Intravenous Moderate Sedation Research Articles

Perioperative Management of a Patient With Idiopathic Pulmonary Hypertension and a History of Syncope: A Case Report

Pulmonary hypertension is characterized by higher-than-normal pulmonary arterial pressures. This case report describes the perioperative management of a male patient with idiopathic pulmonary hypertension and a history of vasovagal syncope during previous dental extractions with local anesthesia. He underwent successful extraction of a single tooth with intravenous moderate sedation using dexmedetomidine and midazolam as well as prilocaine with felypressin for local anesthesia. There are many considerations surrounding the anesthetic management of patients with pulmonary hypertension, including the need to maintain systemic blood pressure, avoid hypoxemia and hypercapnia, and ensure adequate analgesia.

Evaluation of hemodynamic changes and patient-reported outcome measures in surgical therapy with or without intravenous sedation: a prospective controlled clinical study.

To determine whether intravenous (IV) sedation would contribute to the stabilization of patients' hemodynamics during periodontal and oral surgical procedures, and to evaluate the patient-reported outcome measures (PROMs). Periodontal or oral surgery patients were recruited and distributed into two groups: (1) sedation group (SG): intravenous sedation plus local anesthesia; (2) control group (CG): local anesthesia only. Systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), and oxygen saturation (SaO2), were monitored at 15-min intervals from sitting in the dental chair (baseline) until the end of the treatment. In addition, a subjective assessment of PROMs was obtained through a post-operative questionnaire. Forty-nine patients (25 in SG and 24 in CG) were included. The highest SBP and DBP were significantly higher in CG compared to the SG (141.1 ± 18.4 and 133.6 ± 15.1, respectively in SBP; and 85.5 ± 11.0 and 82.9 ± 10.1, respectively in DBP), but no mean significant differences were found between groups (P value of 0.85 and 0.72 for systolic and diastolic BP, respectively). HR and SaO2 did not show statistical intra- and inter-group differences. The overall patient satisfaction score was significantly higher in the SG group compared to CG. Intravenous moderate sedation seems to contribute to the stabilization of patient's hemodynamics, especially the systolic blood pressure, although small differences have been found. Intravenous sedation seems to contribute to stabilize the hemodynamic values, and enhances the patient satisfaction after periodontal and oral surgical treatment in the dental office.

Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks' gestation

ObjectivesThis study aimed to identify predictors of patient satisfaction with their chosen pain control regimen for procedural abortion at <12 weeks' gestation in the outpatient setting. Study designIn this prospective cohort study, we developed an instrument to evaluate predictors of satisfaction with pain control regimens among patients choosing local anesthesia alone (paracervical block with 20 mL of 1% buffered lidocaine) or local anesthesia plus intravenous (IV) moderate sedation with 100 mcg of fentanyl and 2 mg of midazolam. Our primary outcome was to identify predictors of satisfaction with both anesthesia cohorts as measured on a 4-point Likert scale, but due to high satisfaction levels in the IV group, we focused our analysis on the local anesthesia group. ResultsWe enrolled 149 patients in the local anesthesia group and 155 in the moderate IV sedation group. The mean procedure pain scores were 6.9 (±2.1) out of 10 in the local group and 4.0 (±2.7) in the IV group (p < 0.0001). More women in the IV group (92%) were satisfied or very satisfied with the amount of pain relief they experienced compared to the local group (66%; p < 0.0001). In the univariable model, only being afraid of a minor medical procedure was predictive of less satisfaction with local anesthesia for pain control (relative risk 0.8 [95% CI, 0.6–0.9]). Age, gestational age, anticipated pain, self-reported pain tolerance, self-reported anxiety, discomfort with the abortion decision, and history of prior vaginal or cesarean delivery or induced abortion did not predict satisfaction levels. ConclusionsFear of minor medical procedures was the only variable that predicted decreased satisfaction with local anesthesia alone for procedural abortion under 12 weeks. ImplicationsReliable predictors for satisfaction with local anesthesia alone for procedural abortion in the outpatient setting remain elusive. Fear of minor medical procedures may serve as an indicator of decreased satisfaction and could be incorporated into patient counseling. Moderate IV sedation is associated with high satisfaction levels.

Feasibility of Anesthesia Induction by a Combination of Topical Pharyngeal Using Lidocaine Spray and Moderate Intravenous Sedation in a Flexible Bronchoscopic Procedure

Feasibility of Anesthesia Induction by a Combination of Topical Pharyngeal Using Lidocaine Spray and Moderate Intravenous Sedation in a Flexible Bronchoscopic Procedure

Evaluation of Sedation Levels Using SedLine During Intravenous Sedation for Dental Procedures: A Case-Series Study.

