Ketamine-0.5mg/ kg+Propofol-0.5mg/kg) and Dexmedetomidine group (Group D, n=30), who received Dexmedetomidine in a single dose of 2mcg/kg.Spinal anaesthesiawas conducted by injecting a hyperbaric solution of 0.5% bupivacaine 3ml through a 25G spinalneedle at L3-4 level. All parameters were documented at 5 min intervals until arousal of the patient. The onset ofsedation i.e. time from iv (intravenous) injection of Ketofol or Dexmedetomidine to closure of eye lids (OAA/S score of3) and the arousal time from sedation i.e. time from closing of the eye lids to OAA/S score of 5 ( patient is awakeclinically) were noted. Any complication during operation was documented. Patient’s satisfaction with the sedation wasassessed by the 5 point ‘Likert verbal rating scale’. Results: There was no significant difference of mean blood pressure and mean heart rate between the two groups indifferent time intervals (P>0.05). Time of onset of sedation was significantly delayed in Dexmedetomidine group(P<0.001). The arousal time i.e. duration of sedation was comparable between the two groups (P>0.05). Ketofol wasassociated with significantly higher incidence of some adverse effects like pain in arm during drug administration thanDexmedetomidine (33.33% vs 10%, P<0.05). Satisfaction with sedation was comparable between the two groups(66.66% vs 86.66%, P value 0.136). Conclusion: As duration of sedation was comparable between the two drugs but adverse effects was less withDexmedetomidine, it is recommended that Dexmedetomidine is a better choice than Ketofol for sedation in single dosetechnique during Subarachnoid block for Caesarean section. Bangladesh Crit Care J March 2023; 11 (1): 13-18

Sedative and cardiopulmonary effects of intranasal butorphanol with midazolam or dexmedetomidine in New Zealand white rabbits.

This study aimed to compare the sedative and cardiopulmonary effects of intranasal (IN) administration of dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations in New Zealand white rabbits. Eight New Zealand white rabbits were sedated by IN administration of a combination of 0.1mg/kg dexmedetomidine and 0.4mg/kg butorphanol (DB treatment) and 2mg/kg midazolam and 0.4mg/kg butorphanol (MB treatment). The electrocardiogram, pulse rate (PR), respiratory frequency (fR ), arterial haemoglobin oxygen saturation (SpO2 ), fraction of expired carbon dioxide (EtCO2 ), rectal temperature (RT), noninvasive mean arterial pressure (MAP), noninvasive systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) were recorded. The onset of sedation, duration of sedation and sedation score (SS) were also noted. There were no significant differences in the EtCO2 , RT, MAP, SAP and DAP measurements between treatments. The PR significantly decreased in DB compared with MB over time (p = 0.001). Compared with baseline, SpO2 decreased over time in both treatments. The SS was significantly elevated over time in DB compared with MB (p = 0.002). No pharmacokinetic information was available for either treatment, so the findings should be interpreted cautiously. IN DB provides more effective sedation than MB, but cardiopulmonary impairment was observed in both treatments.

Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-AGerman nationwide survey study

Malignant middle cerebral artery infarction is apotentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. From 20 September 2021 to 31 October 2021, 43members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in astandardized anonymous online survey. Descriptive data analysis was performed. Out of 43centers 29 (67.4%) participated in the survey, including 24university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored astandardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3days in 30.8%, ≤ 5days in 19.2%, > 5days in 15.4%). Early tracheotomy (≤ 7days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14days. Hyperosmolar treatment is used on aregular basis in 53.9% and 22 centers (84.6%) agreed to participate in aclinical trial addressing the duration of postoperative sedation and ventilation. The results of this nationwide survey among neurointensive care units in Germany reflect aremarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. Arandomized trial in this matter seems warranted.

Postoperative recovery among head and neck cancer patients receiving microvascular free flap surgery with implementing nurse-protocolized targeted sedation: relationship of use of sedatives and mechanical ventilation to length of ICU stay.

