Higher Levels Of Sedation Research Articles

Impact of dexmedetomidine-assisted anesthesia in elderly patients undergoing radical resection of colon cancer.

Radical resection of colon cancer under general anesthesia is one of the main treatment methods for this malignancy. However, due to the physiological characteristics of elderly patients, the safety of perioperative anesthesia needs special attention. As an α2-adrenergic receptor agonist, dexmedetomidine (Dex) has attracted much attention from anesthesiologists due to its stabilizing effect on heart rate and blood pressure, inhibitory effect on inflammation, and sedative and analgesic effects. Its application in general anesthesia may have a positive impact on the quality of anesthesia and postoperative recovery in elderly patients undergoing radical resection of colon cancer. To investigate the anesthetic effects of Dex during radical surgery for colon cancer under general anesthesia in elderly patients. A total of 165 colon cancer patients who underwent radical surgery for colon cancer under general anesthesia at Qingdao University Affiliated Haici Hospital, Qingdao, China were recruited and divided into two groups: A and B. In group A, Dex was administered 30 min before surgery, while group B received an equivalent amount of normal saline. The hemodynamic changes, pulmonary compliance, airway pressure, inflammatory factors, confusion assessment method scores, Ramsay Sedation-Agitation Scale scores, and cellular immune function indicators were compared between the two groups. Group A showed less intraoperative hemodynamic fluctuations, better pulmonary compliance, and lower airway resistance compared with group B. Twelve hours after the surgery, the serum levels of TLR-2, TLR-4, IL-6, and TNF-α in group A were significantly lower than those of group B (P < 0.05). After extubation, the Ramsay Sedation-Agitation Scale score of group A patients was significantly higher than that of group B patients, indicating a higher level of sedation. The incidence of delirium was significantly lower in group A than in group B (P < 0.05). The use of Dex as an adjunct to general anesthesia for radical surgery in elderly patients with colon cancer results in better effectiveness of anesthesia.

Randomized single-blinded study comparing sedation effectiveness and hemodynamic stability of remifentanil vs dexmedetomidine infusion for electrophysiology procedures in patients of National Heart Institute cathlab.

While studies comparing the effectiveness of remifentanil and dexmedetomidine are prevalent in other nations, using remifentanil alone is uncommon in Malaysia. This research aims to evaluate the effectiveness of sedation with remifentanil or dexmedetomidine infusion in monitored anesthesia care for electrophysiology procedures. This study is a single-center, single-blinded, prospective randomized clinical study. One hundred twenty patients were randomized into two groups (remifentanil vs dexmedetomidine). Demographic characteristics and clinical outcomes, including level of sedation, vital signs, and patient satisfaction were monitored and recorded. Group R showed a higher mean observer's assessment of alertness/sedation score (3.9 ± 0.7 vs 3.6 ± 0.8; p = 0.008), mean arterial pressure (92.0 ± 12.0 vs 83.0 ± 13.0mmHg; p < 0.001), heart rate (82.0 ± 20.0 vs 73.0 ± 18.0 beats/min; p = 0.006), systolic blood pressure (139.0 ± 16.0 vs 123.0 ± 17.0mmHg; p < 0.001) and diastolic blood pressure (75.0 ± 13.0 vs 69.0 ± 14.0mmHg; p = 0.009) than Group D. Oxygen saturation (99.0 ± 1.0%; p = 0.220) and respiration rate (16.0 ± 3.0 breaths/min; p = 0.361) for both groups were the same. Adverse events, including hypotension, bradycardia, and respiratory depression were observed in both groups. Both groups gave positive responses ranging from fair to good for patient satisfaction. Dexmedetomidine is a better choice of anesthesia as it was associated with a higher level of sedation, more stable hemodynamics, lower incidence of adverse events, and better patient satisfaction.