The Patient State Index (PSI) is the numerical value of anesthesia depth as measured using a SedLine Sedation Monitor (Masimo Corporation). In this pilot study, we evaluated PSI values captured during intravenous (IV) moderate sedation for dental treatment. During the dental treatment, a dental anesthesiologist maintained the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score at 3 to 4 by adjusting the administration of midazolam and propofol while PSI values were recorded. The mean (SD) and median (25th percentile, 75th percentile) PSI values during dental treatment under IV moderate sedation were 72.7 (13.6) and 75 (65, 85), respectively.

Commentary.

It was a great tribute to be awarded the 2022 Jay A. Heidbrink Award from the American Dental Society of Anesthesiology (ADSA). As part of that award, it is also my honor to select a “Landmark Article,” a contribution to the dental anesthesia literature that was of significance to the field.I am pleased to choose an article by Norman Trieger, DMD, MD, (1929-2012) published in Anesthesia Progress in 1969. Those of us with greying hair remember Norm as a consummate gentleman and scholar. Younger readers may recognize the name which headlines the Continuing Education Article in each Anesthesia Progress publication.Dr. Trieger, a Phi Beta Kappa at Emory University, completed his dental degree and oral surgery residency at Harvard School of Dental Medicine. He subsequently joined the faculty at UCLA before returning to his childhood home in New York City to become the long-standing professor and chairman of the Department of Dentistry and Oral and Maxillofacial Surgery at the Montefiore Medical Center and Albert Einstein College of Medicine, where he also earned his medical degree. Dr. Trieger was a Fellow in General Anesthesia of the ADSA as well as a past president and editor of Anesthesia Progress. He helped develop the first American Dental Association (ADA) guidelines for teaching intravenous (IV) moderate sedation for dentists. He was an early supporter of a specialty in anesthesiology for dentistry, having authored the first ADA specialty application which was not submitted due to opposition from oral surgery at the time.Dr. Trieger was also a prolific researcher. One of his enduring contributions to the field became known as the Trieger Test. The test is a semi-objective measure of psychomotor recovery from sedation or general anesthesia. As this presented article points out, it was a modification of the Bender Motor Gestalt Test. I have used the Trieger Test in several of my own and my graduate students' research projects as new sedatives have been released or different techniques studied to help determine the duration of recovery needed to return to baseline psychomotor function. Oral surgeons, as they were known at the time before “maxillofacial” was added to their name, were really the pioneers of office-based anesthesia and the rapid recovery techniques that we all use today. In the early days, IV barbiturates for deep sedation and general anesthesia were commonly used as sole agents. We speak of the “Wild West” of office-based anesthesia today, but that technique could really lead to an anesthesia rodeo where only tooth extraction could be completed and more delicate dentistry impossible.One of the fascinating aspects of this article to me is that the actual data from the initial study are not presented. The data are referenced from an article in Anesthesia and Analgesia which I found and read. The data is, in fact, included in that article, and much of the same language in the Anesthesia Progress article is taken directly from the Anesthesia and Analgesia article, also co-authored by Dr. Trieger. This is a practice that would surely not be allowed today unless the article was part of a review of other published articles.Dr. Trieger made significant contributions to oral surgery, dental anesthesiology, moderate sedation for general dentists, and to the dental and medical professions. This early manuscript is but a small piece of his legacy.Respectfully submitted,This continuing education (CE) program is designed for dentists who desire to advance their understanding of pain and anxiety control in clinical practice. After reading the designated article, the participant should be able to evaluate and utilize the information appropriately in providing patient care.The American Dental Society of Anesthesiology (ADSA) is accredited by the American Dental Association and Academy of General Dentistry to sponsor CE for dentists and will award CE credit for each article completed. You must answer 3 of the 4 questions correctly to receive credit.Submit your answers online at www.adsahome.org. Click on “On Demand CE.”CE questions must be completed within 3 months and prior to the next issue.