Patients receiving microvascular free flap surgery are usually admitted to a high-dependency adult intensive care unit (ICU). Research is limited to investigate postoperative recovery among head and neck cancer patients in the ICU. This study aimed to evaluate a nursing-protocolized targeted sedation on postoperative recovery and to examine the relationship of demographic characteristics, use of sedation, mechanical ventilator to length of ICU stay in patients receiving microvascular free flap surgery for head and neck reconstruction. This retrospective study involves 125 ICU patients at a medical centre in Taiwan. Medical records were reviewed between 1 January 2015 and 31 December 2018 including surgery-related data, medications and sedations used, and ICU-related outcomes. The mean length of ICU stay was 6.2days (SD = 2.6), and the mean duration of mechanical ventilation was 4.7days (SD = 2.3). The daily dosage of sedation used in patients who received microvascular free flap surgery was dramatically reduced since the postoperative day (POD) 7. Over 50% of patients switched to PS + SIMV ventilator mode on POD 4. Duration of sedation used (r = 0.331, p < 0.001), total dosage of sedation (r = 0.901, p < 0.001), clear consciousness (r = - 0.517, p < 0.001), and duration on mechanical ventilator (r = 0.378, p < 0.001) are correlated with the length of ICU stay. This study provides an understanding of the use of sedation, mechanical ventilator, and length of ICU stay to inform the continued education for clinicians.

Does sevoflurane sedation in pediatric patients lead to "pseudo" leptomeningeal enhancement in the brain on 3 Tesla magnetic resonance imaging?

Prominent leptomeningeal contrast enhancement (LMCE) in the brain is observed in some pediatric patients during sedation for imaging. However, based on clinical history and cerebrospinal fluid analysis, the patients are not acutely ill and do not exhibit meningeal signs. Our study determined whether sevoflurane inhalation in pediatric patients led to this pattern of 'pseudo' LMCE (pLMCE) on 3 Tesla magnetic resonance imaging (MRI). To highlight the significance of pLMCE in pediatric patients undergoing enhanced brain MRI under sedation to avoid misinterpretation in reports. A retrospective cross-sectional evaluation of pediatric patients between 0-8 years of age was conducted. The patients underwent enhanced brain MRI under inhaled sevoflurane. The LMCE grade was determined by two radiologists, and interobserver variability of the grade was calculated using Cohen's kappa. The LMCE grade was correlated with duration of sedation, age and weight using the Spearman rho rank correlation. A total of 63 patients were included. Fourteen (22.2%) cases showed mild LMCE, 48 (76.1%) cases showed moderate LMCE, and 1 case (1.6%) showed severe LMCE. We found substantial agreement between the two radiologists in detection of pLMCE on post-contrast T1 imaging (kappa value = 0.61; P < 0.001). Additionally, we found statistically significant inverse and moderate correlations between patient weight and age. There was no correlation between duration of sedation and pLMCE. pLMCE is relatively common on post-contrast spin echo T1-weighted MRI of pediatric patients sedated by sevoflurane due to their fragile and immature vasculature. It should not be misinterpreted for meningeal pathology. Knowing pertinent clinical history of the child is an essential prerequisite to avoid radiological overcalling and the subsequent burden of additional investigations.

Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic.

This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The following factors were assessed: tolerance to the ventilation, sedation level on the Richmond Agitation-Sedation Scale (RASS), hemodynamic and saturation profile, adverse effects, and discontinuation or mortality during ventilation. The study included 66 patients who underwent sedation for non-invasive ventilation using keta-dex (KETA-DEX group, n = 22), ketamine (KET group, n = 22), or dexmedetomidine (DEX group, n = 22). The DEX group showed a slower sedation rate and a significant reduction in blood pressure compared to the KETA-DEX group (p < 0.05). An increase in blood pressure was recorded more frequently in the KET group. No reduction in oxygen saturation and no deaths were observed in any of the groups. None of the patients discontinued ventilation due to intolerance. The mean duration of sedation was 28.12 h. No cases of delirium were observed in any of the groups. Overall, keta-dex was associated with faster sedation rates and better hemodynamic profiles compared to dexmedetomidine alone. Keta-dex is effective and safe for sedation of uncooperative patients undergoing non-invasive ventilation.

