Sedation Guidelines Research Articles

Effectiveness of pharmacological procedural sedation in children with autism spectrum disorder: A systematic review and meta-analysis.

Management of primary healthcare and routine minor procedures for children with autism spectrum disorder (ASD) can be challenging; therefore, when behavioural strategies fail, sedative medications are often employed. We evaluated the effectiveness of the current pharmacological strategies for managing children with ASD. We performed a systematic review and meta-analysis of the current approaches for procedural sedation in children with ASD. Twenty studies met inclusion criteria. Dexmedetomidine, midazolam, propofol and chloral hydrate were the most efficient agents for successful procedures, while propofol had the highest number of adverse events. The most frequently used agents were dexmedetomidine and midazolam or a combination of the two, and the effectiveness of dexmedetomidine plus midazolam was superior to dexmedetomidine alone. Multiple effective drug regimens exist for procedural sedation in children with ASD. These results could support the development of specific guidelines for procedural sedation in children with ASD.

Association Between Sex, Race, and Ethnicity and IVSedation Use in Patients Receiving Invasive Ventilation

BackgroundIntravenous sedation is an important tool for managing invasively ventilated patients, yet excess sedation is harmful, and dosing could be influenced by implicit bias. Research questionWhat is the association between sex, race and ethnicity, and sedation practices? MethodsWe performed a retrospective single-center cohort study of adults receiving invasive ventilation for 24 hours or more using the MIMIC-IV (2008-2019) database from Boston, USA. We used a repeated-measures design (4-hour intervals) to study the association between sex (female, male) or race and ethnicity (Asian, Black, Hispanic, White) and sedation outcomes. Sedation outcomes included sedative use (propofol, benzodiazepine, dexmedetomidine) and minimum sedation score. We categorized sedative use as follows: no sedative, then lowest, second, third, and highest quartiles of sedative dose. We adjusted for covariates with multilevel Bayesian proportional odds modeling and reported odds ratios (OR) with 95% credible intervals (CrI). ResultsWe studied 6,764 patients: 43% female; 3.5% Asian, 12% Black, 4.5% Hispanic and 80% White. Benzodiazepines were administered to 2,334 (36%) patients. Black patients received benzodiazepines less often and at lower doses than White patients (OR for more benzodiazepine 0.66, CrI 0.49-0.92). Propofol was administered to 3,865 (57%) patients. Female patients received propofol less often and at lower doses than male patients (OR for more propofol 0.72, CrI 0.61-0.86). Dexmedetomidine was administered to 1,439 (21%) patients, and use was similar across sex or race and ethnicity. Female patients were less sedated than male patients (OR for deeper sedation 0.71, CrI 0.62 to 0.81), and Black patients were more sedated than White patients (OR for more sedated 1.28, CrI 1.05 to 1.55). InterpretationAmong patients invasively ventilated for at least 24 hours, intravenous sedation and attained sedation levels varied by sex and race and ethnicity. Adherence to sedation guidelines may improve equity in sedation management for critically ill patients.

The Attitudes and Experiences of Hospice Nurses Regarding Palliative Sedation: A Cross-Sectional Descriptive Study.

Background: Despite the global acceptance of palliative sedation, China's engagement in this field remains comparatively restricted. There exists a scarcity of information regarding the attitudes and experiences of hospice nurses concerning palliative sedation. Objectives: This survey aimed at investigating the attitudes of Chinese hospice nurses toward palliative sedation, as well as their practices in palliative sedation. Design: A cross-sectional descriptive study. Setting/Subjects: In 2023, the survey on palliative sedation was introduced during the opening ceremony of the largest National Symposium on New Advances in Hospice Nursing in China. Subsequently, the study questionnaire was disseminated through email to a cohort of 806 hospice nurses attending the conference. Measurements/Results: The statistical analysis was based on 641 valid responses. Among them, 508 had no experience with palliative sedation, while only 133 had such experience. Around 92.5% of hospice nurses with experience in palliative sedation agreed with the physician's instructions to begin palliative sedation. Nurses were present at the start of sedation in nearly all cases (97.0%), and most doctors (79.7%) and family members (82.0%) were also present. However, 8.3% of them perceived that there was no difference between palliative sedation and euthanasia. Furthermore, 13.5% of participants believed that the purpose of palliative sedation was to hasten death. Conclusions: Hospice nurses play a crucial role in the process of palliative sedation, yet they also face significant challenges. It suggests that there is an urgent need in China for the development of consensus or guidelines for palliative sedation to clarify the roles of team members, including hospice nurses.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI).

