Need For Sedation Research Articles

Prospective Observational Cohort Study on Dexmedetomidine and Midazolam in Mechanically Ventilated Children

Introduction: Though target sedation was achieved with Midazolam and Dexmedetomidine, Dexmedetomidine has demonstrated the lesser complications and shorter duration of stay in Intensive Care Unit (ICU). Most of the studies are reported from high income countries. The studies on Midazolam and Dexmedetomidine use in mechanically ventilated children are scanty in low-middle income regions. Aim: To compare the efficacy of Midazolam and Dexmedetomidine for sedation in mechanically ventilated children. Materials and Methods: This prospective observational cohort study was conducted in academic hospital Paediatric Intensive Care Unit (PICU) from March 2015 to June 2016. Children aged less than 13 years mechanically ventilated for more than 24-hour and received sedative with either infusion of Midazolam or Dexmedetomidine without loading dose were involved. Patients with unstable haemodynamic throughout PICU stay and expired within 24-hour and incomplete medical data were excluded. Intermittent Fentanyl/Morphine was used as when needed as per treating team decisions. Sedation assessment was performed with Ramsey sedation scale (RSS, target=3-4 out of 6), Tracheal suctioning score and PICU sedation score. The primary outcome was “percentage of time with target sedation” till extubation. The secondary outcome was the cumulative dose of sedation used, the need for rescue sedation and the rate of complications, organ dysfunction {by Sequential Organ Failure Assessment (SOFA) score and Paediatric Logistic Organ Dysfunction (PELOD) score} and the length of stay in ventilation, PICU and mortality. Results: A total of 115 patients (Midazolam-group, n=63 and Dexmedetomidine-group, n=52) were enrolled. The median age was 12 months (IQR 8-30). Mean (±SD) PRISM-III score was 11.3±7.2. About 54.8% were ventilated for respiratory pathology, followed by CNS pathology (25.2%) and sepsis (10.4%). Mean (±SD) percentage of the duration of proper sedation was not significantly different in Midazolam-group (83.4±15.6) and Dexmedetomidine-group (81.4±17) (p=0.510). The cumulative dose (microgram per kg) requirement was higher in Midazolam-group {median (IQR) 12.2 (9.8-17.1) vs. 9.6 (5-15.3); p=0.019)}.No difference was note in need for “rescue dose of sedation” per patient {median (IQR) 1 (0-2) vs. 1 (0-2)}, rate of complications (bradycardia 9.5% vs. 1.9%; hypotension 9.5% vs. 5.8%). No difference was noted in organ dysfunction score {mean difference, 95% CI; SOFA score: -0.2 (-1.6 to 1.33); p=0.808 and PeLOD score: 1.3 (-1.5 to 4.1); p=0.364}, duration of ventilation (median, IQR 2.7 (2-3.3) vs. 2.0 (1.5-3.1) days and mortality (20.6% vs. 21.2%). PICU stay was significantly lower in Midazolam-group (median, IQR 3 days, 1-5 vs. 5 days, 4-6; p=<0.001). Conclusion:Midazolam and Dexmedetomidine were associated with similar target sedation with a comparable rate of complications in mechanically ventilated children. However, Midazolam required a higher cumulative dose to achieve target sedation.

Endoscopic Carpal Tunnel Release: One-Portal Technique.

