Sedation Research Articles

Clinical Experience and Video Description of Minimally Invasive Surgery for Benign Prostatic Obstruction using the Schelin Catheter®.

Although designed for in-office use, water vapor thermal therapy (RezumTM) remains a painful procedure, and oral ± intravenous sedation is often required. Schelin Catheter® (ProstaLund AB, Lund, Sweden) is an innovative bladder catheter that delivers local anesthesia to the prostate in a sterile transurethral way. We aimed to evaluate the safety and feasibility of RezumTM for male lower urinary tract symptoms due to benign prostatic obstruction (LUTS/BPO) with local anesthesia delivered with Schelin® catheter, and to report its first step-by-step video description. A total of 15 patients were enrolled, and 14 analyzed. Median pain numeric rating scale at catheter insertion, anesthetic injection, RezumTM insertion, RezumTM treatment, and at 2-h post-operatively were 3(2-5), 3(2-5), 1(0-3), 3.5(2-6), and 0(0), respectively. In 1 patient local anesthesia protocol failed and intravenous sedation was used. All RezumTM therapies were performed successfully. Local anesthesia with Schelin® catheter opens up new possibilities for ultra-minimally invasive surgery for LUTS/BPO.

The reality of bronchoscopy care in Germany: a survey by the German Respiratory Society

In September 2022, sites where bronchoscopy was carried out were systematically surveyed regarding structural and process quality features in an anonymized DGP survey with 33 questions. The data collected were analyzed descriptively. Of the 196 participating sites, bronchoscopies were performed regularly at 180 sites. The majority were standard secondary care (n=51) and tertiary care (n=43) hospitals (range of services: diagnostic bronchoscopy, predominantly (80%) including endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA). Extended treatment options were guaranteed for acute cases at >90% of these locations. University hospitals (n=24) and specialist pulmonary hospitals (n=35) also offered more complex diagnostic procedures and therapeutic-interventional techniques. The performance figures were significantly higher in the specialist pulmonary hospital (specialist pulmonary hospitals: 62%: >2000 bronchoscopies/year; university hospitals: 25%: >2000 bronchoscopies/year; p<0.001). In the practice setting (n=21, partly in co-operation with hospitals) , <500 bronchoscopies/year were performed.Intensive care units were available in 97% of the hospitals; 88% of the hospitals had fluoroscopy facilities in the bronchoscopy room. Propofol (91%) and/or midazolam (62%) were the preferred drugs for sedation. At 21% of the sites, >200 bronchoscopies under ventilation/year were performed. BAL and transbronchial forceps biopsies were mainly performed via the nasal or oral approach, EBUS-TBNA via a bronchoscopy tube or the oral approach, the EBUS mini-probe/navigation, cryotechnique or more complex interventions via the rigid tube or a bronchoscopy tube. ASA >2 led to involvement of a second physician at 46% of clinical sites, at 47% of sites at an ASA classification >3. The majority of bronchoscopic examinations are performed in respiratory departments at secondary care centres as well as maximum care hospitals. For more complex procedures, cooperation with hospitals specialized in bronchoscopy (e.g. university hospital or a specialist lung clinic) is advisable.

