Local Sedation Research Articles

Study of clinical experiments of novel sedative drugs based on chi-square test and logistics regression model

Local sedation and analgesic drugs are often indispensable in medical trauma surgery. They can not only assist doctors to complete the operation, but also greatly reduce the pain of patients. Therefore, constantly looking for better effective sedative drugs is an extremely important field in medical research. For the new sedative drug "R drug", this paper uses the data analysis of patient intraoperative and postoperative adverse reactions, patient vital signs, patient satisfaction and related problems to establish an appropriate mathematical model and evaluate its clinical efficacy. First, Data cleaning was performed on the data[1], Quantification and normalized dimensionless pretreatment; Next, We calculated K2 values using the chi-square test and Yates's correction, By comparing the K2 values to the standard values, Then to judge whether there are significant differences between each index; Then, When predicting adverse reactions, we used a logistics regression model to predict the probability that each reaction may occur, The accuracy of the model is tested by the heat map of the confusion matrix and the ROC curve; Last, We performed the data analysis of each index in 0-5 minutes, By mapping the nuclear density of the different indicators under the B and R drugs, Mann-Whitney U test using independent samples, P values were calculated to determine whether the new drug group and the original drug group showed significant differences in vital sign data.

COMPARED EFFECTIVENESS, SAFETY AND COST OF DEXMEDETOMIDINE WITH MIDAZOLAM: A REVIEW

Dexmedetomidine, an alpha 2 receptor agonist sedative drug, has recently garnered attention as a viable alternative to midazolam, a widely used benzodiazepine for sedation in adult patients. The aim of this study was to conduct a comprehensive comparison of the clinical sedative efficacy, cost-effectiveness, and safety profiles of dexmedetomidine versus midazolam, utilizing a randomized controlled trial design. The search encompassed several databases, including PubMed, Scopus, Web of Knowledge, CINAHL, the United States National Library of Medicine, and Google Scholar for Systematic Reviews, using the keywords 'dexmedetomidine,' 'midazolam,' and 'effectiveness.' The findings revealed that dexmedetomidine demonstrated a more favorable safety profile, with a lower incidence of delirium compared to midazolam. In terms of effectiveness, no significant differences were observed between the two drugs for local sedation. Notably, adult patients treated with dexmedetomidine had a shorter Intensive Care Unit (ICU) stay (7 days) compared to those receiving midazolam (10 days). Similarly, pediatric ICU treatment indicated a shorter duration with dexmedetomidine (20 hours) as opposed to midazolam (38 hours). Regarding cost-effectiveness, dexmedetomidine emerged as a cost-saving option, being approximately 10% cheaper than midazolam for adult ICU patients. These findings collectively highlight the advantages of dexmedetomidine over midazolam, encompassing superior safety, effectiveness, and cost-efficiency, thus providing valuable insights for healthcare practitioners and decision-makers.

Local Anesthesia versus Conscious Sedation among Patients Undergoing Transcatheter Aortic Valve Implantation-A Propensity Score Analysis.

Background: Conscious sedation (CS) has been used successfully to treat patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) and as such is considered the standard anesthesia method. The local anesthesia (LA) only approach may be feasible and safe thanks to improvements in operators’ experience. Objective: To evaluate differences between LA only versus CS approaches on short- and long-term outcomes among patients undergoing TAVI. Methods: We performed a propensity score analysis on 1096 patients undergoing TAVI for severe AS. Two hundred and seventy-four patients in the LA group were matched in a ratio of 1:3 with 822 patients in the CS group. The primary outcome was a 1-year mortality rate. Secondary outcomes included procedural and peri-procedural complication rates and in-hospital mortality. Results: Patients in the CS group had significantly higher rates of grade 2–3 acute kidney injury and were more likely to have had new left bundle branch block and high-degree atrioventricular block. Patients who underwent TAVI under CS had significantly higher in-hospital and 1-year mortality rates compared to LA (1.6% vs. 0.0% p-value = 0.036 and 8.5% vs. 3.3% p-value = 0.004, respectively). Kaplan–Meier’s survival analysis showed that the cumulative probability of 1-year mortality was significantly higher among subjects undergoing CS compared to patients LA (p-value log-rank = 0.024). Regression analysis indicated that patients undergoing CS were twice more likely to die of at 1-year when compared to patients under LA (HR 2.18, 95%CI 1.09–4.36, p-value = 0.028). Conclusions: As compared to CS, the LA-only approach is associated with lower rates of peri-procedural complications and 1-year mortality rates.