Anesthetic Management of a Patient With Catecholaminergic Polymorphic Ventricular Tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited arrhythmogenic disorder induced by adrenergic stress. Electrophysiologically, it is characterized by emotional stress- or exercise-induced bidirectional ventricular tachycardia that may result in cardiac arrest. Minimizing perioperative stress is critical as it can reduce fatal arrhythmias in patients with CPVT. Dexmedetomidine (DEX), a centrally acting sympatholytic anesthetic agent, was used in the successful intravenous (IV) moderate sedation of a 27-year-old female patient with CPVT, a history of cardiac events, and significant dental fear and anxiety scheduled to undergo mandibular left third molar extraction. Oral surgery was successfully performed under DEX-based IV sedation to reduce stress, and no arrhythmias were observed. IV sedation with DEX provided a sympatholytic effect with respiratory and cardiovascular stability in this patient with CPVT who underwent oral surgery.

Comparison of the effects of target-controlled infusion-remifentanil/midazolam and manual fentanyl/midazolam administration on patient parameters in dental procedures.

BackgroundModerate sedation is an integral part of dental care delivery. Target-controlled infusion (TCI) has the potential to improve patient safety and outcome. We compared the effects of using TCI to administer remifentanil/manual bolus midazolam with manual bolus fentanyl/midazolam administration on patient safety parameters, drug administration times, and patient recovery times.MethodsIn this retrospective chart review, records of patients who underwent moderate intravenous sedation over 12 months in a private dental clinic were assessed. Patient indicators (pre-, intra-, and post-procedure noninvasive systolic and diastolic blood pressure, respiration, and heart rate) were compared using independent t-test analysis. Patient recovery time, procedure length, and midazolam dosage required were also compared between the two groups.ResultsEighty-five patient charts were included in the final analysis: 47 received TCI-remifentanil/midazolam sedation, and 38 received manual fentanyl/midazolam sedation. Among the physiological parameters, diastolic blood pressure showed slightly higher changes in the fentanyl group (P = 0.049), respiratory rate changes showed higher changes in the fentanyl group (P = 0.032), and the average EtCO2 was slightly higher in the remifentanil group (P = 0.041). There was no significant difference in the minimum SpO2 levels and average procedure length between the fentanyl and remifentanil TCI pump groups (P > 0.05). However, a significant difference was observed in the time required for discharge from the chair (P = 0.048), indicating that patients who received remifentanil required less time for discharge from the chair than those who received fentanyl. The dosage of midazolam used in the fentanyl group was 0.487 mg more than that in the remifentanil group; however, the difference was not significant (P > 0.05).ConclusionThe combination of TCI administered remifentanil combined with manual administered midazolam has the potential to shorten the recovery time and reduce respiration rate changes when compared to manual administration of fentanyl/midazolam. This is possibly due to either the lower midazolam dosage required with TCI remifentanil administration or achieving a stable, steady-state low dose remifentanil concentration for the duration of the procedure.

Emerging Approaches in Intravenous Moderate and Deep Sedation

Successful pharmacological innovations that have made a difference in daily practice are rare in the world of anesthesia and sedation. After many years of research, it seems that we finally have two new drug innovations that are likely to change the paradigm of moderate and deep sedation. These are oliceridine and remimazolam. Both have been in development for over a decade. Oliceridine was synthesized in a lab as an entirely new molecule. It is a biased μ- receptor agonist that acts preferentially on the G-protein pathway (which is responsible for analgesia). At least in lower doses, it has minimal effect on the beta-arrestin pathway, which is responsible for unwanted effects of μ-opioid receptor activation such as respiratory depression and gastrointestinal dysfunction. Like any other μ- receptor agonist, it produces appropriate dose-dependent analgesia. Remimazolam is structurally similar to midazolam; however, it has an additional ester linkage that delivers the kinetics of remifentanil. As a result, while pharmacodynamically identical to midazolam, remimazolam is metabolized by ester hydrolysis and subsequently its elimination is rapid and predictable. The present review discusses the two drugs in detail with a particular emphasis on their potential role in moderate and deep sedation.

Characteristics and selection of the sedative agents and clinical strategies of intravenous moderate sedation during dental treatment