The 1-portal technique, as described by Agee et al., is performed with the patient under general anesthesia, supplemented with only a small amount of local anesthesia in the beginning to blunt the pain response during the incision. Then, once the patient is fully anesthetized, the endoscope is inserted, and the carpal ligament is visualized and incised. The incision is closed and the dressing is applied. Another surgical alternative is open carpal tunnel release. Nonsurgical alternatives include corticosteroid injection, splinting, nonsteroidal anti-inflammatory drugs, and ergonomics. The incision is smaller and less painful than the incision utilized during open carpal tunnel release. There is less need for analgesia. Unlike the incision utilized during open carpal tunnel release, the incision in this procedure is not made in a weight-bearing surface of the hand and generally is not firm and tender. Studies also show an earlier return to work with this technique. The endoscopic technique is only for a primary release. Surgical intervention for recurrent carpal tunnel syndrome needs to be performed with the open technique. Because of the need for deep sedation, only patients who are healthy enough for general sedation are candidates for the 1-portal technique. The risk of nerve injury with this technique is higher than with open carpal tunnel release. Generally, the patient will have very rapid resolution of the preoperative paresthesia. The incision typically heals very well; however, when closing the 1.5-cm incision with skin glue and Steri-Strips (3M), there may be cases of delayed wound-healing if the patient is overly physically active in the first 2 weeks after the procedure. Make sure that the endoscope is properly set up and that the patient is supine and the arm is abducted 90° at the shoulder with the hand and forearm fully supinated. Seating of the surgeon and assistant(s) and placement of the monitor are important.Make sure that the patient is fully anesthetized, particularly when the endoscope is being used. If the patient moves during the endoscopic incision of the ligament, other structures (i.e., vessels, nerves, and tendons) could be injured.Difficulty with the insertion of the scope can result in injuries. The carpal ligament must be visualized with the scope prior to any attempts at cutting the ligament. Convert to an open procedure if there are any difficulties with endoscope insertion or visualizing the carpal ligament.

A Comparative Study of Periarticular Infiltration with Dexmedetomidine versus Ketorolac as an Additive to Ropivacaine after Total Knee Arthroplasty: A Prospective, Randomized Double-Blind Study.

Background:Periarticular infiltration (PAI) analgesia has been found to be an effective analgesia modality after total knee arthroplasty (TKA). Dexmedetomidine has many beneficial effects on postoperative analgesia by different routes, but studies on PAI are lagging.Aims and Objectives:In this study, we compared postoperative analgesia after PAI with dexmedetomidine versus ketorolac as an additive to ropivacaine after TKA.Setting and Design:This is a prospective, randomized, double-blind study conducted on 75 patients belonging to American Society of Anesthesiologists I to III, undergoing total knee arthroplasty, of either gender, belonging to American Society of Anesthesiologists I to III.Materials and Methods:After institutional ethics committee approval and written informed consent, patients were randomly allocated into three groups. Group C (n = 25) received cocktail of 60 mL ropivacaine (0.25%) infiltration with adrenaline 5 mL (0.1 mg.mL−1), Group D (n = 25) received additive dexmedetomidine 1 ug.kg−1 to above cocktail, and Group K (n = 25) received ketorolac 30 mg. Postoperatively pain by Visual Analog Scale, vitals, total duration of analgesia, need for rescue analgesia, sedation, patient satisfaction, mobilization time, and complications were recorded.Statistical Analysis:The Statistical Package for the Social Sciences version 20 was used for statistical analysis. Analysis of variance has been used to find the significance of study parameters between the three groups of patients. P < 0.05 was considered statistically significant.Results:Postoperative pain score was lesser in the ketorolac group (1.52 ± 0.71, P = 0.001) than the other two groups. Duration of analgesia was more with ketorolac (343.00 ± 144.45, P < 0.001) compared with the other two groups, and epidural activation timings (462 ± 235.84) were significantly delayed in Group K compared to Group C and Group D. There was no significant difference in mobilization time, patient satisfaction, and complications between the three groups.Conclusion:Ketorolac was a better additive to ropivacaine than dexmedetomidine for postoperative analgesia after TKA.

Consider Heightened Awareness of Propofol Infusion Syndrome after Extracorporeal Membrane Oxygenation (ECMO) Decannulation