Dental sedation—Airing a concept

AbstractAimTo establish current practices and experiences of dental practitioners, who are carrying out procedures under sedation in primary care, relating to assessment and management of the airway. We also review current recommendations and consider a need for further clinical guidance to standardise practice.MaterialsThe survey was created using Survey Monkey and distributed through social media channels such as WhatsApp, Facebook and via emailing a local sedation group.MethodsA service evaluation was carried out in the form of an online survey. This was distributed via social media and by emailing previous and current attendees of Dental Sedation Courses. This link remained active for 3 months with a minimum target of 50 completed responses. During this period, a total of 64 responses were received.Results51 of 64 respondents stated they complete airway assessments, of which, less than half used a pro‐forma for this purpose. Within this cohort, 21.9% of respondents acknowledged a compromised airway incident requiring initial management, with the most favoured adjunct/manoeuvre being a head tilt chin lift of the patient.ConclusionAs sedation operators, dentists carry the responsibility for the provision of dental treatment alongside the management of the airway. Conscious intravenous sedation is usually carried out using midazolam, a short acting and amnesic benzodiazepine. Whilst this is widely used, risks such as respiratory depression or loss of the airway remain. To prevent this, it is vital for an airway assessment to be carried out pre‐operatively as echoed by the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) and Scottish Dental Clinical Effectiveness Programme (SDCEP). This article highlights the need for guidance to support general dental practitioners in the pre‐operative assessment of airways to further streamline and improve patient care.

The Physiological Basis Of The Oral Surgical Management Of A Patient With Polycythemia Rubra Vera: A Pathway For The Development Of A Protocol

Various oral surgical procedures are currently performed under local anaesthesia and conscious sedation as a day surgery procedure. Both oral and intravenous conscious sedation are available as a choice. Oral sedation with Alprazolam and Codeine is very effective for most oral surgical procedures especially the removal of impacted third molars and surgical placement of implants. It is this sedation regimen that comprises the synergistic use of both aprazolam and codeine to effect sedation with amnesia that is the standard procedure at the Faculty of Dentistry of the International Postgraduate Medical College. The purpose of this case report is to appraise the possible negative effect of Alprazolam and Codeine sedation mentioned above on a patient who presented with polycythaemia rubra vera (a very rare haematological condition). This is because the codeine component of this combination will depress the respiratory centre in the medulla oblongata putting the patient at risk. The case study is that of a 70-Year-old male patient who had been a regular patient for approximately 10 years ago at the Faculty of Dentistry, International Postgraduate Medical College (IPMC), where a total upper denture and a partial lower denture were placed. The patient returned in 2019 with the chief complaint of halitosis and pain in the mandibular posterior right region. The patient gave past medical history of PRV, epilepsy and hypertension and history of being on multiple medications for these conditions. The treatment plan advised was total extraction of the remaining mandibular dentition and excisional biopsy of the suspicious lesion mesial to the mandibular right first molar, together with a complete lower denture replacement. The procedure was done without sedation and at no time was the patient considered to be in danger as it relates to oxygen saturation, carbon dioxide drive to the brain and bleeding. Every hematologist managing patients with PRV will be very concerned as to how these patients are managed by dentists, particularly as it relates to oxygen saturation, carbon dioxide drive to the brain and hemostasis. Similarly, most dental practitioners that are managing such patients may not be familiar with the technicalities surrounding the clinical and operative management of these patients. It is for this reason that this case report focusing on oral surgical management of a patient with PRV is of significance to the dental literature, particularly as it aims to develop a working group for the development of the protocol for the management of PRV.