A COMPARATIVE STUDY OF DEXMEDETOMIDINE AND FENTANYL AS AN ADJUVANT TO EPIDURAL BUPIVACAINE IN INFRAUMBILICAL SURGERIES

Background Early postoperative mobilization, minimal pain and recovery are desirable features of modern anaesthesia post surgery. Epidural anaesthesia is most commonly used for providing postoperative analgesia. To achieve this, larger volume of local anaesthetics are used epidurally which increased the possibility of local anaesthetic toxicity. To reduce the local anaesthetic toxicity adjuvants to epidural infusion such as opioids, α2 agonists, benzodiazipines are added. Present study is done to evaluate the efcacy of dexmed Objective: etomidine and fentanyl for studying the duration of postoperative analgesia and sedation. Methodology: 80 patients of ASA grade I and II posted for elective lower abdominal and lower limb surgeries were selected for our study.They were premedicated with table tranitidine 150mg and tablet alprazolam 0.25mg night prior to surgery. Baseline parameters of vitals were recorded. Patients were preloaded with Ringer lactate solution of 15ml/kg . Under strict aseptic precautions, epidural catheter was introduced at L3-L4 space and test dose was given using 3ml of 2% Lignocaine with adrenaline followed by SAB given with injection hyperbaric bupivacaine 0.5% 15mg. After 90 min of subarachnoid block they were injected either 25ml of 0.125% bupivacaine with 0.5μg/kg dexmedetomidine or 25 ml 0.125% bupivacaine with 1μg/kg fentanyl epidurally at a rate of 5ml/hour using syringe pump. Rescue analgesia was supplemented with injection morphine 0.1mg/kg through intravenous route. Duration of analgesia , hemodynamic parameters and sedation score were noted. Analgesic effect was noted by visual analogue scale. Patients were observed for side effects Duration of postoperative analgesia, hemodynamic stability Results: and sedation were better with dexmedetomidine than fentanyl. Dexmedetomidine is a better adjuvant to epidural b Conclusion: upivacaine than fentanyl in terms of prolonged duration of analgesia with better sedation and hemodynamic parameters

Subcutaneous alfaxalone for sedation of the domestic ferret (Mustela putorius furo)

BackgroundVeterinary care of the domestic ferret often utilizes chemical restraint for venipuncture, radiographs, and ultrasonography. Common forms of chemical restraint for ferrets include inhalant anesthetics and parenteral sedatives. Disadvantages of these forms of chemical restraint include adverse patient reaction and environmental contamination for inhalant anesthetics while small muscle mass and patient reactivity are challenging for intramuscular injections. Alfaxalone is a unique neurosteroid anesthetic that can be used as an induction agent intravenously and a sedative agent intramuscularly and subcutaneously. Subcutaneous injection appears to be well tolerated in small exotic species due to the increased volume the subcutaneous space can accommodate as well as the ease of administration. MethodsA randomized, blinded, complete crossover study evaluating two doses (10 mg/kg and 12.5 mg/kg) of subcutaneous (SC) alfaxalone alone was performed in 10 clinically healthy ferrets (5 neutered males and 5 spayed females). Once alfaxalone was administered sedation scores (body posture, righting reflex, jaw tone, front limb withdrawal, and toe pinch) and vital parameters (heart rate, respiratory rate, rectal temperature, SpO2 and blood pressure) were evaluated at regular intervals. ResultsSedation characterized by the loss of righting reflex for more than ten minutes was observed in 90% of ferrets in both groups. The higher dose of alfaxalone (12.5 mg/kg) produced a statistically significant increase in the duration of sedation, as well as in the values of all sedation scores. Temperature significantly decreased over time for both groups, while SpO2 and respiratory rate did not display any significant changes. At both doses, no cardiovascular depression was noted but there were significant increases in heart rate and blood pressure parameters. ConclusionSubcutaneous alfaxalone in ferrets produces adequate sedation characterized by the loss of righting reflex and easy limb manipulation with no significant adverse effects. This type of sedation is appropriate for noninvasive procedures such as a physical exam, ultrasonography, and radiographic positioning without manual restraint. The limitations for SC alfaxalone, as a sole sedative agent, include the variable range in times to onset and variable durations of sedation.