MiRNA Expression: I/R Cardiomyocyte and Sevoflurane

Background: The effects of anesthetic drugs on myocardial cells have been a subject of research for the last 50 years. The clinical benefits of halogenated agents, particularly sevoflurane, have been demonstrated in cardiac surgery patients. These benefits are due to the action of different enzymes and a variety of molecular pathways mediated by the action of small noncoding RNAs (sRNA) such as microRNAs (miRNAs). However, the modulation potential induced by anesthetic drugs on the miRNA expression and their cardioprotective effects is unknown. Objective: To analyze the variation in the expression of a panel of miRNAs induced by halogenated agents to identify their cardioprotective effects. Aims: Variations in the expression of specific miRNAs induce the potential cardioprotective effects of halogenated agents. Methods: An ischemia/reperfusion (I/R) in vitro model of primary human cardiac myocytes (HCMs) was performed. Four study groups were performed: control group (standard culture conditions), I/R group (without hypnotic drugs exposition), I/R-propofol group (I/R-P), and I/R-sevoflurane group (I/R-S). The secretion of p53 and Akt1 cytokines was quantified in the different cell study groups using an Enzyme-Linked ImmunoSorbent Assay, and the differentially expressed miRNAs were identified carrying out a complete genomic sequencing using the Next Generation Sequencing (NGS). Results: HCMs subjected to the I/R procedure and exposed to sevoflurane showed lower secretion levels of p53 factor and higher levels of Akt-1 cytokine compared to HCMs exposed to propofol (p53: I/R-S: 10.43 ± 0.91 ng/mL; I/R-P: 137.92 ± 7.53 ng/mL; p &gt; 0.05); (Akt1: I/R-S: 0.62 ± 0.12 ng/mL; I/R-P: 0.23 ± 0.05 ng/mL; p &gt; 0.05). The miRNA gene expression analysis (NGS) showed significantly increased expression of the hsa-miR-140-5p and hsa-miR-455-5p, both miRNAs associated with cardiac function; the hsa-miR-98-5p and hsa-miR-193a-5p, both related to apoptosis inhibition; and the hsa-let-7d-5p associated with myocardial protection. This increase was observed in the HCMs group exposed to sevoflurane in comparison to the propofol group. Conclusions: Sevoflurane-induced miRNAs overexpression confers cardioprotection through various mechanisms at the DNA level and the different signaling pathways levels, such as Akt/ERK.

Molecular displacement approach for the electrochemical detection of protein-bound propofol

Propofol is one of the principal drugs used for the sedation of patients undergoing mechanical ventilation in intensive care units. The correct dosage of such sedative drugs is highly important, but current methods of determining infusion rates are limited and there is a lack of suitable methods for directly determining patient blood propofol concentrations. A significant challenge for the development of propofol sensors is that propofol demonstrates very high protein binding, leading to a low free fraction in blood. Here we present a method for improving the efficacy of an electrochemical propofol sensor by increasing the free fraction via a molecular displacement approach. When used in conjunction with a carbon nanotube/graphene oxide/iron oxide nanoparticle functionalised screen-printed electrode, it was found that this approach dramatically improved the sensor's sensitivity towards propofol. Ibuprofen was found to be the most effective displacement agent, with an optimal concentration of 30 mM. The resultant sensitivity was 2.82 nA/μg/ml/mm2 with a coefficient of variation of 0.07, and the limit of detection was 0.2 μg/ml. This approach demonstrates high specificity towards drugs commonly administered to intensive care patients.

Guideline on the Use of Intravenous Ketamine for Procedural Sedation in the Children's Emergency Department: A Quality Improvement Project.

In pediatric emergency medicine, sedation is crucial for performing some therapeutic procedures in children. Ketamine is still not widely used, despite being the preferred agent due to its effectiveness and safety profile. Implementing a guideline for intravenous ketamine in emergencies requiring procedural sedation in children, as well as training and evaluating staff competencies in performing this procedure, are the aims of this study. Senior and mid-level physicians, including pediatric nurses working in the children's emergency department (ED), have easy access to this concise repository for carrying out this procedure safely and effectively. The main objective was to implement a policy (guideline) for sedation in the children's ED. The secondary objectives were to determine whether the introduction of this policy increased the overall satisfaction rating of procedural sedation as a service offered in the Trust, to close skillgaps among staff through targeted training, and to assess the degree of recommendation for this ongoing standard of practice, in line with the current best evidence. A retrospective review of pediatric sedation cases with fractures in the children's ED of Buckinghamshire Healthcare National Health Service (NHS) Trust was conducted between June 2022 and August 2023. Surveys were sent out to assess attitudes, sedation skills, and compliance with the Royal College of Emergency Medicine (RCEM) guidelines. A policy for pediatric sedation with intravenous ketamine was later created and put into effect. Pre- and post-intervention data were compared to assess changes in sedation competency, compliance, and confidence. Out of the 103 pediatric fracture cases reviewed, 16 were identified as needing reduction upon initial evaluation, based on the child's condition at presentation. However, only one (6%) was treated with ketamine sedation in the children's ED, whereas nine cases (56%) were reduced under general anesthesia. The remainder was treated with varying use of nitrous oxide gas (Entonox) and diamorphine. Significant progress had been made after a clinical guideline for intravenous ketamine-assisted sedation in children was put into practice. Physicians reported improved knowledge of sedation techniques, knowledge of airway control, and safety in administering ketamine sedation. The percentage of respondents supporting the guidelines increased from 61% before the intervention (nValue=11) to 94% after (nValue​=17), using various metrics. These results demonstrated how well evidence-based policies and training can improve performance, competence, and safety. The use of procedural sedation in the children's EDincreased and the need for general anesthesia was significantly reduced after a uniform pediatric ketamine sedation policy was implemented. Targeted training to address skillgaps increased employee confidence and adherence to best practices.