Combined Endoscopic and Intraoral Approach or Intraoral Alone in Surgical Management of Odontogenic Sinusitis

The physiological behavior of paranasal sinuses depends on the potency of the ostiomeatal complex and on normal mucociliary function. The interruption of this delicate equilibrium can lead to pathological conditions such as sinusitis. Anywhere between 10% and over 25% of cases of maxillary sinusitis have an odontogenic origin, such as: dental infection; alveolar dental trauma; or iatrogenic causes, such as extractions, endodontic therapies, maxillary osteotomies or placement of endosseous implants. The resolution of sinus pathology is related to the resolution of odontogenic pathology. Aim: to evaluate the therapeutic efficacy of a combined oral and endoscopic approach in the treatment of chronic odontogenic sinusitis vs. oral dental management through a case control study. Materials and Methods: all patients showing signs and symptoms of odontogenic sinusitis with obliteration (appreciable radiopacity in CT) of unilateral maxillary sinus between January 2018 and September 2019 at Padua University Hospital were enrolled in this retrospective study. The exclusion criteria were: maxillary sinusitis without odontogenic origin, or resolution with a systemic antibiotic therapy; and presence of anatomical abnormalities that promote the onset of rhinosinusitis. The patients were divided into two groups: one group was treated with a combined surgical approach under general anesthesia (Functional Endoscopic Sinus Surgery-FESS and simultaneous closure of oroantral communication with Bichat’s fat pad advancement); while the other group was treated only with an intraoral approach under local anesthesia and conscious sedation (closure of oroantral communication with Bichat’s fat pad advancement). The variable “success of the surgical procedure” in the two groups was compared by a Student test (with p < 0.05). Results: among the patients enrolled, 10 patients (aged between 42 and 70) made up the case group and the other 10 patients (aged between 51 and 74) constituted the control group. There was no statistically significant difference in success between the two groups (p < 0.025). Conclusions: according to this case study, an exclusive annotation invasive intraoral approach seemed to be comparable to the transoral endoscopic combined method. However, during diagnosis it is necessary and fundamental to distinguish between odontogenic and rhinogenic sinusitis in order for the resolution of odontogenic sinusitis to be achieved.

Stress load and neurodegeneration after gastrostomy tube placement in amyotrophic lateral sclerosis patients.

Dysphagia and progressive swallowing problems due to motoneuron death is one of amyotrophic lateral sclerosis (ALS) symptoms. Malnutrition and body weight loss result in immunological disturbances, fatigability and increase risk of secondary complications in ALS patients, percutaneous endoscopic gastrostomy tube (PEG) placement representing a well-recognized method for malnutrition correction and potentially increasing life expectancy. However, despite nutritional correction, occasional rapid neurological deterioration may develop after PEG placement. We have hypothesized that this decline can be a result of exteroceptive stress during PEG placement and promote neurodegeneration in ALS patients. Intravenous sedation may decrease stress during invasive procedures and it is safe during PEG placement in ALS patients. The aim of the study was comparing different PEG placement protocols of anesthesia (local anesthesia or local anesthesia plus intravenous sedation) in ALS from perspectives of stress load and neurological deterioration profile. During 1.5years 94 ALS patients were admitted; gastrostomy was performed in 79 patients. After screening according to inclusion and exclusion criteria, 30 patients were included in the prospective consecutive study. All patients were divided in two groups, with local anesthesia and with combination of local anesthesia and intravenous sedation. Routine biochemical indices, neurodegeneration and stress markers were measured. The age of ALS patients was 61 ± 10years; 20 patients were included at stage 4A and 10 at stage 4B (King's College staging). PEG was placed at average14 months after the diagnosis and 2.2years after first symptoms. Mean ALSFunctional Rating Scale-Revised was 27.8, mean forced vital capacity of lung 46.3% (19-91%). After one year of observation only 8 patients survived. Mean life duration after PEG was 5months (5days-20months). Comparison of two PEG placement protocols did not reveal differences in survival time, stress load and inflammation level. Higher saliva cortisol levels, serum cortisol, glucose, C-reactive protein and interleukin-6 were detected after PEG placement, confirming considerable stress response. PEG is a stressful factor for ALS patients, PEG placement representing a natural model of exteroceptive stress. Stress response was detected as increased cortisol, C-reactive protein, interleukin-6, and glucose levels. Intravenous sedation did not increase the risk of PEG placement procedure, however, sedation protocol did not affect stress load.

Delivering Essential Surgical Care for Lower-limb Musculoskeletal disorders in the Low-Resource Setting

BackgroundMismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia.MethodsA 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated.ResultsDuring this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients.ConclusionRemote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

Uniportal VATS pleural biopsy in the diagnosis of exudative pleural effusion: awake or intubated?