As reported in the previous review, midazolam, propofol and their combination are common choices for intravenous moderate sedation of dental outpatients in Japan. In the “Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018”, midazolam and dexmedetomidine are recommended for “sedative/analgesic medications not intended for general anesthesia”, that is moderate sedation. The aim of this review is to introduce modern view of the sedative agents’ characteristics and to present the clinical strategies of intravenous moderate sedation during dental treatment. Practitioners should select the sedative agent or its combination depending on the patient’s condition and coexisting diseases. Suppression of hemodynamic fluctuation is important in the dental treatment of medically compromised patients such as patients with cardiovascular diseases including hypertension and/or ischemic heart disease. Intravenous moderate sedation has stronger sedative effects than inhalation sedation with nitrous oxide (Minimal sedation: Anxiolysis). Both midazolam and propofol are commonly used in phobic and medically compromised patients. In contrast, propofol is a good candidate for patients with gag reflex and receiving prolonged treatment. Patients with acute closed angle glaucoma and myasthenia gravis, and taking HIV protease inhibitor are contraindications of benzodiazepines including midazolam. Systemic condition of the patient should be evaluated before sedation. Practitioners should consult the family doctor and obtain medical information including laboratory data and regular medications. During sedation basic monitoring items include consciousness, oxygenation, ventilation and circulation such as heart rate and blood pressure. In addition, electrocardiography, capnography and bispectra index monitoring may be appended in some patients with coexisting cardiorespiratory diseases or during deep sedation. Airway protective reflex may be to some degree suppressed during moderate sedation. Airway protective reflex may be to some degree suppressed during moderate sedation. Conclusion. Intravenous moderate sedation has wide range of indications and practitioners can propose safe and comfortable dentistry to the patients.

Dexmedetomidine reduces the amount of benzodiazepines and opioids administered during moderate conscious sedation for dental treatment

To assess the efficacy of dexmedetomidine (DEX) on the intravenous moderate sedation (IVMS) regimen, while treating patients of the special patient care (SPC) population. This study aims to incorporate DEX into the typical IVMS drug regimen in order to reduce the amount of benzodiazepines (BZD) and opioids administered and as a result reduce the amount of unwanted side effects. A retrospective study was performed in the University of California Los Angeles (UCLA) SPC Clinic, where 42 patients were seen with and without DEX for dental treatment under IVMS. Medications administered, vital signs, and complications were recorded at 5 minute intervals over the first hour. All BZDs and opioids were converted to their IV midazolam and IV fentanyl equivalents, respectively. An opioid conversion equation was developed to summate the total amount of anesthetic agents administered. Data were analyzed by t-test. The amount of BZDs administered was reduced, however the decrease was not statistically significant (P=.066). There was a significant reduction in opioids (P<.05) and total anesthetic agents (P<.05) administered. The addition of DEX to the anesthetic regimen results in a reduction of overall medications administered.

Gabapentin for pain control during same-day dilation and evacuation: A double-blind randomized controlled trial

Introduction Scant research evaluates pain management during dilation and evacuation (D&E). Gabapentin has emerged as an effective adjunct for peri-operative pain control. We investigated the effect of gabapentin on pain during D&E. Method We conducted a randomized controlled double-blinded trial among patients undergoing same-day D&E at 14 through 19 weeks gestation under intravenous moderate sedation. Participants were randomized 1:1 to oral gabapentin 600 mg or placebo, administered after misoprostol cervical preparation. Pain was assessed by 100-mm visual analog scale. We assessed satisfaction with pain control, nausea, vomiting, and anxiety using 5-point Likert scales and State Trait Anxiety Inventory. The study was powered to detect a 30% reduction in maximum operative pain (13-mm) assessed five minutes postoperatively. Results We enrolled 126 participants and randomized 61 to gabapentin and 65 to placebo, with study medication administered a mean of 3.5 hours preoperatively (range 1.2–6.2 h). No difference was observed in baseline demographics, parity, or gestational age. Gabapentin was associated with reduced pain after speculum insertion (45 vs 56 mm, p = 0.03) and during uterine aspiration (56 vs 71 mm p = 0.003), compared to placebo. Thirty-minutes post-procedure, the gabapentin group had lower pain (12 vs 23 mm, p=0.008) and higher satisfaction (p = 0.01). Median fentanyl dose was 25 mcg lower in the gabapentin group (75 vs 100 mcg, p = 0.005). Maximum operative pain did not differ between groups (41 vs 49 mm, p = 0.2). Versed dose, nausea, vomiting, and anxiety did not differ between groups. No serious adverse events occurred nor was sedation reversal required. Conclusions The addition of gabapentin to moderate sedation during D&E resulted in reduced intra-operative pain, lower fentanyl dosing, and increased satisfaction with pain control. However, maximum pain reported after the procedure was not different.