Comparison Between Effects of Ketofol and Fenofol as Sedative in Elective Caesarean Section Under Subarachnoid Anaesthesia

Background: Regional anaesthesia has become an important anaesthetic technique now a days. The use of spinal (subarachnoid) anaesthesia is often limited by the unwillingness of patients to remain awake during surgery. Pharmacologically induced tranquility improves acceptance of regional technique. Objective: This study compares Ketofol (Ketamine+Propofol) and Fenofol (Fentanyl+ Propofol) in terms of onset and recovery of sedation, haemodynamic effects, respiratory effects and adverse effects of both the drugs during elective Caesarian section under spinal anaesthesia. Methods: This randomized clinical trial included 60 ASA (American Society of Anaesthesiologists) grade I or II patients between age 20-40 years undergoing elective Caesarean sections under Subarachnoid anaesthesia during the period of January 2022 to June 2022. Patients were randomly allocated to one of two groups: Ketofol group (Group KP, n=30), who received Ketofol in a single dose of 0.5mg/kg (Ketamine- 0.5mg/kg+Propofol-0.5mg/kg) and Fenofol group (Group FP, n=30), who received Fenofol in a single dose of Fentanyl-0.5mcg/kg+Propofol-0.5mg/kg. Spinal anaesthesia was conducted by injecting a hyperbaric solution of 0.5% bupivacaine 3ml through a 25G spinal needle at L3-4 level. All parameters were documented at 5 min intervals until arousal of the patient. The onset of sedation i.e. time from iv (intravenous) injection of Ketofol or Fenofol to closure of eye lids and the arousal time from sedation i.e. time from closing of the eye lids to OAA/S score of 5 (patient is awake clinically) were noted. Any complication during operation was documented. Patient’s satisfaction with the sedation was assessed by the 5 point ‘Likert verbal rating scale. Results: There was no significant difference of mean blood pressure and mean heart rate between the two groups (P&gt;0.05). Time of onset of sedation was comparable between the two groups (P&gt;0.05). Duration of sedation was significantly less in Fenofol group (p value=&lt;0.001). Significant percentage of patients required oxygen supplementation after sedation with Fenofol due to hypoventilation (66.66% vs 10%, p value &lt;0.001). Incidence of nausea and vomiting was significantly more with Fenofol (46.66% vs 10%, p value &gt;0.001). Conclusion: The study showed that the arousal time i.e. duration of sedation was significantly more with Ketofol than Fenofol which is beneficial for the patient in single dose technique for sedation. Fenofol was associated with significantly high incidence of nausea, vomiting. Moreover, significantly higher percentage of patients required O2 supplementation due to hypoventilation during sedation with Fenofol. Thus it is recommended that Ketofol is a better choice than Fenofol for sedation in single dose technique during subarachnoid block for Caesarean section. J Rang Med Col. March 2023; Vol. 8, No. 2:20-26

Comparison between Effects of Fentanyl and Fenofol as Sedative in Elective Caesarean Section under Subarachnoid Anaesthesia