BackgroundThe aim of this study is to compare the diagnostic efficacy and safety of video-assisted thoracoscopic surgery (VATS) with awake VATS (AVATS) pleural biopsy in undiagnosed exudative pleural effusions.MethodsThe diagnostic efficacy of pleural biopsy by uniportal VATS under general anesthesia or AVATS under local anesthesia and sedation performed by the same surgeon in patients with undiagnosed exudative pleural effusion between 2007 and 2020 were retrospectively evaluated. Test sensitivity, specificity, positive predictive value and negative predictive value were compared as well as age, gender, comorbidities, procedure safety, additional pleural-based interventions, duration time of operation and length of hospital stay.ResultsOf 154 patients with undiagnosed exudative pleural effusion, 113 (73.37%) underwent pleural biopsy and drainage with VATS, while 41 (26.62%) underwent AVATS pleural biopsy. Sensitivity, specificity, positive predictive value and negative predictive value were 92, 100, 100, and 85.71% for VATS, and 83.3, 100, 100, and 78.9% for AVATS, respectively. There was no significant difference in diagnostic test performance between the groups, (p = 0.219). There was no difference in the rate of complications [15 VATS (13.3) versus 4 AVATS (9.8%), p = 0.557]. Considering additional pleural-based interventions, while pleural decortication was performed in 13 (11.5%) cases in the VATS group, no pleural decortication was performed in AVATS group, (p = 0.021). AVATS group was associated with shorter duration time of operation than VATS (22.17 + 6.57 min. Versus 51.93 + 8.85 min., p < 0.001). Length of hospital stay was relatively shorter in AVATS but this was not statistically significant different (p = 0.063).ConclusionsOur study revealed that uniportal AVATS pleural biopsy has a similar diagnostic efficacy and safety profile with VATS in the diagnosis and treatment of patients with undiagnosed pleural effusion who have a high risk of general anesthesia due to advanced age and comorbidities. Accordingly, uniportal AVATS pleural biopsy may be considered in the diagnosis and treatment of all exudative undiagnosed pleural effusions.

Fast track sacrospinous ligament fixation: subjective and objective outcomes at 6\xa0months

BackgroundSacrospinous ligament fixation (SSLF) is a widely used vaginal procedure for correction of apical vaginal prolapse. The objective of this study was to evaluate subjective and objective outcomes of SSLF performed in a fast-track setting.MethodsThis was a prospective cohort study of sacrospinous ligament fixation performed using local anesthesia and light sedation in a fast-track setting at Aarhus University Hospital between April 2016 and December 2017. Objective signs of prolapse were assessed by gynecological examination preoperatively and at 6 months after the operation. Subjective symptoms were evaluated by questionnaires (the Pelvic Floor Distress Inventory (PFDI 20), and the Patient Global Impression of Improvement (PGI-I) supplemented with individual questions from the ICIQ-vaginal Symptoms (ICIQ-VS) and Sexual Questionnaire-IR (PISQ-12) questionnaires).ResultsOne hundred and three women with a median age of 65 (36–84) years were included. Previous hysterectomy had been performed in 40% of the women, and 43% had a history of previous prolapse operations. At follow-up, 75% of the women had apical descent less than stage 2. However, 18% had anterior vaginal wall prolapse beyond the hymen, and 25% had recurrence of the apical prolapse stage 2 or more and were offered reoperation. Bladder and anal symptoms improved in most women after the operation, and the number of women reporting dyspareunia was halved. In the overall assessment by Patient Global Impression of Improvement (PGI-I) questionnaire, 76% reported improvement. No serious operative complications were reported, and 81% of the patients were discharged on the day of the surgery.ConclusionIn this cohort with a high rate of previous prolapse surgery, sacrospinous ligament fixation performed in a fast-track setting showed subjective and objective results comparable to the results of apical native tissue repair reported in the literature. Furthermore, the complication rate was low.Trial registration This study was notified to The Central Denmark Region Committees on Health Research Ethics on July 7, 2015, and was approved by The Danish Data Protection Agency (1-16-02-442-15). All methods were performed in accordance with the relevant guidelines and regulations. An informed consent for participation in the study and acceptance of using data for scientific purposes and publication was signed by all patients.