Effectiveness of acupuncture treatment in post-stroke depression and anxiety disorders: a prospective, randomized, controlled, single-blind study.

Our aim was to examine the effectiveness of acupuncture in post-stroke depression/anxiety disorders and to determine whether it reduces the need for anxiolytic and sedative drug use. This study included 54 stroke patients with depression and/or anxiety disorder. Patients were randomly assigned to the acupuncture treatment group (n = 27) or the control group (n = 27). A conventional rehabilitation program was applied to all patients and acupuncture was performed twice a week for 4 weeks. Patients were evaluated blindly by a psychiatrist at baseline (week 0), week 4 and week 8, using the Hamilton depression rating scale (HAM-D) and Hamilton anxiety rating scale (HAM-A), and drug doses were adjusted when necessary. The HAM-D and HAM-A scores at week 4 were pre-specified as the two primary outcome measures. Within each group, there was a significant decrease in the mean scores of HAM-D and HAM-A at weeks 4 and 8. No between-group differences in HAM-A or HAM-D scores were seen at 4 weeks but there was a significant decrease in HAM-D scores in favor of the acupuncture group at week 8 (p < 0.025). At week 4, the number of cases whose selective serotonin reuptake inhibitor (SSRI) dose was increased was found to be significantly higher in the control group. While the study was negative with respect to its primary outcomes, the findings with respect to certain secondary outcomes suggests further research is warranted to determine if acupuncture treatment is an effective/safe treatment to alleviate post-stroke depression/anxiety. NCT04283591 (ClinicalTrials.gov).

The potency-ratio of ciprofol and propofol under procedural sedation and anesthesia for outpatient hysteroscopy during cervical dilation: a study using up-and-down sequential allocation method.

Ciprofol(HSK3486) is a novel 2,6-disubstituted phenol derivate, a short-acting intravenous sedative, which has similar efficacy characteristics as propofol with less incidence of side effect. Both ciprofol and propofol are often used in outpatient hysteroscopic surgery for sedation. However, the relative potency of these two drugs has not been fully determined in this context. Our study aimed to investigate the potency-ratio of ciprofol and propofol under procedural sedation and anesthesia in restraining reaction of outpatient hysteroscopy dilatation. The ED50 (effective dose in 50% of subjects) value for ciprofol and propofol were calculated by Up-and-Down Sequential Allocation Method. 60 healthy patients undergoing daytime hysteroscopy were randomly divided into two groups, which were intravenously injected with ciprofol at an initial dose of 0.4mg/kg (group C) or propofol at an initial dose of 2mg/kg (group P) at 2min after intravenous injection of sufentanil 0.15ug/kg. A successful response is defined as the absence of patient movement in the case of cervical dilation. Conversely, the presence of patient movement is defined as failure. After successful or failed responses, each follow-up patient in the corresponding group was reduced or increased with propofol 0.5mg/kg or ciprofol 0.1mg/kg, respectively. The estimated ED50 value for ciprofol and propofol in restraining reaction of hysteroscopy dilatation was 0.444mg/kg (95% CI, 0.385-0.503mg/kg) and 1.985mg/kg (95% CI, 1.801-2.170mg/kg), respectively. The incidence of respiratory depression, hypoxemia and injection pain in ciprofol was significantly lower than those in propofol. The ED50 of ciprofol and propofol in preventing hysteroscopy dilatation reaction was 0.444mg/kg (95% CI, 0.385-0.503mg/kg) and 1.985mg/kg (95% CI, 1.801-2.170mg/kg) for outpatient hysteroscopy. The potency-ratio of ciprofol and propofol observed in our study was 1.0:4.5(95%CI,1:3.9-1:5.1). The study was registered at Chinese Clinical Trial Registry http//www.chictr.org.cn/ (Registration date19/11/22 Trial ID ChiCTR2200065954).