THE PHARMACOKINETICS of sedative drugs can be affected by multiple factors in critically ill patients. Moreover, in patients undergoing extracorporeal membrane oxygenation (ECMO), data regarding appropriate dosing of sedative drugs is limited. ECMO is an invasive management for those who have failed conservative treatment for refractory respiratory or cardiac failure. Currently there are no consensus guidelines regarding sedation strategies for these patients. However, it is understood that lipophilic agents such as propofol can be sequestered in the extracorporeal circuit (ie, tubing and oxygenators), resulting in reduced plasma drug levels and the need for higher doses to achieve the same clinical effect seen in non-ECMO patients. 1 Hammaren E. Rosenberg P. Hynynen M. Coating of extracorporeal circuit with heparin does not prevent sequestration of propofol in vitro. Br J Anaesth. 1999; 82: 38-40 Abstract Full Text PDF PubMed Scopus (25) Google Scholar Further complicating matters, the configuration of ECMO may also affect medication requirements. Patients on venovenous (VV) ECMO appear to need higher doses as compared with patients on venoarterial (VA) ECMO. 2 Shekar K. Roberts J.A. Mullany D.V. Corley A. Fisquet S. Bull T.N. et al. Increased sedation requirements in patients receiving extracorporeal membrane oxygenation for respiratory and cardiorespiratory failure. Anaesth Intens Care. 2012; 40: 648-655 Crossref PubMed Google Scholar Pharmacokinetic data related to ECMO are often derived from in vitro studies, and to the best of the authors’ knowledge there is no strong literature describing this phenomenon that could help guide care for critically ill patients on ECMO. The need for sedation in the critically ill is often unavoidable and frequently necessary to promote comfort, alleviate pain and anxiety, relieve agitation and distress from the acute illness, and facilitate ventilator synchrony. 3 Sessler C.N. Wilhelm W. Analgesia and sedation in the intensive care unit: an overview of the issues. Crit Care (London). 2008; 12: S1 Crossref PubMed Scopus (30) Google Scholar However, excessive use of sedatives can have adverse outcomes. 4 Jackson D.L. Proudfoot C.W. Cann K.F. et al. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010; 14: R59 Crossref PubMed Scopus (104) Google Scholar Sedation needs in ECMO patients are often safety related, as it reduces the risk of catheter dislodgement or malposition (an important consideration in those centrally cannulated with an open chest), reduces coughing and Valsalva (which may negatively impact venous drainage), and facilitates comfort and ventilator synchrony in those unable to be extubated. The authors describe an interesting case of propofol infusion syndrome developing in a patient who was recently decannulated from VA ECMO.

Pediatric minor head injury imaging practices: results from an ESPR survey.

Computed tomography (CT) for minor head injury exposes a large number of children to ionizing radiation, with an associated increased lifetime risk of malignancy. To study imaging practices for children with minor head injury and the level of awareness of radiologists of the current clinical decision rules for minor traumatic brain injury (TBI). A questionnaire consisting of 17 questions was distributed electronically to 472 ESPR members. The questionnaire covered demographic information, employment status, years of experience and the current practice setting of the participants, the number of CTs performed for pediatric head trauma, awareness of clinical decision rules and use of shielding, pediatric CT protocol and MRI. The response rate was 18.4%. The majority of participants was aged over 50years and was full-time consultants. Regarding decision rules, 73.8% of respondents cited the NICE head injury guidelines, and 79% reported that the decision to perform CT was agreed between specialists. Shielding was used by 58.3% and 67.4% applied a specific pediatric protocol. MRI was not used for pediatric head trauma by 70.6% of respondents, although always available in 68.6% of cases. The reported obstacles to MRI use were machine availability (42.7%), the long acquisition time (39%) and patients' intolerance (18.3%), and less frequently the cost and the need for sedation. There is room for decreasing the use of CT for pediatric minor TBI. The use of shielding and application of pediatric CT protocols constitute areas for improvement.

Serratus anterior plane block in subcutaneous implantable cardioverter defibrillator implantation: A case‐control analysis

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 to provide anesthesia/analgesia during S-ICD implantation. We performed a case-control analysis in which a standardized SAPB approach was compared with the typical local anesthesia and sedation approach. Ninety-one 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 a standard local approach. The mean procedure duration was 59 ± 15 minutes in the SAPB group and 76 ± 23 minutes in the control group (P < .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 < .001) remained awake. Lower values of pain intensity at the device pocket (P = .005) and the lateral tunneling site (P = .046) were reported in the SAPB group. The difference in static (P = .002) and dynamic (P = .007) pain intensity between the groups persisted at 1 hour, while no differences were observed 6 hours after the end of the procedure. 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.