Mechanical Nociceptive Threshold, Tissue Alterations and Horn Growth in Calves after Injection of Isoeugenol or Clove Oil under the Horn Bud.

Simple SummaryHot-iron disbudding of calves is a common but painful practice. We investigated the injection of clove oil or isoeugenol under the horn bud as a potential alternative. Compared to hot-iron disbudding (with local anesthesia), pain sensitivity increased much less and for a shorter time in isoeugenol-injected calves. After injection of clove oil, the differences to hot-iron disbudding were smaller, and there was a high occurrence of swellings of the eyelids. Neither injection was as effective as the use of a hot iron in preventing horn growth. In sum, the injection of clove oil is not recommendable, and regarding the use of isoeugenol further research is needed, in particular on possibilities to improve its effectiveness.Disbudding of calves is a common, painful intervention. Due to cytotoxic and anesthetic properties, the injection of clove oil or its component isoeugenol may be less detrimental to animal welfare. We investigated mechanical nociceptive threshold (MNT), possible tissue alterations and horn growth for up to 12 weeks after injection of 1.5 mL clove oil (CLOV), isoeugenol (ISO) or saline (CON) or after hot-iron disbudding (BURN; with local anesthesia and sedation, n = 10/treatment). MNT was measured using von Frey filaments and a pressure algometer at four locations around the horn bud. There was a treatment*time point interaction (linear mixed model, p < 0.05). MNT decreased most strongly and for the longest time for BURN in most calves at least for 3 weeks. For ISO, the decrease was less distinct and most calves’ values returned to baseline after 1–2 weeks. MNT in CLOV was intermediate, with decreased values up to 3 weeks in some animals. 12 weeks after the treatment, horn growth was prevented in about 50% of the horns in CLOV and ISO. Tissue alterations such as swellings of the eyelids often occurred in CLOV, but less so in ISO. Our results suggest that injection of isoeugenol causes less pain and thus seems to be beneficial compared to hot-iron disbudding, while clove oil was not advantageous. Regarding the effectiveness of isoeugenol to prevent horn growth, more studies are needed.

Extending the limits of vaginal hysterectomy under local anesthesia and conscious sedation

In this video we present the surgical management of a 58-year-old woman presenting with a large prolapsed myomatous uterus treated with vaginal hysterectomy (VH) and pelvic floor repair (PFR) (uterosacral ligament suspension and posterior colporraphy) under local anesthesia and conscious sedation. The patient underwent VH and PFR by using an infiltration of a local anesthetic solution of lidocaine, ropivacaine and adrenaline in combination with intravenous (iv) conscious sedation. Debulking techniques, such as intramyometrial coring, uterine bisection, myomectomy and wedge resection, were used to facilitate VH. The final weight of the removed uterus was 870g. This video demonstrates that performing a surgically challenging VH under local anesthesia is feasible. Vaginal uterine morcellation can be performed to debulk the enlarged uterus so that hysterectomy can be accomplished under local anesthesia. The use of local anesthesia may safely be offered as an alternative to patients undergoing a complex vaginal hysterectomy and reconstructive surgery.

Monitored Anesthesia Care Versus General Anesthesia as the Primary Anesthetic for Ankle Amputations

The authors hypothesized that monitored anesthesia care (MAC)-either by local sedation or regional anesthesia (RA)-compared with general anesthesia (GA), would be associated with lower odds of significant 30-day postoperative complications and mortality in patients undergoing an ankle amputation. Retrospective cohort study. Inpatient. The authors used data from patients who underwent ankle amputation from the American College of Surgeons National Surgical Quality Improvement Program registry. RA as primary anesthetic. A multivariate logistic regression was used to evaluate the association of primary anesthesia type with the outcomes. The regression analysis included all covariates to test the association of the primary exposure variable (anesthesia type) with each outcome of interest. The odds ratio (OR), with associated 95% confidence interval (CI), was reported for each covariate. There were a total of 3,368 patients undergoing guillotine amputation through the tibia/fibula (n = 2,935) or ankle disarticulation (n = 433). Among these patients, 15.5% (n = 491) received MAC as their primary anesthetic. Among all patients, 11.4% (n = 363) experienced a significant postoperative complication. On multivariate logistic regression, MAC was found to decrease odds of postoperative complications (OR 0.57, 95% CI 0.40-0.82, p = 0.002), but not mortality (OR 1.26, 95% CI 0.87-1.84, p = 0.22). This study showed that MAC was associated with improved outcomes, as opposed to GA, as the primary anesthetic in ankle amputations.