Safety and efficacy of remimazolam tosilate for general anaesthesia in paediatric patients undergoing elective surgery: a multicentre, randomised, single-blind, controlled trial.

Remimazolam is an ultra-short-acting benzodiazepine sedative drug. This study aimed to compare the efficacy and safety of remimazolam with propofol for induction and maintenance of general anaesthesia in children undergoing elective surgery. Children (aged 3-6 y, ASA physical status 1 or 2, BMI 14-25 kg.m-2) undergoing elective surgery under general anaesthesia with tracheal intubation were eligible for inclusion. Children were allocated randomly using a web-based system to receive either remimazolam or propofol in a 3:1 ratio. After receiving fentanyl 3 μg.kg-1, children received their allocated drug for both induction and maintenance of general anaesthesia. Induction doses were remimazolam 0.3 mg.kg-1 or propofol 2.5 mg.kg-1, with a second dose given should they not achieve loss of consciousness. After neuromuscular blockade and tracheal intubation, maintenance anaesthesia was achieved with an infusion either remimazolam 1-3 mg.kg-1.h-1 or propofol 4-12 mg.kg-1.h-1, alongside a remifentanil infusion (0.1-0.5 μg.kg-1.min-1) titrated to surgical stimulus and haemodynamic parameters. Primary outcomes were the incidence of successful induction and maintenance of anaesthesia. Secondary outcomes included: time to loss of consciousness, awakening and tracheal extubation; incidence of emergence delirium and moderate or severe pain in post-anaesthesia care unit; incidence of negative behaviour change after surgery at postoperative day 3; and incidence of adverse events. A total of 187 children were analysed (140 allocated to remimazolam and 47 to propofol). All children achieved successful induction of anaesthesia. Successful maintenance of anaesthesia was achieved in 139 (99%) children who received remimazolam compared with 46 (98%) who received propofol (rate difference 1.4%, 95%CI -2.9-5.8%, p = 0.441). Adverse events occurred in 27 (19%) children who received remimazolam and 23 (49%) who received propofol. Remimazolam was well tolerated for the induction and maintenance of general anaesthesia in pre-school-age children and was non-inferior to propofol.

Comparison of remimazolam and propofol on postoperative subjective quality of recovery in patients undergoing general anesthesia: a meta-analysis of randomized controlled trials.

Remimazolam, a recently approved drug for surgical sedation and general anesthesia, has been compared with propofol in previous studies regarding its efficacy as a general anesthetic. However, the question of whether remimazolam demonstrates non-inferiority to propofol in postoperative subjective quality of recovery (QoR) among patients under general anesthesia has not been definitively answered. PubMed, Embase, and Cochrane Library databases were systematically searched for all published randomized controlled trials (RCTs) comparing the efficacy of remimazolam and propofol. The primary outcome assessed was the quality of recovery (QoR-15, QoR-40) on postoperative days (POD) 1-3. Secondary outcomes included the duration until consciousness recovery, extubation time, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay. The analysis involved 10 RCTs with a total of 1077 patients. Remimazolam showed comparable QoR scores to propofol on POD1 (nine trials, standardized mean difference [SMD]: 0.14, 95% confidence interval [CI]: -0.15 to 0.44, P=0.34), POD 2 (two trials, SMD: 0.09, 95% CI: -0.18 to 0.36, P=0.5), and POD 3 (four trials, SMD: 0.17, 95% CI: -0.51 to 0.85, P=0.62). Subgroup and sensitivity analyses confirmed the robustness of these findings. Furthermore, no significant differences were observed in recovery time for consciousness, extubation duration, incidence of PONV, or length of hospital stay between the remimazolam and propofol groups. Remimazolam is similar to propofol in terms of postoperative subjective QoR for patients receiving general anesthesia.