The anxiolytic effects of preoperative administration of pregabalin in comparison to diazepam and placebo

We aimed to evaluate the potential anxiolytic effects of premedication with pregabalin, compared with diazepam and placebo. We conducted this non-inferiority, double-blind, randomized controlled trial in ASA classification I-II patients aged 18–70 years, scheduled for elective surgery under general anesthesia. They were allocated to receive pregabalin (75 mg the night before surgery and 150 mg 2 h before surgery), diazepam (5 and 10 mg in the same manner) or placebo. Preoperative anxiety was evaluated using verbal numerical rating scale (VNRS) and Amsterdam Preoperative Anxiety and Information Scale (APAIS) before and after premedication. Sleep quality, sedation level, and adverse effects were assessed as secondary outcomes. A total of 231 patients were screened and 224 completed the trial. The mean change (95%CI) in anxiety scores from before to after medication in pregabalin, diazepam, and placebo groups for VNRS were − 0.87 (− 1.43, − 0.30), − 1.17 (− 1.74, − 0.60), and − 0.99 (− 1.56, − 0.41), and for APAIS were − 0.38 (− 1.04, 0.28), − 0.83 (− 1.49, − 0.16), and − 0.27 (− 0.95, 0.40). The difference in change for pregabalin versus diazepam was 0.30 (− 0.50, 1.11) for VNRS and 0.45 (− 0.49, 1.38) for APAIS, exceeding the limit of inferiority for APAIS of 1.3. Sleep quality was statistically different between pregabalin and placebo groups (p = 0.048). Sedation in pregabalin and diazepam groups were significantly higher than placebo group (p = 0.008). No significant differences of other side effects, except dry mouth was higher in placebo group compared with diazepam (p = 0.006). The study filed to provide evidence at non-inferiority of pregabalin compared to diazepam. Furthermore, premedication with either pregabalin or diazepam did not significantly reduce the preoperative anxiety in comparison to placebo, despite the fact that both resulted in higher levels of sedation. Clinicians should weigh the benefits and risks of premedication with these 2 drugs.Thai Clinical Trials Registry: TCTR20190424001 (24/04/2019) Registry URL: https://www.thaiclinicaltrials.org/.

Effect of two different doses of oral midazolam premedication on separation anxiety in children scheduled for herniotomy

Background: Peri-operative separation anxiety in children adversely impacts on their cognitive function and behavioural outcome. The aim of the study was to assess the effect of two different doses of oral midazolam premedication on separation anxiety in paediatric patients scheduled for herniotomy. Methods: Eighty-four eligible children aged 1-6 years, of American Society of Anesthesiologists (ASA) class I or II, scheduled for herniotomy, were randomized into two groups, A and B, of 42 each after ethical clearance and written parental consent. Children in group A and group B received 0.5 mg/kg and 0.75 mg/kg respectively of oral midazolam flavoured with paracetamol syrup, were observed, and later separated from parents at 30 min post-premedication. Premedicant acceptability was noted, and separation anxiety was assessed using the Richmond agitation sedation scale (RASS). Statistical significance was set at p&lt;0.05. Results: All 84 children completed the study. At 30 min post-premedication, 47.6% in group A and 19.1% in group B had light sedation, while 52.4% in group A and 80.9% in group B were moderately sedated, p=0.0001. Premedicant acceptability and agitation scores between the groups were comparable, p&gt;0.05. Conclusions: Oral 0.5 mg/kg and 0.75 mg/kg midazolam induced desirable sedation in children at the 30th min with comparable lower agitation scores; however, the 0.75 mg/kg dose achieved significantly faster onset and higher level of sedation in a greater proportion of the subjects.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

An exploration of patient experience of sleep, physical activity, and exercise in early psychosis