Anesthetic Management of a Patient With Systemic Sclerosis and Microstomia

Systemic sclerosis (SSc) is an autoimmune disease that can cause fibrosis in vital organs, often resulting in damage to the skin, blood vessels, gastrointestinal system, lungs, heart, and/or kidneys. Patients with SSc are also likely to develop microstomia, which can render dental treatment difficult and painful, thereby necessitating advanced anesthetic management. This is a case report of a 61-year-old woman with a history of SSc with microstomia, interstitial pneumonia, and gastroesophageal reflux disease in whom intravenous moderate sedation was performed using a combination of dexmedetomidine and ketamine for dental extractions. Both anesthetic agents are known to have analgesic effects while minimizing respiratory depression. Consequently, the increased discomfort caused by opening the patient's mouth and stretching the buccal mucosa was sufficiently managed, permitting an increase in maximum interincisal opening and completion of treatment without complications. Patients with SSc present with serious comorbidities that can negatively impact anesthetic management, so the implementation of an anesthetic plan that takes such risks into account is required. Furthermore, emergency airway management is likely to be difficult in patients with microstomia. For intravenous moderate sedation, combined use of dexmedetomidine and ketamine, which have analgesic effects while minimizing respiratory depression, may be particularly effective in patients with SSc and microstomia.

Clinical practices and education of intravenous moderate/deep sedation in Japan

Safety and comfort during dental procedures are the key factors for high quality dentistry and fundamentals for patient satisfaction. Systemic managements such as general anesthesia and moderate/deep sedation are widely applied to dental outpatients for safe and comfortable dentistry by dentists in Japan. For intravenous moderate sedation, midazolam, propofol and their combination are common choices for dental outpatients. Sometimes deep sedation is required especially in patients with intellectually disability, severe fear/anxiety or severe gaging reflex. Some of these patients may undergo general anesthesia instead of intravenous sedation. The Japanese Dental Society of Anesthesiology (JDSA) established “Practice Guidelines for Intravenous Conscious Sedation in Dentistry” in 2017, and these guidelines become standard for routine clinical practices. In Japan, dental school has 6-year curriculum. Lectures and preclinical practices are given to 4th grade students and clinical practices are to 5th grade students. They learn wide range of knowledge and skills for systemic management of dental patients. JDSA has two board systems for dental anesthesiologists; Japanese Board of Dental Anesthesiology (JBDA) and Board Certified Dental Anesthesiology Specialist (BCDAS). BCDAS is authorized by the Ministry of Health, Labour and Welfare, Japan since 2006. The author would expect the development of dental anesthesiology field in Russia and the progress of anesthesiology collaboration system in dental and medical field.

Moderate and deep sedation training and pharmacology for nonanesthesiologists: recommendations for effective practice.

The purpose of this review is to discuss current drugs used for intravenous moderate and deep sedation by nonanesthesiologists in the United States. We also explore training expectations for moderate and deep sedation as they play key roles in anesthetic selection and preprocedural planning. Although opioids and benzodiazepines are considered the standard for moderate sedation, increased interest in propofol, dexmedetomidine, and other sedative-hyptonic drugs require additional attention in terms of training providers and complying with current practice guidelines. Moderate sedation providers should be familiar with titrating benzodiazepines and opioids to achieve targeted sedation. The use of propofol and ketamine is generally reserved for deep sedation by qualified professionals. However, the role of dexmedetomidine in procedural sedation continues to evolve as its use is explored in moderate sedation. Providers of all sedation types should be aware of hypotension, apnea, hypoventilation, and hypoxia that can develop and they should be able to manage the patient under these circumstances. Preprocedural planning is an integral training expectation to minimize patient risks.

1% versus 2% lignocaine for airway anesthesia in endobronchial ultrasound-guided transbronchial needle aspiration: A pilot, double-blind, randomized controlled trial.

Background and Objectives:No previous study has compared different concentrations of lignocaine for topical anesthesia during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this pilot study, we compared 1% versus 2% lignocaine for topical airway anesthesia during EBUS-TBNA.Methods:In this double-blind, randomized trial, subjects were randomized to receive either 1% or 2% lignocaine for “spray-as-you-go” administration. All received combined moderate intravenous sedation (midazolam and fentanyl). Ten percent pharyngeal lignocaine spray (two sprays) and nebulized lignocaine (2.5 ml of 4% solution) were administered to all subjects. Administration of additional lignocaine was allowed at operator's discretion. The primary endpoints were operator-rated overall procedural satisfaction and cough, each assessed on visual analog scale (VAS), while the secondary outcomes included patient-rated faces pain scale scores, cumulative lignocaine dose, number of subjects receiving lignocaine >8.2 mg/kg, doses of midazolam/fentanyl between groups, and adverse events during procedure.Results:The mean (standard deviation [SD]) VAS scores for operator-rated procedure satisfaction were 64.2 (25.6) and 68.7 (23.7) in 1% and 2% group, respectively (P = 0.35). The median (interquartile range) VAS scores for operator-rated cough were 48.4 (23.9–69.9) in 1% group and 38.7 (18.6–69.5) in 2% group (P = 0.24). The mean [SD] cumulative lignocaine received in the 2% lignocaine group (248.6 [29.1] mg) was significantly greater than in 1% lignocaine group (178.5 [14.6] mg) (P < 0.01).Conclusion:One percent lignocaine is equally efficacious as 2% lignocaine for topical anesthesia during EBUS-TBNA, at a significantly lower cumulative lignocaine dose.