Sleep Problems and Quality of Life in Children with Epilepsy Without Neurodevelopmental Disorders.

Background/Objectives: Sleep problems affect the quality of life (QoL) and treatment prognosis of children with epilepsy (CWE). We analyzed sleep problems and QoL in CWE but without neurodevelopmental disorders, which affect sleep and QoL. We also examined discrepancies between child self-reports and parent proxy reports in QoL assessments. Methods: Thirty-two CWE in grades 2-6 (aged 7-12 years) in regular classes who attended Osaka Metropolitan University Hospital and PL General Hospital between January 2022 and August 2023 were compared with 21 children who had attended the hospitals for acute non-neurological disorders and had recovered (control group). Children with neurodevelopmental disorders, those unable to answer questionnaires, and those taking sleeping pills were excluded. Children in both groups completed the Kinder Lebensqualität Fragebogen (KINDL-R); their parents completed the KINDL-R and Japanese Sleep Questionnaire for Elementary Schoolers (JSQ-ES). Results: There were no significant differences in mean (±SD) JSQ-ES total scores between the epilepsy and control groups (71.6 ± 21.4 vs. 63.2 ± 15.2, respectively; p = 0.16). In the epilepsy group, there were no significant differences in total or subscale KINDL-R scores between children with (JSQ-ES ≥ 80) and without (JSQ-ES < 80) sleep problems. Correlation coefficients between child self-reports and parent proxy reports for KINDL-R total scores were 0.171 (p = 0.348) and 0.656 (p = 0.001) for the epilepsy and control groups, respectively. There was a significant difference between the total scores of children's self-reports and parents' proxy reports in the control (p = 0.008) group, but not in the epilepsy group (p = 0.837). Conclusions: Sleep problems may not have significant impacts on the QoL of CWE without neurodevelopmental disorders. Parents of CWE do not always correctly assess their children's QoL, so it is important to ask both children and their parents to obtain a comprehensive picture of their QoL.

Dual Au/Ag Catalyzed Regiospecific Intramolecular Hydroacyloxylation and Hydroalkoxylation of Unactivated Geminal-Substituted Olefins.

A mild, regiospecific Gold-Silver bimetallic catalytic system has been devised for the intramolecular hydroacyloxylation and hydroetherification of alkenoic acids and alcohols. This method exhibits precise specificity for the geminal substituted olefinic center and facilitates the synthesis of substituted phthalide and hydroisocoumarin derivatives. This method has been effectively applied for late-state functionalization to produce bioactive natural products such as rumphellaone A, mycophenolate, and (-)-ambrox. The successful gram-scale synthesis of the anticonvulsant, hypnotic drug (±)-ethyl phenyl butyro lactone (EPBL), (±)-Boivinianin A and the ability to synthesize challenging spiro and bicyclic lactone underscores the synthetic potential of this methodology. Mechanistic insights into gold-silver catalyzed lactonization of olefins have also been discussed.

Portable Miniaturized IoT-Enabled Point-of-Care Device for Electrochemical Sensing of Zopiclone in Cocktails.

This study proposes a portable and IoT-based electrochemical point-of-care sensing device for detecting zopiclone in cocktails. The system utilizes an electrochemical laccase biosensor and a potentiostat, offering a low-cost and portable device for detecting this sedative drug in cocktails. The sensor characterization experiments demonstrated the linear behavior of the oxidation and reduction currents for each of the targeted concentrations of zopiclone, enabling their detection and quantification even when mixed with an interfering substance. The proposed system could be used for the in situ analysis of cocktails, providing a valuable tool for monitoring the presence of hypnotic drugs in various social and clinical settings. The study utilized materials and reagents, including zopiclone, lab-made lemon juice, lab-made tequila, and lab-made triple sec, all prepared with reactants obtained in Bogotá, Colombia. The potentiostat used in the system was designed to manage cyclic voltammetry measurements. The electrochemical cells' durability and longevity were also tested and characterized, with all electrodes undergoing 200 tests and their performance degradation varying according to the molecule used. The study concludes that the proposed system offers a valuable tool for detecting and monitoring pharmaceutical substances in various interfering ingredients that build up cocktails. Further research and application of this system can help address the global concern surrounding the administration of hypnotic substances to unknowing consumers through food or drinks to enable robbery and sexual assault.