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others. To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology. An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method. Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability. This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

The Effect of Noise and Light on Sedation in Critical Care Patients. A Cross-Sectional Study of Critical Care Nurses in Three Intensive Care Units in Norway

Background: International guidelines for pain, sedation, delirium, immobility, and sleep in critically ill patients recommend the use of noise and light reduction strategies to improve sleep. The aims of this study were: 1) to evaluate critical care nurses’ (CCNs) perceptions regarding sources of noise and light in the intensive care unit (ICU), and 2) to identify factors associated with critical care patients’ need for sedation when their sleep is disturbed by noise or light. Methods: A cross-sectional study was conducted in three Norwegian ICUs (n = 193). Results: A total of 87% of the CCNs stated that critical care patients were exposed to noise, and the most frequent sources were alarms from monitoring equipment (71%) and mechanical ventilators (70%), and nurses talking (65%). The results demonstrated higher odds for critical care patients needing sedation when sleep was disturbed by noise, if the CCNs reported that noise disturbed patients sleep (OR 3.05), and lower odds if the CCN was from ICU C (OR 0.39). Most CCNs (82%) answered that there was a difference in the level of light during day versus night, and that the most frequent source of light at night was from small lamps (46%). It was higher odds that the CCNs perceived that critical care patients needed sedation when sleep was disturbed by light if the light disturbed the patient’s sleep in the unit (OR 4.78). There were lower odds if the CCNs was from ICU A (OR 0.32) or ICU C (OR 0.34). Conclusion: The findings from this study indicate that CCNs use sedatives to induce sleep for critical care patients to compensate for environmental factors such as noise and light. Variations between ICUs indicate different sedation practices between Norwegian ICUs.

Updated sedative basics guide: everything you need to know about sedatives in clinical practice

Background: As interventional procedures become more common in clinical practice, sedatives are being increasingly used to enhance patient experience, overall safety, and procedural efficacy. An appropriate sedation depth, which is crucial for patient safety, is determined according to sedative dosage, procedural stimuli, and patient status. Thus, it is important that clinicians understand the continuous nature of sedation levels.Current Concepts: Although sedation offers benefits, it also carries risks. Thus, vigilant monitoring during and after a procedure is important for preventing excessive sedation depth and related complications. Combining sedatives with analgesics, including opioids, often has a synergistic effect that necessitates a dosage reduction. Interdisciplinary guidelines for moderate sedation were recently developed to address expanding procedural scopes and patient population diversity.Discussion and Conclusion: To ensure sedation safety and success in new procedures, healthcare providers should refer to relevant studies. In cases with limited evidence, sedative dosages should be determined based on their pharmacological characteristics.

Prevention of peri-interventional hypothermia during endoscopic retrograde cholangiopancreatography using a forced-air heating system.