Moderate intravenous sedation for first trimester surgical abortion: a comparison of adverse outcomes between obese and normal-weight women

ObjectiveTo determine if obese women experience increased rates of adverse outcomes with moderate intravenous sedation during first trimester surgical abortion compared to normal weight women. Study designWe performed a retrospective cohort study of all first trimester surgical abortions with moderate intravenous sedation at an outpatient facility between September 2010 and June 2015. The primary outcome was supplemental oxygen administration. Secondary outcomes included reversal agent administration, anesthesia-related adverse events, and intraoperative lowest level of consciousness (LLOC). We compared three obesity groups [I (Body Mass Index, BMI=30–34.9), II (BMI=35–39.9), and III (BMI ≥40)] to normal weight women (BMI <25). We exported data from electronic medical records and reviewed adverse outcomes individually. ResultsOf 20,381 first trimester surgical abortion procedures, 31 (0.15%) utilized supplemental oxygen, 24 (0.12%) utilized a reversal agent, 40 (0.20%) had a presumed anesthesia-related adverse event and 184 of 19,725 (0.93%) had a documented low intraoperative LLOC. One patient (0.005%) required hospital transfer or hospitalization. Supplemental oxygen administration (obesity versus normal weight: obese I, aOR 0.52, 95% CI 0.12–2.27; II/III, aOR 1.51, 95% CI 0.50–4.54), low intraoperative LLOC, and anesthesia-related adverse events were not associated with obesity. The rate of reversal agent administration was lower among obese I, II and III women combined compared to normal weight women (aOR 0.13, 95% CI 0.02–0.96). ConclusionsAdverse outcomes were rare across all BMI categories with no detectable increased risk among obese women compared to normal weight women. ImplicationsWith appropriate clinical screening, obese women can safely receive moderate intravenous sedation for first trimester surgical abortion in an outpatient clinical setting. Restrictions on moderate intravenous sedation based on BMI alone may be unnecessary.

BMI as predictor of adverse outcomes with moderate intravenous sedation during surgical abortion

BMI as predictor of adverse outcomes with moderate intravenous sedation during surgical abortion

A Novel Anesthetic Technique for PEVAR

Percutaneous endovascular aneurysm repair (PEVAR) continues to evolve. Device profiles continue to decline, further reducing the physiological insult of the procedure. Anesthesia, however, has not evolved with a large proportion of patients continuing to receive general anesthesia for their increasingly less invasive procedures. We report on a novel anesthetic technique providing outstanding anesthesia in patients undergoing PEVAR in an outpatient setting. The total anesthesia used was remarkably cost effective. Six patients underwent PEVAR in an outpatient setting. The patients received moderate intravenous (IV) access sedation using versed and fentanyl in combination with bilateral ilioinguinal nerve blocks. Patients received 25mL bilaterally of 0.5% bupivicaine with epinephrine. All patients were American Society of Anesthesiologists class III. None received central venous access, arterial, or urinary catheters. Standard noninvasive monitoring was used. A board-certified anesthesiologist was present at all times during the procedures. All patients underwent successful repair. Average cost per case for anesthetic supplies averaged around $7.00. The fentanyl dose ranged from 100 to 200μg with an average dose of 130 μg. Versed dose ranged from 2 to 3mg with an average dose of 2.4mg. No patient required conversion to general anesthesia. Postoperative pain relief was excellent. Two patients required pain medication before discharge. Two patients required oral narcotic analgesic the night of discharge. No patients required narcotics after that time. Bilateral ilioinguinal nerve block, when combined with moderate IV sedation allows outstanding anesthesia for patients undergoing PEVAR. This novel combination has not been reported previously. The technique provides safe, effective, care for of a subset of patients not requiring general anesthesia. It offers a greatly reduced cost when compared with general anesthesia. Additional benefits include prolonged pain relief perioperatively as well as potentially decreasing the physiologic and cognitive effects seen with general anesthesia.

Ifdas Meeting is Coming Up

Ifdas Meeting is Coming Up