Ce qu'un réanimateur doit savoir des TAVI

Le rétrécissement aortique est la valvulopathie acquise la plus fréquente. Quand il devient serré et symptomatique, la mortalité à 2 ans est proche de 80% en l’absence de prise en charge. Le traitement repose sur le remplacement valvulaire, historiquement réalisé par voie chirurgicale. L’avènement des procédures percutanées par cathétérisme cardiaque TAVI (Trans-catheter Aortic Valve Implantation) a tout d’abord permis de traiterdes patients jugés inopérables, puis avec l’avancée des connaissances cette procédure s’est étendue aux populations à risque chirurgicale élevépuis intermédiaire, et a même été validée chez les patients à bas risque aux Etats-Unis suite à de grandes études multicentriques. Le principe consiste à implanter une bioprothèse aortique suturée sur un stent directement au sein de la valve native calcifiée, soit par un procédé de dilatation au ballonnet, soit par un procédé auto-expansé. Le TAVI présente l’avantage d’une procédure peu invasive, le plus souvent réalisée sous anesthésie locale et sédation, et une durée de séjour courte. La récupération fonctionnelle est plus rapide qu’après chirurgie cardiaque conventionnelle.Un autre avantage par rapport à la chirurgie cardiaque conventionnelle est un moindre taux de complications graves (choc cardiogénique, saignement majeure, accident vasculaire cérébrale, insuffisance rénale, décès toute cause). En revanche certaines complications sont plus spécifiques du TAVI comme l’apparition d’un trouble conduction de haut degré nécessitant la pose d’un pacemaker, et l’existence de complications vasculaires. La surveillance en soins intensifs en découlant est donc plus courte qu’après chirurgie et doit probablement être personnalisée selon le risque du patient.&#x0D; L’utilisation du TAVI chez les sujets à risque et/ou âgés semble parfaitement implanté en France. L’extension des indications à des sujets à bas risque et plus jeunes n’est pas encore autorisée en France et en Europe. L’étude de la durabilité des bioprothèses implantées par voie percutanée à long terme nécessite des investigations supplémentaires.

Percutaneous Cryoablation of Symptomatic Abdominal Wall Endometriosis at a Military Treatment Facility

Study Objective To describe a case of symptomatic abdominal wall endometriosis treated with cryoablation Design Case report Setting Academic military hospital Patients or Participants A 31 year-old active duty female with one prior cesarean section reported 7 years of cyclic pain at her cesarean scar that was nonresponsive to trigger point injections or oral contraceptives. The pain resolved with leuprolide, however, it was stopped due to intolerable side effects. She was initially scheduled for excision of her abdominal wall endometriosis (AWE), but the procedure was cancelled due to a year-long military deployment. Interventions Two years later the patient presented to our facility with cyclic pain and enlarging cesarean scar mass. An MRI revealed 5.5 × 3.1cm left rectus muscle AWE. General surgery recommended against surgical excision as rectus resection and reconstruction could impact her military readiness with a high risk of medical discharge. Interventional Radiology was consulted and recommended minimally invasive percutaneous cryoablation. Percutaneous cryoablation was performed outpatient under local and moderate sedation with ultrasound- and CT-guidance. Image-guided hydrodissection was used to protect the skin, abdominal wall, and underlying bowel from ice. Appropriate cytotoxic temperatures were monitored and achieved throughout the mass. Periodic CT evaluation confirmed the ablation margin of ice extended just beyond the tumor margin. The patient tolerated the procedure well and was discharged home same-day. Measurements and Main Results Patient noted complete resolution of pain at 6 weeks post-procedure without residual AWE on follow-up MRI. Norethindrone was continued for endometriosis suppression and physical therapy initiated for core strengthening with continued absence of symptoms at 6 months post-procedure. Conclusion Surgical resection of large AWE may not be feasible given the physical demands of military servicewomen. Percutaneous cryoablation provides a minimally invasive and less morbid treatment option with long-term resolution of pain symptoms in this patient.