Background: Regional anaesthesia has become an important anaesthetic technique now a days. Pharmacologically induced tranquility improves acceptance of regional technique. Objective: To compare Fentanyl and Fenofol (Fentanyl+Propofol) in terms of onset and recovery of sedation, haemodynamic effects, respiratory effects and adverse effects of both the drugs during elective Caesarian section under spinal(subarachnoid) anaesthesia. Materials and Methods: This randomized clinical trial included 60 ASA (American Society of Anaesthesiologists) grade I or II patients between age 20-40 years undergoing elective Caesarean sections under Subarachnoid anaesthesia during the period January 2022 to June 2022. Patients were randomly allocated to one of two groups: Fentanyl group (Group F, n=30), who received Fentanyl in a single dose of 0.5mcg/kg and Fenofol group (Group FP, n=30), who received Fenofol in a single dose of Fentanyl-0.5mcg/kg+Propofol-0.5mg/kg. Spinal anaesthesia was conducted by injecting a hyperbaric solution of 0.5% bupivacaine 3ml through a 25G spinal needle at L3-4 level. All parameters were documented at 5 min intervals until arousal of the patient. The onset of sedation i.e. time from iv (intravenous) injection of Fentanyl or Fenofol to closure of eye lids (OAA/S score of 3) and the arousal time from sedation i.e. time from closing of the eye lids to OAA/S score of 5 ( patient is awake clinically) were noted. Any complication during operation was documented. The patient’s satisfaction with the sedation was assessed by the 5 point ‘Likert verbal rating scale.’ Results: There was no significant difference of mean blood pressure and mean heart rate between the two groups in different time intervals (P&gt;0.05). Time of onset of sedation and the arousal time i.e. duration of sedation was comparable between the two groups (P&gt;0.05). Significant percentage of patients required O2 supplementation in Fenofol group due to hypoventilation (66.66% vs 10%, P&lt;0.001). Pain in arm during drug administration was significantly more with Fenofol (46.66% vs 6.66%, P&lt;0.001). Conclusion: As a significantly higher percentage of patients required O2 supplementation during sedation with Fenofol and pain in arm during drug administration was significantly more in Fenofol group, it is recommended that Fentanyl is a better choice than Fenofol for sedation in single dose technique during subarachnoid block for Caesarean section. KYAMC Journal Vol. 13, No. 04, January 2023: 234-239

Postintubation Sedation Practices Within Multiple Emergency Departments Across a Large Pediatric Health Care Organization.

Children requiring rapid or standard sequence intubation are at risk of experiencing paralysis without adequate sedation when the duration of neuromuscular blockade exceeds the duration of sedation provided by the induction agent. The objective of this study was to evaluate the rate of appropriately timed postintubation sedation (PIS; defined as the administration of PIS before the clinical effects of the induction agent have dissipated) in patients requiring intubation across multiple emergency department/urgent care sites within a large pediatric health care organization. This retrospective cohort study included patients admitted to 1 of 6 affiliated pediatric emergency department or urgent care sites who were intubated with an induction agent and neuromuscular blocker between January 2016 and December 2021. Patients were excluded if they were intubated in the setting of status epilepticus or cardiac arrest. Stepwise logistic regression identified factors associated with appropriately timed PIS. A total of 283 patients met the inclusion criteria (mean age, 8 ± 7.6 years; 56% male). Two hundred thirty-eight patients (83%) received some form of PIS (105 [37%] received appropriately timed PIS and 133 [47%] received delayed PIS), and 45 patients (16%) received no PIS. The median time to receive PIS following administration of the induction agent was 21 minutes (interquartile range, 11-40 minutes). Patients induced with fentanyl were the least likely to receive PIS, whereas patients induced with etomidate were the most likely. However, because of the short duration of etomidate, most patients induced with etomidate failed to receive PIS in a timely manner. Delayed PIS is common and may result in periods of ongoing paralysis without adequate sedation. Emergency department providers and pharmacists must recognize the brevity of some induction agents and provide more timely PIS.