ABSTRACT Background Compared to the general population, people with experience of psychosis have poorer physical fitness, higher levels of sedation, lower levels of physical activity, more sleep problems, and higher incidence of insomnia. Methods Thirty-one early intervention psychosis (EIP) service patients took part in an eight-week intervention: provision of a Fitbit, Fitbit software apps, sleep and physical activity guidance, and three discussion sessions with clinicians. Fifteen participants consented to be interviewed, 9 males and 6 females, age range 19–51, average age 29. In-depth interviews investigating patient experiences of sleep and physical activity were conducted. Thematic analysis was employed. Results Patients using an EIP service experience particular issues, problems, and barriers to engaging in effective and healthy sleep and physical activity/exercise; these can have a negative effect on mental and physical health, wellbeing, recovery, and sociability. Patients used factors such as medication, social support, practical strategies, and motivation enhancement to overcome issues, problems, and barriers. Discussion Healthy effective sleep and physical activity/exercise is important to EIP service patients’ wellbeing and mental and physical health. EIP services should consider and assess sleep and physical activity/exercise issues, and promote healthy effective sleep and physical activity/exercise within recovery focused practice.

Wearable Physical Activity and Sleep Tracker Based Healthy Lifestyle Intervention in Early Intervention Psychosis (EIP) Service: Patient Experiences

Background: Physical activity, sleep, mental health, physical health, wellbeing, quality of life, cognition, and functioning in people who experience psychosis are interconnected factors. People experiencing psychosis are more likely to have low levels of physical activity, high levels of sedation, and sleep problems. Intervention: An eight-week intervention; including the provision of a Fitbit and its software apps, sleep hygiene and physical activity guidance information, as well as three discussion and feedback sessions with a clinician. Participants: Out of a sample of 31 using an early intervention psychosis (EIP) service who took part in the intervention, fifteen participants consented to be interviewed—9 (60%) males and 6 (40%) females, age range: 19 - 51 years, average age: 29 years. Method: In-depth interviews investigating patient experience of the intervention and its impact on sleep, exercise, and wellbeing were undertaken. Thematic analysis was applied to analyse the qualitative data and content analysis was used to analyse questions with a yes/no response. Results: Most of the participants actively used the Fitbit and its software apps to gain information, feedback, and set goals to make changes to their lifestyle and daily routines to improve quality of sleep, level of physical activity, and exercise. Conclusion: The intervention was reported to be beneficial, and it is relatively easy and low cost to implement and therefore could be offered by all EIP services. Furthermore, there is potential value for application in services for other psychiatric disorders, where there is often a need to promote healthy lifestyle, physical activity, and effective sleep.

Zero-Contrast Conscious Sedation Transcatheter Aortic Valve Replacement-Keeping It Safe and Simple.

1.Contrast-free transfemoral transcatheter aortic valve replacement was performed in a case series of 4 patients using a novel technique guided by transthoracic echocardiography under conscious sedation.2.Outcomes including mortality, incidence of cerebrovascular accident, or heart block were comparable with those of the traditional approach while minimizing the risk of renal injury.3.This approach gives the heart team a technically feasible, safe, and effective option to minimize the risk of renal injury, the need for transesophageal echocardiogram, and higher levels of sedation.

Effect of tramadol as a local anesthetic adjuvant in epidural labor analgesia: Randomized controlled study

ABSTRACT Background: Epidural analgesia has been established to be the best modality for painless labor. This study hypothesized to evaluate the effect of adding tramadol as an adjuvant to bupivacaine in epidural labor analgesia. Methods: Sixty parturients were allocated into two equal groups. Group B received a total volume of 10 ml bupivacaine 0.25% in normal saline. Group BT received a total volume of 10 ml bupivacaine 0.25% plus tramadol 5 mg/ml in normal saline as a loading dose, followed by continuous infusion of bupivacaine 0.125% at rate 10 ml/h 15 min after a loading dose for both groups. The onset of analgesia, degree of motor block, sedative effect, hemodynamic parameters, visual analogue scale (VAS), number of top-up doses, fetal outcomes, any related side effects, and maternal satisfaction were recorded. Results: Faster onset of analgesia was achieved in BT group compared to B group (7.9 ± 2.68 vs 15.3 ± 3.3, respectively: P < 0.001). BT group has a longer duration of analgesia (181.1 ± 44.3 min) than B group (89.6 ± 32.6 min) (P < 0.001). VAS was significantly decreased at 10, 15, 60, 120 and 180 min in BT group compared to B group (P < 0.001, < 0.001, 0.001, < 0.001, and 0.006, respectively). Motor block was comparable between both groups. Higher levels of sedation were reached in group BT. Conclusion: Tramadol in epidural labor analgesia as an adjuvant to bupivacaine can provide a better quality of analgesia with faster onset, and prolonged duration with no relevant adverse effects Pan African Clinical Trial registration: (PACTR201804003261749)