Background and study aims Perioperative hypothermia is associated with significant complications and can be prevented with forced-air heating systems (FAHS). Whether hypothermia occurs during prolonged endoscopic sedation is unclear and prevention measures are not addressed in endoscopic sedation guidelines. We hypothesized that hypothermia also occurs in a significant proportion of patients undergoing endoscopic interventions associated with longer sedation times such as endoscopic retrograde cholangiopancreaticography (ERCP), and that FAHS may prevent it. Patients and methods In this observational study, each patient received two consecutive ERCPs, the first ERCP following current standard of care without FAHS (SOC group) and a consecutive ERCP with FAHS (FAHS group). The primary endpoint was maximum body temperature difference during sedation. Results Twenty-four patients were included. Median (interquartile range) maximum body temperature difference was -0.9°C (-1.2; -0.4) in the SOC and -0.1°C (-0.2; 0) in the FAHS group ( P < 0.001). Median body temperature was lower in the SOC compared with the FAHS group after 20, 30, 40, and 50 minutes of sedation. A reduction in body temperature of > 1°C ( P < 0.001) and a reduction below 36°C ( P = 0.01) occurred more often in the SOC than in the FAHS group. FAHS was independently associated with reduced risk of hypothermia ( P = 0.006). More patients experienced freezing in the SOC group ( P = 0.004). Hemodynmaic and respiratory stability were comparable in both groups. Conclusions Hypothermia occurred in the majority of patients undergoing prolonged endoscopic sedation without active temperature control. FAHS was associated with higher temperature stability during sedation and better patient comfort.

Early processed electroencephalography for the monitoring of deeply sedated mechanically ventilated critically ill patients.

Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative-induced delirium. Whether processed electroencephalography (p-EEG) is useful in this setting is unclear. We conducted a single-centre observational study of non-neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between -5 and -4) during the acute phase of respiratory and/or cardio-circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19-91] vs. 47% [12.2-78.9]) in non-delirious patients (p .047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001-1.027, p = .036). A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI-targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation. Patients requiring deep sedation are at high risk of being over-sedated and developing delirium despite the application of an evidence-based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients.

Korean clinical practice guidelines for diagnostic and procedural sedation.

Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.

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.

Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity?

BackgroundProcedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult. DiscussionSuch requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, “ketofol,” etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, “ketofol,” and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure. ConclusionThere is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.

Clinical practice guidelines for diagnostic and procedural sedation

The American Dental Association states that the administration of local anesthesia, sedation and generalanesthesia is an integral part of dental practice. It is significant that the American Dental Association definessedation as well as local anesthesia as an integral part of dental practice. A new sedation guideline was published in Korea in 2022. This guideline has been published to help both anesthesiologists and non-anesthesiologists provide safe and effective moderate sedation to patients consistently, without limitation, at any medical institu-tion. This guideline was developed with a focus on moderate sedation before, during, and after examinations or procedures for diagnostic and therapeutic purposes. Considering that there is a possibility of transition from moderate to deep sedation depending on the drug administered and the characteristics of each patient, the guideline also includes items for monitoring and coping with complications that may occur due to cardiovascular and respiratory depression. It consists of recommendations for a total of 15 PICO (participants, intervention, comparator, outcome) questions. Individual items covered include education on sedation providers, requirements for supplying drugs and equipment for sedation, selection of appropriate patients, referral to an anesthesiologist when performing sedation for high-risk patients, fasting before sedation, and typical use in adults and children. Comparison of drugs, monitoring of respiratory system, cardiovascular system, depth of sedation during sedation, measures to cope with respiratory complications during sedation in children, and discharge criteria after sedation are included.

To Create or Not to Create: How to Establish a System-Wide Proportionate Palliative Sedation Guideline Through Comprehensive Interdisciplinary Collaboration (TH108A)

To Create or Not to Create: How to Establish a System-Wide Proportionate Palliative Sedation Guideline Through Comprehensive Interdisciplinary Collaboration (TH108A)

Cognitive impairment and behavioural emergencies within the acute hospital setting

BackgroundPatients with cognitive impairment exhibiting agitation and aggression are challenging to manage in the acute hospital setting. When a patient’s behaviours place themselves or others at risk of harm, a...