Comparison between Effects of Midazolam and Dexmedetomidine as Sedative in Elective Caesarean Section under Spinal Anaesthesia

This randomized clinical trial compares midazolam and dexmedetomidine in terms of onset and recovery of sedation, haemodynamic effects, respiratory effects, and adverse effects of both the drugs in elective Caesarian section under spinal anaesthesia. The study included 60 ASA grade-I patients between age 20- and 40-years undergoing elective Caesarean sections under subarachnoid anaesthesia, from January 2022 to June 2022. Patients were randomly allocated to one of the two groups: midazolam group (Group-I, n=30), who received midazolam in a single dose of 0.10mg/kg and Dexmedetomidine group (Group-II, n=30), who received dexmedetomidine in a single dose of 2mcg/kg. Spinal anaesthesia was conducted by injecting a hyperbaric solution of 0.5% bupivacaine 3ml through a 25G spinal needle at L3-4 level. All parameters were documented at 5-minute intervals until arousal of the patient. The onset of sedation i.e., time from IV (intravenous) injection of Midazolam or Dexmedetomidine to closure of eye lids (OAA/S score of 3) and the arousal time from sedation i.e., time from closing of the eye lids to OAA/S score of 5 (patient is awake clinically) were noted. Any complication during operation was documented. The patient’s satisfaction with the sedation was assessed by the 5-point ‘Likert verbal rating scale’. There was no significant difference of mean blood pressure and mean heart rate between the two groups at different time intervals (P&gt;0.05). Time of onset of sedation was significantly delayed in dexmedetomidine group (P&lt;0.05). Duration of sedation was comparable between the two groups (P&gt;0.05). Incidence of peroperative complications were comparable between the two groups (P&gt;0.05). Haemodynamic effects and adverse effects of two drugs were comparable. Therefore, it is recommended that either midazolam or dexmedetomidine can be used for sedation in single dose technique during subarachnoid block for Caesarean section.&#x0D; CBMJ 2023 January: Vol. 12 No. 01 P: 99-106

Sedation protocols in non-traumatic SAH (SPRINT-SAH): A cross-sectional survey among German-speaking neurointensivists.

In subarachnoid hemorrhage (SAH), titrating sedation to find a balance between wakefulness with the ability to perform valid clinical examinations on the one hand, and deep sedation to minimize secondary brain damage, on the other hand, is challenging. However, data on this topic are scarce, and current guidelines do not provide recommendations for sedation protocols in SAH. We designed a web-based, cross-sectional survey for German-speaking neurointensivists to map current standards for the indication and monitoring of sedation, duration of prolonged sedation, and biomarkers for the withdrawal of sedation. Overall, 17.4% (37/213) of neurointensivists answered the questionnaire. Most of the participants were neurologists (54.1%, 20/37) and exhibited a long-standing experience in intensive care medicine (14.9 years, SD 8.3). Among indications for prolonged sedation in SAH, the control of intracranial pressure (ICP) (94.6%) and status epilepticus (91.9%) were most significant. With regard to further complications in the course of the disease, therapy refractory ICP (45.9%, 17/37) and radiographic surrogates of elevated ICP, such as parenchymal swelling (35.1%, 13/37), were the most relevant topics for experts. Regular awakening trials were performed by 62.2% of neurointensivists (23/37). All participants used clinical examination for the therapeutic monitoring of sedation depth. A total of 83.8% of neurointensivists (31/37) used methods based on electroencephalography. As a mean duration of sedation before attempting an awakening trial in patients with unfavorable biomarkers, neurointensivists suggested 4.5 days (SD 1.8) for good-grade SAH and 5.6 days (SD 2.8) for poor-grade SAH, respectively. Many experts performed cranial imaging before the definite withdrawal of sedation [84.6% (22/26)], and 63.6% (14/22) of the participants required an absence of herniation, space-occupying lesions, or global cerebral edema. The values of ICP tolerated for definite withdrawal were smaller compared to that of awakening trials (17.3 mmHg vs. 22.1 mmHg), and patients were required to stay below the threshold value for several hours (21.3 h, SD 10.7). Despite the paucity of clear recommendations for sedation management in SAH in the pre-existing literature, we found some level of agreement indicating clinical efficacy for certain clinical practices. By mapping the current standard, this survey may help to identify controversial aspects in the clinical care of SAH and thereby streamline future research.