Tracheotomy in Ventilated Patients With COVID-19.

Tracheotomy in Ventilated Patients With COVID-19.

Cerebrovascular reactivity is not associated with therapeutic intensity in adult traumatic brain injury: a CENTER-TBI analysis

BackgroundImpaired cerebrovascular reactivity in adult traumatic brain injury (TBI) is known to be associated with poor outcome. However, there has yet to be an analysis of the association between the comprehensively assessed intracranial hypertension therapeutic intensity level (TIL) and cerebrovascular reactivity.MethodsUsing the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived pressure reactivity index (PRx) as the moving correlation coefficient between slow-wave in ICP and mean arterial pressure, updated every minute. Mean daily PRx, and daily % time above PRx of 0 were calculated for the first 7 days of injury and ICU stay. This data was linked with the daily TIL-Intermediate scores, including total and individual treatment sub-scores. Daily mean PRx variable values were compared for each TIL treatment score via mean, standard deviation, and the Mann U test (Bonferroni correction for multiple comparisons). General fixed effects and mixed effects models for total TIL versus PRx were created to display the relation between TIL and cerebrovascular reactivity.ResultsA total of 249 patients with 1230 ICU days of high frequency physiology matched with daily TIL, were assessed. Total TIL was unrelated to daily PRx. Most TIL sub-scores failed to display a significant relationship with the PRx variables. Mild hyperventilation (p < 0.0001), mild hypothermia (p = 0.0001), high levels of sedation for ICP control (p = 0.0001), and use vasopressors for CPP management (p < 0.0001) were found to be associated with only a modest decrease in mean daily PRx or % time with PRx above 0.ConclusionsCerebrovascular reactivity remains relatively independent of intracranial hypertension therapeutic intensity, suggesting inadequacy of current TBI therapies in modulating impaired autoregulation. These findings support the need for investigation into the molecular mechanisms involved, or individualized physiologic targets (ICP, CPP, or Co2) in order to treat dysautoregulation actively.

Physiological and Psychological Determinants of Quality of Life for Patients after Cardiac Surgery and the Associated Factors