Endoscopic Submucosal Dissection for Upper Gastrointestinal Neoplasia—a North American Perspective

ObjectivesOrgan-sparing endoscopic submucosal dissection (ESD) is an acceptable treatment strategy for superficial neoplastic lesions of the esophagus and stomach. The adoption of this technique has lagged in North America compared with Asia, and we sought to report on our experiences with ESD for upper GI neoplasia. MethodsA prospectively entered database of all patients undergoing endoscopic resection of esophageal and gastric neoplasia at McGill University from 2009 to 2019 was queried for those who received ESD. ResultsA total of 103 consecutive ESDs were identified from 2009 to 2019. Seventy-one (69%) patients were male and the median age was 72 (range: 38–90). Sixty-one (59%) cases were esophageal and 42 (41%) gastric. Forty-nine (48%) were performed in the endoscopy suite under local sedation only. Perforation occurred in 9 patients (7 esophageal and 2 stomach), of which 3 required operative repair. Histology was principally invasive carcinoma (79, 77%), with 17 (16%) dysplastic lesions (e.g., HGD), 1 (1%) neuroendocrine tumor, and 7 (7%) benign lesions. En bloc resection was achieved in 90 (87%), and the complete resection rate was 74 (72%), with 51 (50%) of procedures fulfilling the criteria for curative resection. At medium of 23-month (2–199) follow-up of these 51 curative resections, one case of recurrent carcinoma was found at follow-up and was managed with repeat endoscopic resection. Non-curative ESDs were found 45 (R1 resection = 29: risk of lymph node metastasis = 16), 21 had active surveillance, and 24 were resected. ConclusionESD is a viable, effective, and safe therapeutic and staging modality for superficial lesions of the stomach and esophagus.

Dexmedetomidine infusion for sedation in a patient with myotonic dystrophy*

Myotonic dystrophy type 1 is the most common muscular dystrophy in adults. Anaesthetic management should take into consideration the numerous body systems affected, including the musculoskeletal; respiratory; cardiovascular; gastro-intestinal; and central nervous systems. A 42-year-old man with myotonic dystrophy presented for septoplasty and bilateral inferior turbinate reductions. He had severe upper and lower extremity myotonia and weakness, pulmonary impairment with non-obstructive patterns and first-degree atrioventricular block with reduced ejection fraction. He used bilevel positive airway pressure, a cough assist device and was paced 3% of the time with a single-chamber pacemaker. To reduce potential complications associated with opioid use and general anaesthetics, an opioid-free technique was planned using local anaesthetic infiltration and sedation with a dexmedetomidine infusion. The patient maintained spontaneous ventilation and haemodynamic stability, and had an uneventful postoperative course. Dexmedetomidine is a highly selective α2-adrenergic receptor agonist that has the ability to provide sedation, analgesia and anxiolysis with a stable haemodynamic profile. Avoiding both opioids and general anaesthetics in these patients may decrease the risk of peri-operative complications.

A Comparison of Respiratory Outcomes after Treating Retinopathy of Prematurity with Laser Photocoagulation or Intravitreal Bevacizumab

To compare respiratory outcomes after treatment of retinopathy of prematurity (ROP) between infants treated with laser therapy under general anesthesia and infants treated with intravitreal bevacizumab under bedside sedation. Retrospective cohort study. One hundred thirty-eight consecutive infants treated for ROP from September 2010 through September 2018 at 1 institution. Retrospective medical, procedural, and ophthalmologic data were collected, including preprocedure (baseline) and postprocedure (24 hours, 48 hours, 7 days, and 28 days) respiratory status, birth weight, gestational age, gender, ROP treatment method, postmenstrual age at treatment, and coincident nonocular procedures during anesthesia. Respiratory outcomes at 48 hours were compared between infants treated with laser therapy under general anesthesia and infants treated with intravitreal bevacizumab under local sedation using multivariate logistic regression analysis to control for potentially confounding factors. Proportion of infants who had returned to their respiratory baseline by 48 hours after ROP treatment. Return to respiratory baseline was significantly less common among 119 infants initially treated with laser therapy compared with 19 infants initially treated with bevacizumab at 24 hours (40% vs. 74%; P= 0.0115), 48 hours (53% vs. 79%; P= 0.0453), and 7 days (79% vs. 100%; P= 0.0242). In a multivariate logistic regression analysis, infants treated with laser therapy were less likely to return to respiratory baseline at 48 hours (odds ratio, 0.14; 95% confidence interval, 0.04-0.54). At 28 days, no difference was found between groups (laser, 97%; bevacizumab, 100%; P > 0.99). Infants treated with intravitreal bevacizumab using bedside sedation returned to their preprocedure respiratory baseline faster than infants treated with laser under general anesthesia, with the differences persisting at least to 7 days or more after the procedure.