Adherence to guidelines in patients with non-variceal upper gastrointestinal bleeding (UGIB) – results from a retrospective single tertiary center registry

Background Guidelines for the management of upper gastrointestinal bleeding (UGIB) are regularly published, yet little is known concerning adherence to recommendations in practice. Objectives We aimed to assess adherence to European Society of Gastrointestinal Endoscopy (ESGE) recommendations in patients with non-variceal UGIB. Materials and methods All hospitalized patients with an esophagogastroduodenoscopy (EGD) performed due to suspected non-variceal UGIB at our department were included in a prospective registry. Data between 2018–2020 from this registry were retrospectively analyzed. Adherence to the 2015 ESGE bleeding and propofol sedation guidelines was assessed. Adherence to recommendations concerning preendoscopic (risk) evaluation, preendoscopic PPI, transfusion management, and endoscopic management of peptic ulcers was analyzed. Results Among 1005 patients (mean age 70.4 years, 42.1% women) the most common bleeding etiologies were gastric or duodenal ulcers (16.8%), esophagitis/GERD (11.1%), and angiodysplasia (9.9%); mortality was 7.6%. Adherence to preendosopic risk evaluation was low, in 0% a Mallampati classification and in 37.5% an ASA scoring was documented. Preendoscopic PPI was started at 58.6%, and adherence to recommended transfusion management was >98%. Peptic ulcers were Forrest-graded in 72.8%. High-risk ulcers were treated appropriately in 77.9% and low-risk ulcers were not treated in 73.6%. Especially Forrest Ib ulcers were undertreated, with an adherence of 59.6%. Only 22/179 (12.3%) patients with peptic ulcers and early endoscopy were consistently managed according to ESGE recommendations. Conclusions Adherence to ESGE guidelines in patients with non-variceal UGIB is moderate to low, even at a tertiary university hospital. Strategies must be devised for guidelines to reach patients in everyday practice.

Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy

The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.

Izazovi u proceduralnoj sedaciji i analgeziji

Introduction. There are several definitions given by various anesthesiology professional organizations that explain the term procedural sedation and analgesia (PSA). The International Committee for the Advancement of PSA has defined procedural sedation as the use of anxiolytics, sedatives, hypnotics, analgesics and/or dissociative drugs to alleviate anxiety, pain and/or movement. These agents are used to facilitate the attainment of amnesia or to reduce the consciousness and/or comfort and safety of the patient during diagnostic or therapeutic procedures. The first guidelines for sedation are based on the mandatory signing of informed consent, monitoring and measuring of vital parameters, implementing a fasting regimen before sedation, possessing the skills to establish and maintain the airway, and resuscitation measures. Since PSA is most often used outside the operating room, this type of anesthesia activity is known as NORA (Non-Operating Room Anesthesia Care). Conclusion. Preprocedural evaluation and preparation, periprocedural management, monitoring and care of postprocedural recovery from PSA is similar to those of general or regional anesthesia. In conclusion, a number of logistical and practical difficulties should be noted, such as the availability of medicines and appropriate staff training, as well as the application of global guidelines on PSA.

Sedação paliativa para controle de sofrimento existencial refratário: um fluxograma

Abstract There is little consensus in the literature on how refractory psychological distress, a serious clinical challenge that may occur at end of life, should be managed. This case report focuses on a patient hospitalized at the Hospital de Apoio in Brasília, who required palliative sedation for refractory psychological distress relief and obtained satisfactory symptom control. A flowchart was elaborated based on bibliographic review which included the European guidelines for palliative sedation, a useful tool for clinical cases in palliative care.