Purpose: This review related to the level of health-related quality of life (HRQOL) and post-traumatic stress disorder symptoms (PTSD) for patients after cardiac surgery, and associated risk factors. Also the HRQOL, PTSD measures and the related factor. Methods: The search strategy was guided by the review aims. The following databases were searched to retrieve related literature: the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO, MEDLINE via PubMed, Ovid, Science Direct, Google Scholar, in addition to the Jordanian Database for Nursing Research. Studies presented in English for the period between 2012 and 2019 were included. Literature was reviewed by using the following strategy: The key word “post-operative HRQOL”, “post-operative PTSD”, “prevalence”, “incidence”, “risk factors”, and “cardiac surgery”, with using of Boolean operators “AND”, “OR”, and “NOT” to conduct the search in databases, Then the titles and abstracts were reviewed for their relevancy and irrelevant and duplicated studies were discarded. EBSCO resulted in 180 articles, Ovid 5 articles, and SCIENCE DIRECT 200 articles, articles with the same ideas were sorted, and full text was included in the review. The overall number after sorting was 25 articles that were included in the review. Results: Literature has aggregated the most common risk factors as age, gender, marital status, social support, medical comorbidities, smoking, alcohol use, ICU environment, surgery techniques and physiological indicators, and the most important is preoperative HRQOL level. Also, the researcher highlighted several important points related to PTSD after cardiac surgery. Firstly, PTSD appears to be present in approximately 10% of the post-cardiac surgical population, with some estimates reaching as high as 38%. ICU care, fright at the time of the event, perceived threat to life, high levels of sedation and social isolation may all contribute to this developing PTSD. Patients with PTSD are susceptible to poor outcomes following surgery including greater physical complication, psychological problems, increased morbidity and mortality, affecting the quality of life and well-being. For the purpose of this study, specified risk factors related to PTSD development after cardiac surgery will be studied concerning demographics, social, medical, psychological, and environmental. Conclusion and Recommendation: HRQOL and PTSD is an important indicator to measure the outcome of cardiac surgery on a short and long term. Researchers should be aware of the effect of various related factors that could affect the improvement of this outcome.

Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality.

Aeromedical evacuation platforms such as Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically injured and ill patients in the combat theater. Mechanical ventilation is used to support patients with failing respiratory function and patients requiring high levels of sedation. Mechanical ventilation, if not managed appropriately, can worsen or cause lung injury and contribute to increased morbidity. The purpose of this study was to evaluate the impact of ARDSNet protocol compliance during aeromedical evacuation of ventilated combat injured patients. We performed a retrospective chart review of combat injured patients transported by CCATTs from Afghanistan to Landstuhl Regional Medical Center (LRMC) in Germany between January 2007 and January 2012. After univariate analyses, we performed regression analyses to assess compliance and post-flight outcomes. Cox proportional hazard models were used to evaluate associations between the risk factor of non-compliance with increased number of ventilator, ICU, or hospital days. Nominal logistic regression models were performed to evaluate the association between non-compliance and mortality. Sixty-two percent (n = 669) of 1,086 patients required mechanical ventilation during transport. A total of 650 patients required volume-controlled mechanical ventilation and were included in the analysis. Of the 650 subjects, 62% (n = 400) were non-compliant per tidal volume and ARDSNet table recommendations. The groups were similar in all demographic variables, except the Non-compliant group had a higher Injury Severity Score compared to the Compliant group. Subjects in the Compliant group were less likely to have an incidence of acute respiratory distress, acute respiratory failure, and ventilator-associated pneumonia when combing the variables (2% vs. 7%, p < 0.0069). The Non-compliant group had an increased incidence of in-flight respiratory events, required more days on the ventilator and in the ICU, and had a higher mortality rate. Compliance with the ARDSNet guidelines was associated with a decrease in ventilator days, ICU days, and 30-day mortality. Therapeutic/care management, level IV.

Comparison of Intravenous Dexmedetomidine with Midazolam in Prolonging Spinal Anaesthesia with Ropivacaine