The efficacy of P0.1-guided sedation protocol in critically ill patients receiving invasive mechanical ventilation: A randomized controlled trial

Background: Mechanical ventilation is a lifesaving treatment in patients with acute respiratory failure. Despite optimal support, some patients still exhibit excessive respiratory drive, leading to patient self-inflicted lung injury (P-SILI) and diaphragmatic dysfunction. Sedation and muscle relaxants are commonly used to reduce respiratory efforts and manage patient-ventilator asynchrony (PVA). Conventionally, sedative drugs are adjusted based on the sedation level assessed by the Richmond Agitation-Sedation Scale (RASS), which may not correlate with the patient’s respiratory drive. Drop in airway pressure at the first 100 milliseconds of the beginning of the inspiration after the end-expiratory occlusion (P0.1) is a simple and reliable method of respiratory drive monitoring by mechanical ventilation at the bedside and may be the more suitable sedation target. Objectives: To assess the efficacy of a sedation protocol targeting optimal P0.1 and RASS score compared to conventional sedation strategy in patients requiring invasive mechanical ventilation in the medical intensive care units in terms of successful extubation. Methods: This is an open-labeled, single-center, randomized controlled trial conducted in medical intensive care units at a tertiary care hospital in Bangkok, Thailand. We randomly allocated mechanically ventilated patients in a 1:1 ratio to receive a sedation protocol targeting both optimal respiratory drive measured by P0.1 (intervention group) and light sedation (RASS 0 to -2) or standard of care (control group targeting RASS alone). The primary outcome is the rate of successful extubation within 14 days after randomization. Hypothesis: We hypothesize that sedation protocol targeting optimal P0.1 and light sedation will increase the rate of successful extubation at 14 days in mechanically ventilated patients compared to conventional sedation strategy. Conclusions: This study aims to evaluate the efficacy of a sedation protocol using P0.1 measurement to monitor and target optimal respiratory drive, in conjunction with sedation scores, in critically ill patients receiving invasive mechanical ventilation. Ethics and dissemination: This study protocol was approved by the Human Research Protection Unit of the Faculty of Medicine, Siriraj Hospital, Mahidol University (Certificate of Approval no. Si 915/2023). Trial registration: NCT06203405

Local anesthesia in 23-gauge vitreoretinal surgery: A comparison of efficacy between retrobulbar and sub-Tenon’s injection

This study aimed to compare sub-Tenon&amp;rsquo;s and retrobulbar blocks during vitreoretinal surgery in terms of postoperative pain and surgeon experience. This prospective study included 53 patients scheduled for 23-gauge pars plana vitrectomy under local anesthesia. Patients were nonrandomly assigned to receive a xylocaine injection through either the transconjunctival sub-Tenon&amp;rsquo;s or retrobulbar routes, supplemented with intravenous (IV) sedation (midazolam + fentanyl). A sharp needle was used for both techniques. In the sub-Tenon&amp;rsquo;s group, anesthetic injection was initiated through subconjunctival administration after prepping and draping. Pain was assessed immediately postsurgery and the following day using a standardized questionnaire. Patient and surgeon satisfaction levels, along with complications in each group, were recorded. Of the 53 patients, 42 (79%) received the sub-Tenon&amp;rsquo;s block and 11 (21%) received the retrobulbar block. No statistically significant differences in pain scores, patient satisfaction, or surgeon satisfaction were found between the groups. Postoperative pain and surgeon satisfaction were negatively correlated in both groups (B = &amp;minus;0.465; P &lt; 0.001), and a moderate-to-high correlation was observed between patient and surgeon satisfaction (B = 0.686; P &lt; 0.001). Overall, sub-Tenon&amp;rsquo;s and retrobulbar blocks showed comparable effectiveness in terms of postoperative pain and patient and surgeon satisfaction in vitreoretinal surgery, with no significant differences in outcomes or complication rates.