A Survey on Procedural Sedation and Analgesia for Pediatric Facial Laceration Repair in Korea

Background Most children with facial lacerations require sedation for primary sutures. However, sedation guidelines for invasive treatment are lacking. This study evaluated the current status of the sedation methods used for pediatric facial laceration repair in Korea. Methods We surveyed one resident in each included plastic surgery training hospital using face-to-face interviews or e-mail correspondence. The health care center types (secondary or tertiary hospitals), sedation drug types, usage, and dosage, procedure sequence, monitoring methods, drug effects, adverse events, and operator and guardian satisfaction were investigated. Results We included 45/67 hospitals (67%) that used a single drug, ketamine in 31 hospitals and chloral hydrate in 14 hospitals. All health care center used similar sedatives. The most used drug administered was 5 mg/kg intramuscular ketamine (10 hospitals; 32%). The most common chloral hydrate administration approach was oral 50 mg/kg (seven hospitals; 50%). Twenty-two hospitals (71%) using ketamine followed this sequence: administration of sedatives, local anesthesia, primary repair, and imaging work-up. The most common sequence used for chloral hydrate (eight hospitals; 57%) was local anesthesia, administration of sedatives, imaging work-up, and primary repair. All hospitals that used ketamine and seven (50%) of those using chloral hydrate monitored oxygen saturation. Median operator satisfaction differed significantly between ketamine and chloral hydrate (4.0 [interquartile range, 4.0-4.0] vs. 3.0 [interquartile range, 3.0-4.0]; p <0.001). Conclusion The hospitals used various procedural sedation methods for children with facial lacerations. Guidelines that consider the patient's condition and drug characteristics are needed for safe and effective sedation.

Japanese Dental Society of Anesthesiology Celebrates 50 Years.

The Japanese Dental Society of Anesthesiology (JDSA), with ∼2600 members, celebrated its 50th anniversary with a special banquet after its annual scientific session at the Imperial Hotel Tokyo on Sunday, October 30th, hosted by JDSA President, Professor Takehiko Iijima. Professor Emeritus Yuzuro Kaneko gave the celebration address titled “The History of Japanese Dental Anesthesiology.”Dental anesthesiology in Japan began with physician anesthesiologists who saw the need to train dentists to provide anesthesia for dental and oral & maxillofacial surgery. Professor Yasuya Kubota, a physician who later trained as a dentist, opened the first dental anesthesiology department in Japan at Tokyo Medical and Dental University in 1967. Gradually, virtually every dental school opened their own separate department in the 1970s and 1980s, and these departments began dental anesthesiology residency programs. To manage patients who required hospital admission following surgery, dedicated dental hospitals run jointly by dental anesthesiology and oral & maxillofacial surgery emerged with some facilities having dedicated intensive care units for patients requiring intubation following surgery, such as for head and neck cancer surgery and, as was common in the past, orthognathic surgery. Dental anesthesiology was recognized as one of only 5 dental specialties by the Japanese federal government in 2006.The Japanese Board of Dental Anesthesiology (JBDA) was formed to assess competence in anesthesia care in 1977. With time, 2 examinations were developed – Board Certification (1336 dentists) and Specialist Certification (339 dentists). The examination for JDBA board certified dentists occurs after 2 years of dental anesthesiology residency and allows these dentists to provide conscious sedation (as it is referred to in Japan), including the use of propofol to achieve this level of sedation, in private dental offices. Specialist Certification allows for general anesthesia to be administered in dental offices and generally requires an additional 3 years of training. Oral & maxillofacial surgeons may also provide conscious sedation after their residencies. Unlike in the US, conscious sedation guidelines recommend that the sedation dentist does not participate in the surgical procedure. Deep sedation and general anesthesia may only be provided by dentist anesthesiologists dedicated to anesthesia provision as is the case in all other parts of the world other than North America.At the 50th Anniversary Celebration, congratulations were offered by the presidents of the Japanese Society of Dental Sciences, the Japanese Dental Association, the Japanese Society of Anesthesiology, and various elected officials representing several agencies of government. Greetings and congratulations from the ASDA and the ADSA were made by Dr. Steven Ganzberg, who also lectured at the annual scientific session.We applaud the outstanding research and high level of clinical activity by dental anesthesiology in Japan. We in the US are all proud to have Japanese dental anesthesiologists as our colleagues. We wish the JDSA continued success as we celebrate 50 years of dedication to the art and science of dental anesthesiology with them.Respectfully submitted,