Midazolam and dexmedetomidine both being sedatives, but the latter with additional analgesic properties is expected to prolong the duration of sensory and motor block obtained with spinal anaesthesia. To compare intravenous dexmedetomidine with midazolam and placebo with respect to sensory and motor block duration, analgesia, and sedation in patients undergoing lower limb and lower abdominal surgeries with intrathecal ropivacaine anaesthesia. In this single blind placebo controlled trial, 60 patients, classified as American Society of Anaesthesiologists' (ASA) physical status I-II, were randomized into three groups (n=20 per group). All patients were administered ropivacaine (15 mg) for spinal anaesthesia. Intravenous dexmedetomidine was administered in Group D (1 μg/kg loading dose over 10 minutes, followed by a continuous infusion (0.5 μg/kg/hr), intravenous midazolam was administered in Group M (0.05 mg/kg) loading dose, followed by a continuous infusion (0.02 mg/kg/hr) and normal saline was infused in Group C. Intraoperative haemodynamic changes, onset, level and duration of sensory block, onset and duration of motor block, level of sedation, postoperative analgesia and side effects were recorded. Heart rate was seen to fall significantly in Group D patients for the first 15 minutes. Measurements of mean blood pressure revealed significant decrease in Group D after 40 minutes, whereas the fall in Group C occurred after 15 minutes. Duration of sensory block was significantly longer in Group D patients (208±19.358 mins) as compared to Group M and C where the duration was (177±15.252 mins) and (177±17.800 mins) respectively. Higher levels of sedation were achieved in Group D and M where sedation score was 3 (fully asleep but arousable), 90% cases in Group D and 100% cases in Group M. The time at which first analgesic was given to patients (VAS score 4) was (271.50±21.831) in Group D and (202±25.047) in M and (218.50±38.013) in Group C. Dexmedetomidine significantly prolongs duration of analgesia providing pain relief in intraoperative and postoperative period. Injection of diclofenac sodium 75 mg intramuscular was used as rescue analgesic. The VAS score reached a value of 4 earlier in the midazolam and saline group than dexmedetomidine group. Intravenous dexmedetomidine prolonged spinal anaesthesia, though midazolam did not. It also provided sedation and additional analgesia. Therefore, dexmedetomidine is appropriate during spinal anaesthesia, although heart rate needs to be monitored cautiously.

Safety and Effectiveness of Endoscopist-Directed Nurse-Administered Sedation during Gastric Endoscopic Submucosal Dissection.

Background and Aims Endoscopic submucosal dissection (ESD) is routinely performed in treating gastric neoplasia and requires long-term higher levels of sedation. Endoscopist-directed nurse-administered sedation (EDNAS) has not been well studied in ESD. This study aimed to evaluate the safety and effectiveness of EDNAS for ESD. Methods Patients treated with ESD for gastric tumors between 2013 and 2015 were retrospectively collected. Patients were divided into a midazolam-treated group (M group) and a midazolam plus propofol-treated group (MP group). Clinical outcome, safety, effectiveness, adverse events of ESD, and adverse events of sedation were analyzed. Results Of 209 collected patients, 83 were in the M group and 126 were in the MP group. Of all patients, 67 patients had the circulatory adverse event during the ESD procedure. Sedation method was the only significant risk factor (M versus MP: 2.17 (1.14–4.15), p = 0.019). In analysis of MP subgroups, 47 patients suffered an adverse event from sedation, and current smoking was the only significant association factor for adverse event (0.15 (0.03–0.68), p = 0.014). Conclusions In performing ESD, the effect of sedation is reduced in smoking patients. EDNAS may be acceptable for ESD under careful monitoring of vital sign and oxygen saturation.

Utilizing bi-spectral index (BIS) for the monitoring of sedated adult ICU patients: a systematic review.

The ideal level of sedation in the ICU is an ongoing source of scrutiny. At higher levels of sedation, the current scoring systems are not ideal. BIS may be able to improve both. We evaluated literature on effectiveness of BIS monitoring in sedated mechanically ventilated (MV) ICU patients compared to clinical sedation scores (CSS). For this systematic review, full text articles were searched in OVID, MEDLINE, EMBASE, and Cochrane databases from 1986 - 2014. Additional studies were identified searching bibliographies/abstracts from national/international Critical Care Medicine conferences and references from searched articles retrieved. Search terms were: 'Clinical sedation scale, Bi-spectral Index, Mechanical ventilation, Intensive care Unit'. Included were prospective, randomized and non-randomized studies comparing BIS monitoring with any CSS in MV adult (>18 yr old) ICU patients. Studies were graded for quality of evidence based on bias as established by the GRADE guidelines. Additional sources of bias were examined. There were five studies which met inclusion criteria. All five studies were either unclear or high risk for blinding of participants and blinding of outcome assessment. All papers had at least one source of additional high risk, or unclear/unstated. BIS monitoring in the mechanically ventilated ICU patient may decrease sedative drug dose, recall, and time to wake-up. The studies suggesting this are severely limited methodologically. BIS, when compared to subjective CSSs, is not, at this time, clearly indicated. An appropriately powered randomized, controlled study is needed to determine if this monitoring modality is of use on the ICU.