P524Serratus anterior plane block in subcutaneous implantable cardioverter defibrillator implantation: a case-control analysis

Abstract Funding Acknowledgements No Funding OnBehalf RHYTHM DETECT study group Background A two-incision technique, in association with inter-muscular positioning of the subcutaneous defibrillator (S-ICD), is now the most frequently adopted implantation approach in Europe. Ultrasound-guided serratus anterior plane block (SAPB) has been proposed in order to provide anesthesia/analgesia during S-ICD implantation. Objective We performed a case-control analysis in which a standardized SAPB approach was compared with the typical local anesthesia and sedation approach. Methods 91 consecutive patients underwent implantation of an S-ICD with the SAPB approach for anesthesia/analgesia at 10 centers. The control group consisted of 55 consecutive patients who underwent S-ICD implantation with standard local approach. Results The mean procedure duration was 59 ± 15min in the SAPB group and 76 ± 23min in the control group (p &amp;lt; 0.001). No operative complications were reported in either group. During the procedure, 79 (87%) patients in the SAPB group and 25 (46%) patients in the control group (p &amp;lt; 0.001) remained awake. Lower values of pain intensity at the device pocket (p = 0.005) and the lateral tunneling site (p = 0.046) were reported in the SAPB group. The difference in static (p = 0.002) and dynamic (p = 0.007) pain intensity between the groups persisted at 1 hour, while no differences were observed 6 hours after the end of the procedure. Conclusions SAPB is feasible and effective in providing anesthesia/analgesia during S-ICD implantation. The procedures were successfully accomplished and no complications occurred in either group. However, SAPB was associated with lower pain levels, enabling the need for sedation to be reduced and more patients to remain awake. Moreover, it resulted in shorter procedure durations.

Awake Emergency Department Thoracoscopic Investigation of Penetrating Diaphragmatic Injuries: A Novel Minimally Invasive Technique of Diagnosis.

Background: The diagnosis of occult penetrating diaphragmatic trauma remains challenging, with conventional imaging offering inadequate accuracy for diagnosis. Minimally invasive surgical options for evaluating the diaphragm conventionally require general anesthesia. We propose a technique for evaluating the diaphragm via awake thoracoscopy in the emergency department. Methods: A prospective interventional study was conducted to investigate the safety and accuracy of emergency department awake thoracoscopy for diagnosing diaphragmatic injuries in penetrating thoracoabdominal trauma. All adult patients who presented to the trauma unit with penetrating thoracoabdominal trauma who were hemodynamically stable were enrolled. The patients underwent emergency department awake thoracoscopy with a rigid endoscope through a previously inserted intercostal drain. Only local anesthesia and conscious sedation were provided. Results: Forty patients were enrolled. All 40 (100%) were men, and the median age was 34 years. Thirty-four had stab wounds (85%), 5 had gunshot wounds (12.5%), and 1 had a suspected iatrogenic diaphragm injury during intercostal drain insertion (2.5%). In 32 (80%), the diaphragm was well visualized, of whom 7 (17.5%) had diaphragm injuries. In the remaining 8 patients in whom the diaphragm was not well visualized, only 1 (2.5%) had a diaphragmatic injury. The diaphragmatic injuries that were identified were confirmed and repaired during a subsequent explorative laparoscopy. There were no procedure-related complications in any of the patients during short-term follow-up. Conclusions: Awake thoracoscopy is safe, feasible, and accurate for the diagnosis of occult diaphragm injuries and may offer a modality for assessment that does not require general anesthesia.