An experimental evaluation of anticonvulsant activity of aqueous extract of Caralluma dalzielii N.E. Brown

Ethnopharmacological RelevanceCaralluma dalzielii belongs to the family of Asclepiadiaceae. It is a succulent perennial plant widely distributed across the Sahel region from Senegal to Northwest Nigeria. Extracts from Caralluma dalzielii are used traditionally in the treatment of pain, infertility, epilepsy and other neurological diseases. Aim of the studyThe aim of the present study was to evaluate the anticonvulsant effects of aqueous extracts of aerial parts of Caralluma dalzielii using various experimental models. Materials and methodsThe anticonvulsant effect of the plant extract (250, 500 and 1000 mg/kg p.o) were assessed using maximal electroshock (MES) model in chicks, pentylenetetrazole (PTZ) and strychnine (STN)-induced seizures models in mice. Diazepam-induced sleep in chicks was used to study the sedative property of the plant. In the anticonvulsant and sedative property studies, the onset and duration of seizures and sleep were recorded respectively. The oral acute toxicity study was assessed. The extract was screened preliminarily for its phytochemicals and was further analysed using Gas chromatography-mass spectrometry (GC–MS) to identify its major chemical components. ResultsThe oral acute toxicity studies showed that the LD50 was greater than 5000 mg/kg in mice. Pre-treatment of mice with the aqueous extract of Caralluma dalzielii produced a dose-dependent protection against PTZ-induced seizures and mortality with 100% protection at the highest dose of the extract. The extract also significantly increased the latency/onset of myoclonic jerks and reduced the duration of tonic seizures dose dependently. In STN-induced seizure, the extract had no protection against seizure induction similar to diazepam the positive control. However, it significantly (p < 0.05) prolonged the latency of seizure and increased the survival time before death in a dose dependent manner. Caralluma dalzielii had zero protection against maximal electroshock. Phytochemical screening showed the presence of flavonoids, tannins, saponins, steroids, glycosides, cardiac glycosides and phenols. GC–MS analysis revealed the presence of some compounds. ConclusionThe extract of Caralluma dalzielii possesses anticonvulsant activity with less marked sedative activity. It also contains several phytochemicals which may be responsible for the activity. This study serves to validate the use of this plant in folkloric medicine for the treatment of epilepsy and convulsions.

Comparing the anti-nociceptive, sedative and clinicophysiological effects of epidural detomidine, detomidine-lidocaine and lidocaine in donkeys.

Epidural analgesia using the alpha-2 agonist detomidine (DE), alone or in combination with lidocaine (LD), is frequently employed for standing surgical procedures in horses, but its use has not been evaluated in donkeys. In a randomised controlled prospective trial, 24 healthy adult donkeys were assigned to four groups (n = 6), each receiving 40μg/kg of DE, 0.22mg/kg of LD, combined DE and LD (DELD) or 0.9% sterile normal saline epidurally. After epidural injection of each treatment, the onset, degree and duration of sedation and anatomical extension of anti-nociception were observed. DE and DELD treatments resulted in complete bilateral analgesia with loss of sensation in the tail, perineum, inguinal area, chest and the caudal aspect of the upper pelvic limb, and extended distally to the dorsal metatarsal area. DE and DELD resulted in a significantly (p < 0.05) longer duration of anti-nociception (110 ± 15.4min and 141.6 ± 14.7min, respectively) than LD (75.8 ± 4.9min). The DELD duration of sedation was significantly (p < 0.05) longer than the DE duration (118.3 ± 19.4min and 108.3 ± 7.5min, respectively). The current study's main limitation is using only one dose of DE. DE and DELD produced a very effective, safe and acceptable sedative and analgesic effect in the perineal and inguinal regions of donkeys.