Comparison of ramelteon with clonidine as an adjuvant to anesthesia: A placebo-controlled, randomized, double-blinded trial

Context: We have evaluated the effect of ramelteon, clonidine, and a placebo on perioperative sedation, anxiety, cognition, and postoperative analgesia in cases of laparoscopic cholecystectomies. Aims: To study the comparative efficacy of ramelteon and clonidine on sedation and in reducing anxiety perioperatively. Settings and Design: Prospective, randomized, double-blinded, placebo-controlled trial. Materials and Methods: Ninety patients undergoing laparoscopic cholecystectomies were randomized into the following three groups; the control group (placebo), the clonidine group, and the ramelteon group. The sedation, anxiety, orientation scores, psychomotor functions, the hemodynamic parameters, and the recall and total analgesic consumption postoperatively for 24 h were assessed. Statistical Analysis Used: Statistical analysis was done with Student's t-test for the quantitative data and Chi-square test for the categorical data. Results: The anxiety scores were significantly lower in both the clonidine group and the ramelteon group in comparison to the placebo group. Higher level of sedation was noted in the clonidine and ramelteon groups compared to the placebo group. Patient satisfaction score was significantly higher in the clonidine group. Analgesic consumption was noted to be significantly less in the clonidine group. Statistically significant reduction in the mean arterial pressure (MAP) and heart rate were observed in the clonidine group. Conclusions: We observed that oral premedication of ramelteon and clonidine resulted in a significant level of sedation and reduction of anxiety score with no significant impairment of the psychomotor functions compared to the placebo. The clonidine group, in addition, showed significant analgesic sparing effect in the first 24 h and reduction in the MAP and heart rate pre- and postoperatively.

Association between ASA grade and complication rate in patients receiving procedural sedation for relocation of dislocated hip prostheses in a UK emergency department

ObjectiveTo determine the association between the American Society of Anesthiologists (ASA) grade and the complication rate of patients receiving procedural sedation for relocation of hip prosthesis in an adult emergency...

You get what you inspect, not what you expect: can we make the transseptal puncture safer?