Dexmedotomidina

Procedural sedation is often required in paediatrics to execute diagnostic procedures. There are many sedative drugs that may be used, but all of them carry not negligible side effect risks and may not be easy to manage. The use of dexmedetomidine has increased in the last few years because of its sedation efficacy in painless procedures. Paediatricians should know the use of dexmedetomidine because of its sensational safety profile even in neonates, its administration route versatility, its neuroprotective properties and its in-home palliative care role in children with otherwise untreatable sleep disorders. This article summarizes the main characteristics of dexmedetomidine, its use, strengths and weaknesses.

Protocol for Comparing Benzodiazepine-Ketamine and Benzodiazepine-Fentanyl Sedation in Phacoemulsification (BEKEF): A Double-Blind Crossover Non-Inferiority Clinical Trial Study.

Cataract surgery, particularly phacoemulsification, often requires sedation alongside topical anesthesia to manage patient anxiety and discomfort. This protocol proposes a study comparing the efficacy of ketamine and fentanyl, both combined with benzodiazepine, as sedation options for patients undergoing bilateral phacoemulsification. In a randomized, double-blind, crossover clinical trial, at least 48 patients scheduled for bilateral cataract surgery will receive fentanyl with midazolam for one eye and ketamine with midazolam for the other. Sedation levels will be assessed using the Ramsay Sedation Scale, and the SURG-TLX Scale will measure intraoperative difficulties. Secondary outcomes include anesthesia-related complications, pain scores, and patient satisfaction. The primary outcomes, utilizing the Ramsay Sedation Scale, will determine if ketamine combined with a benzodiazepine is non-inferior to fentanyl combined with a benzodiazepine for sedation during phacoemulsification. Secondary outcomes will provide insight into complications, patient and surgeon comfort, and overall satisfaction. This trial will evaluate whether ketamine offers a safe and effective alternative to fentanyl for sedation in cataract surgery, potentially optimizing sedation protocols to enhance patient and surgeon experiences.

Caudal block, high flow oxygen insufflation and dexmedetomidine sedation for inguinal hernia surgery in infants-A prospective evaluation of an alternative anesthesia technique.

Inguinal hernia repair is the most common operation in infants, with well recognized anesthetic and perioperative risks. The aim was to investigate if the combination of caudal block, high-flow nasal oxygen insufflation and intravenous dexmedetomidine sedation is suitable for infants undergoing inguinal hernia surgery. A prospective multicenter international study was performed in three centers in Australia and New Zealand. Fifty infants less than 64 weeks post-menstrual age undergoing inguinal hernia surgery were enrolled. Exclusion criteria were any condition that contraindicated the use of the anesthesia technique. The technique included intravenous dexmedetomidine with a loading dose of 1-2 mcg/kg over 10 min and maintenance of 0.2-3 mcg/kg/h, high-flow nasal oxygen insufflation 2 L/kg/min with an oxygen blender, and a caudal block using 1 mL/kg 0.2% ropivacaine. The primary outcome was the successful completion of surgery without conversion to general anesthesia. Completion of surgery with the technique was successful in 41/50 (82%) infants. Care was provided by 22 anesthesiologists and 11 surgeons. Infants had a low incidence of intraoperative complications, including apnea [1 (2.4%)], bradycardia [2 (4.9%)], hypotension [2 (4.9%)], and desaturation [1 (2.4%)]. Postoperative complications included apnea [3 (7.3%)], bradycardia [3 (7.3%)], hypotension [3 (7.3%)], desaturation [4 (9.8%)]. No infants were intubated in the first 24 h postoperatively. Caudal block, high-flow nasal oxygen insufflation and intravenous dexmedetomidine sedation is a potential alternative to general anesthesia for infant inguinal hernia surgery with a low rate of complications in this small cohort of infants.