Comparison of Analgesic Effect of Dexmedetomidine versus Tramadol as Adjuvants to Caudal Ropivacaine in Infraumbilical Surgeries among Pediatric Patients: A Randomized Double Blind Interventional Study

Objective: To compare the postoperative analgesic effects of 0.2% ropivacaine with Dexmedetomidine (2 g/kg) and tramadol (2 mg/kg) among pediatric patients undergoing infra umbilical surgery.Material and Methods: This hospital based, randomized double blind interventional study included 60 pediatric patients, aged 1–7 years, having American Society of Anaesthesiology grade I and II, weighing 7-25 kg, and undergoing infraumbilical surgeries under general anesthesia. Subjects were randomly allocated into two groups to receive either: 2 mcg/ kg of Dexmedetomidine or 2 mg/kg of Tramadol, as adjuvant to 0.2% of Ropivacaine. Pain intensity was assessed using the pediatric observational Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) score. Rescue analgesia was given, when the CHEOPS score was ≥6. Duration of analgesia was defined as: the time period between administrations of block until rescue analgesia was given. Level of sedation was assessed by the Ramsay sedation score.Results: Kaplan Meier analysis showed that the median time to first rescue analgesia (duration of analgesia) was significantly (p-value&lt;0.001) prolonged with Dexmedetomidine (780 minutes; 95% CI: 760.68–799.32 minutes) as compared to Tramadol (648 minutes; 95% CI: 635.92–660.38 minutes). Mean emergence time and duration of sedation were also significantly prolonged with Dexmedetomidine as compared to Tramadol.Conclusion: In pediatric patients undergoing infraumbilical surgeries, Dexmedetomidine as adjuvant to Ropivacaine provides an advantage of longer post-operative analgesia and lack of opioid related adverse events associated with Tramadol.

Comparative evaluation of sedative and anti-nociceptive effects of epidural romifidine, romifidine-lidocaine, and lidocaine in donkeys (Equus asinus).

Local and regional anesthetic procedures are valuable tools in veterinary practice. Caudal epidural administration of local anesthetic agents is widely reported for surgical interventions of the tail, anus, rectum, vulva, vagina, urethra, and bladder in the standing horse. Epidural analgesia is also obtained using various drugs such as alpha-2 adrenoceptor agonists, dissociative anesthetics, and opioids. The present study evaluates the anti-nociceptive and sedative effects of epidural administration of romifidine, a romifidine-lidocaine combination, and lidocaine alone in donkeys. In a randomized prospective study, twenty-four healthy adult donkeys were assigned to four groups (three experimental and one control; n = 6) received either 50 μg/kg of romifidine, 0.30 mg/kg of lidocaine, combined romifidine (50 μg/kg) and lidocaine (0.30 mg/kg) diluted in 0.9% sterile normal saline solution to a total injection volume of 12 ml, or an equivalent volume of sterile saline epidurally. After epidural injection of each treatment, the onset, degree, and duration of sedation and anatomical extension of anti-nociception were documented. Observations began immediately (time 0) pre-administration and at 5, 15, 30, 45, 60, and 30-min intervals subsequently until 210 min after drug injection. Time to onset of perineal analgesia was documented every minute after the epidural injection by evaluating the animal's response to pinpricks. Only romifidine and romifidine-lidocaine induced mild to moderate sedation. Romifidine, romifidine-lidocaine, and lidocaine induced complete bilateral caudal epidural analgesia with loss of sensation in the perineum, tail, inguinal region, caudal aspect of the upper hind limb, chest areas, and extended distally to the dorsal metatarsal area. Sedation lasted longer (p < 0.05) with romifidine (160 ± 15.4 min) than with romifidine-lidocaine (141.6 ± 13.2 min). Longer-lasting analgesia (p < 0.05) was obtained with romifidine (158.3 ± 9.8 min) and romifidine-lidocaine (165 ± 9.4 min) than with lidocaine (75.8 ± 8 min). Epidural administration of a single dose of romifidine or a combination of romifidine-lidocaine produced mild to moderate sedation and complete anti-nociception in the perineal and inguinal regions of donkeys. The clinical usefulness of epidural romifidine or romifidine-lidocaine combinations to perform obstetric procedures in donkeys needs to be assessed.