Progress in the field of catheter ablation for atrial fibrillation has resulted in a renaissance of the technique of transseptal (TS) catheterization. Conventionally, the procedure is performed under fluoroscopic guidance and pressure monitoring. In experienced hands, various modifications of this method have a reasonable safety profile. However, serious complications such as cardiac tamponade (1.31%) or aortic perforation can still occur 1 and can lead to death (0.15%). Even in a more recent, large Italian survey on 5520 TS procedures performed between 1992 and 2003 at 33 centres, some severe complications were reported. 2 Although the complication rate was low (0.79% in 2003 and 0.74% in the previous years), one death was described. To reduce the incidence of such complications, TS puncture can be done under transoesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance. 3,4 Transoesophageal echocardiography in these settings necessitates a higher level of sedation and is often poorly tolerated. Intracardiac echocardiography requires an additional expertise and significantly increases the cost of the procedure. Mitchell-Heggs et al. 5 describe an alternative TEE technique to guide the TS puncture during atrial fibrillation ablation procedures using an ICE catheter introduced transnasally into the oesophagus. This technique was well tolerated and successfully performed in all 79 successive patients without any sedation. Insertion of the catheter was without any mechanical complication and TS puncture was successful and uneventful. The mean duration between the probe insertion and successful TS puncture was 4.5 min and the mean time of ICE in the oesophagus was only 10 min. The authors have concluded that the technique is safe and well tolerated. They recommend it for widespread use, especially due to its good value for money. At first sight, this report may not be so appealing for the electrophysiology community. However, it is an important online imaging strategy which can be used during complex interventions to maximize safety and efficacy. The use of echocardiographic guidance for TS puncture allows direct visualization of the tip of the TS needle within the fossa ovalis and thus, a safe TS puncture in every patient. In this respect, there seems to be no difference between the TEE and ICE approach. Our retrospective analysis of 1692 TS punctures guided by ICE between 2006 and 2009 revealed no complications associated with the puncture (unpublished data). This provides indirect evidence that the use of online imaging may increase the safety of the procedure, especially in anatomical variants of the intraatrial septum that make the procedure challenging (e.g. lipomatous hypertrophy, septal aneurysm, thick septum, or double membrane fossa, etc.). The safety of the echocardiographically guided TS puncture supports the use of a double TS access to prevent interference between the mapping and ablation catheters and to achieve greater mobility and manoeuvrability in the left atrium. It is also important to emphasize that the use of echocardiographic guidance enables selection of the site of the puncture within the fossa ovalis according to the expected type of the procedure (e.g. more anterior puncture for ablation of an accessory pathway at the mitral annulus or for ablation of ventricular tachycardia vs. a lower and more posterior puncture for ablation of atrial fibrillation). Although it is difficult to quantify the benefit of such a selective TS puncture, our experience has shown that even ,1 cm difference in the location of the puncture site can make a significant difference in manoeuvrability of the mapping and/or ablation catheter (Figure 1). This seems to be even more important when using ‘one-size-fits-all’ devices such as a cryoballoon or laser balloon. Today, we use an ICE-guided TS puncture even in cases of a patent foramen ovale since it allows us to optimize puncture in the lower and more posterior portion of the fossa ovalis. A group from Bordeaux has clearly documented that isolation of the pulmonary veins performed via a patent foramen ovale is more difficult, both for the left- and right-sided pulmonary veins. 6 Very superior and anterior location of the foramen ovale changes the radial movement of the catheter entering the left atrium and impedes the manipulation around the pulmonary veins. This results in less accurate positioning of the catheter and its greater instability. Although the authors did not

Oral Medication With Diazepam or Midazolam Associated or Not With Clonidine for Oculoplastic Office Surgery Under Local Anesthesia

To compare the level of sedation of oral administration of diazepam or midazolam associated or not with clonidine and their effects on upper eyelid margin position, heart rate, arterial pressure, and oxygen saturation. Seventy consecutive healthy patients American Society of Anesthesiologists (ASA) grade I-II scheduled for lower eyelid blepharoplasty were randomized into 4 groups according to the oral sedative agent used (group 1, diazepam 10 mg; group 2, diazepam 10 mg plus clonidine 0.15 mg; group 3, midazolam 15 mg; group 4, midazolam plus clonidine 0.15 mg). For all patients, the midpupil-to-upper eyelid margin distance, the heart rate, systolic and diastolic blood pressure, and oxygen saturation were recorded before and 1 hour after the administration of oral medication. The level of sedation at the time of surgery was measured with the Michigan University scale. The depth of sedation was significantly more pronounced with midazolam (median score = 2) than with diazepam (median score = 1). Clonidine slightly increased the level of sedation of both diazepam and midazolam. The diastolic arterial blood pressure drop with midazolam associated or not with clonidine was significantly greater than with diazepam. The mean upper eyelid margin position shift (-1.42 mm) verified when clonidine was associated with midazolam was also significantly greater than with diazepam. Oral sedation with diazepam or midazolam associated or not with clonidine is safe for ASA grade I-II patients. The systemic effects of diazepam and midazolam were small and very similar. The sedation induced by midazolam was clearly greater than that induced by diazepam. However, this higher level of sedation was accompanied by a more important shift in upper eyelid margin position.