Persistent Postsurgical Idiopathic Rhinitis After Sedation Utilizing Supplemental Oxygen Via Nasal Cannula

This case describes an uncommon complication of postprocedural unilateral nonallergic rhinitis in a patient who received moderate intravenous sedation (IV) for an elective oral/periodontal surgical procedure. Some authors suggest this potential problem is underreported, and may not be as rare as the literature implies. The patient, a 48-year old female, received supplemental oxygen and ventilation monitoring via a CO2/O2 nasal cannula during the sedation/surgery. The procedure was completed uneventfully, but postoperatively (PO) she developed persistent rhinitis, sternutation, and rhinorrhea that peaked at day 4 PO, and then slowly started to resolve until symptoms completely gone at day 13 PO. Although the patient was in no distress, the symptoms being continual for longer than a week did interfere with her daily activities. While the rarity of this atypical reaction may be in question, practitioners who utilize sedation should be aware of this possible distressful condition and counsel patients on the risk.

Pediatric nasolacrimal duct intubation using deep sedation outside the operating room- comparison of three types of stents

BackgroundCongenital nasolacrimal duct obstructions that persist after 9 months of age often require surgical intervention through probing and stenting of the tear duct. These procedures typically occur under general anesthesia in an operating room setting. We propose a novel approach using intravenous sedation outside the operating room. MethodsWe reviewed the medical records of patients at a tertiary pediatric hospital treated for nasolacrimal duct obstruction from 2018 to 2023 using monocanalicular Monoka, Masterka, and LacriJet nasolacrimal stents. All procedures were performed outside of the operating room under intravenous sedation provided by a specialized sedation team. Symptom resolution, sedation duration and complications were reviewed for each type of stent. ResultsA total of 64 patients (81 stents) were included in our analysis. Of the 81 stents used, 32 were Monoka, 15 Masterka, and 34 LacriJet. Symptoms resolved in 86% of the eyes. Sedation side effects were minor and infrequent. Occasionally brief apnea, hypoxia, hypotension or laryngospasm occurred, but in no cases were patients harmed or was hospitalization required. A single factor analysis of variance showed no statistically significant difference between the stents for recurrence or sedation time. The Fisher exact test suggested a higher risk of side effects in the Monoka group. ConclusionsIn our pediatric patient cohort, nasolacrimal duct stenting procedures have a high success rate and safety profile when performed under deep sedation outside of the operating room.

Esketamine administered epidurally as an adjuvant to epidural ropivacaine for labour analgesia: a prospective, double-blind dose-response study.

To investigate the efficacy of esketamine as an adjuvant to epidural ropivacaine for labour analgesia by determining its effect on the median effective concentration (EC50) in a 20 ml volume of ropivacaine. A prospective, double-blind dose-response study. This study was conducted in Women's Hospital, School of Medicine, Zhejiang University, China. One hundred and fifty parturients who requested epidural analgesia were recruited in this study to randomly receive epidural ropivacaine alone or with esketamine of 0.2 mg ml-1, 0.3 mg ml-1, 0.4 mg ml-1 or 0.5 mg ml-1, respectively. The primary outcome, EC50 of ropivacaine, was determined using an up-down sequential allocation technique. The secondary outcomes were analgesia characteristics, Ramsay Sedation Scale score, labour duration, caesarean section rate and adverse effects. The EC50 of ropivacaine with the addition of esketamine at concentrations of 0.3 mg ml-1, 0.4 mg ml-1 and 0.5 mg ml-1 resulted in significant reductions in the EC50 of ropivacaine to 0.050%, 0.044% and 0.043%, respectively, from baseline (esketamine 0 mg ml-1) (p<0.0001). However, reductions of the EC50 of ropivacaine were similar among the groups with esketamine of 0.3 mg ml-1, 0.4 mg ml-1 and 0.5 mg ml-1 (p>0.05). The Ramsay Sedation Scale score was higher and more dizziness was observed in the Group of esketamine 0.5 mg ml-1 compared with all other groups (p<0.0001). During the peripartum period, no differences in sensory blockade level, Bromage score, labour duration and percentage of caesarean delivery were found among the groups. Under the conditions of this study, the addition of epidural esketamine of 0.3 mg⋅mL-1, 0.4 mg⋅mL-1 and 0.5 mg⋅mL-1 offered a similar ropivacaine dose-sparing effect; 0.5 mg⋅mL-1 of esketamine produced more adverse effects. ChiCTR2100054348.