Lasting s-ketamine block of spreading depolarizations in subarachnoid hemorrhage: a retrospective cohort study

ObjectiveSpreading depolarizations (SD) are characterized by breakdown of transmembrane ion gradients and excitotoxicity. Experimentally, N-methyl-d-aspartate receptor (NMDAR) antagonists block a majority of SDs. In many hospitals, the NMDAR antagonist s-ketamine and the GABAA agonist midazolam represent the current second-line combination treatment to sedate patients with devastating cerebral injuries. A pressing clinical question is whether this option should become first-line in sedation-requiring individuals in whom SDs are detected, yet the s-ketamine dose necessary to adequately inhibit SDs is unknown. Moreover, use-dependent tolerance could be a problem for SD inhibition in the clinic.MethodsWe performed a retrospective cohort study of 66 patients with aneurysmal subarachnoid hemorrhage (aSAH) from a prospectively collected database. Thirty-three of 66 patients received s-ketamine during electrocorticographic neuromonitoring of SDs in neurointensive care. The decision to give s-ketamine was dependent on the need for stronger sedation, so it was expected that patients receiving s-ketamine would have a worse clinical outcome.ResultsS-ketamine application started 4.2 ± 3.5 days after aSAH. The mean dose was 2.8 ± 1.4 mg/kg body weight (BW)/h and thus higher than the dose recommended for sedation. First, patients were divided according to whether they received s-ketamine at any time or not. No significant difference in SD counts was found between groups (negative binomial model using the SD count per patient as outcome variable, p = 0.288). This most likely resulted from the fact that 368 SDs had already occurred in the s-ketamine group before s-ketamine was given. However, in patients receiving s-ketamine, we found a significant decrease in SD incidence when s-ketamine was started (Poisson model with a random intercept for patient, coefficient − 1.83 (95% confidence intervals − 2.17; − 1.50), p < 0.001; logistic regression model, odds ratio (OR) 0.13 (0.08; 0.19), p < 0.001). Thereafter, data was further divided into low-dose (0.1–2.0 mg/kg BW/h) and high-dose (2.1–7.0 mg/kg/h) segments. High-dose s-ketamine resulted in further significant decrease in SD incidence (Poisson model, − 1.10 (− 1.71; − 0.49), p < 0.001; logistic regression model, OR 0.33 (0.17; 0.63), p < 0.001). There was little evidence of SD tolerance to long-term s-ketamine sedation through 5 days.ConclusionsThese results provide a foundation for a multicenter, neuromonitoring-guided, proof-of-concept trial of ketamine and midazolam as a first-line sedative regime.

LEGO MRI: Decreasing the Need for Sedation, and Improving Patient Anxiety.

LEGO MRI: Decreasing the Need for Sedation, and Improving Patient Anxiety.

Promoting NIV using ICEMAN methodology

One of the main reasons for children needing hospital admission is the need for respiratory support and monitoring. Intubation and ventilation has been the standard method of supporting patients in respiratory failure. With better ventilators and interfaces many of these children with respiratory failure could benefit from non-invasive ventilation (NIV). The main advantages of NIV over its invasive counterpart are reduced need for sedation, avoiding laryngeal and tracheal injuries, reducing nosocomial infections, and shorter length of stay.1,2 NIV can be used for acute conditions. Studies have shown that NIV is more successful in type 2 respiratory failure compared to type 1 respiratory failure as in type 2 respiratory failure, a failing pump is replaced by another pump i.e., NIV machine.3,4 With improvement in technology NIV has emerged as a core therapy in the management of patients with acute and chronic respiratory failure. Use of NIV has not spread worldwide. Even in the countries where they are being used, there is huge variability in the use of NIV. This reluctance in usage could be partly explained by the lack of adequate scientific literature in children concerning this technology.The first thing to do to overcome this barrier is to create an understanding and familiarity of this technology, resulting in more usage of NIV which has been shown to improve the quality of care and reduce cost of healthcare.A FAST-NIVT (Forwarding Advanced Simulation Training in Noninvasive Ventilation Therapy) project supported by the Respiratory group of ESPNIC (European Society of Pediatric and Neonatal Intensive Care) has developed blended courses (online and face to face) for attendees and for NIV trainers in order to promote the teaching and learning of NIV around the world.As an extension of this project we have developed a structured algorithm with the acronym ICEMAN (Figure 1) and used it to train our clinicians in the judicious selection of patients, contraindications and equipment used for NIV.2 This approach helps the teams to recognize failure of non-invasive ventilation, troubleshoot hypercapnia and hypoxemia, manage asynchrony and plan for weaning or escalation of care using algorithms.We have conducted workshops globally to provide clinicians with best practice recommendations and guidance about how to best deliver non-invasive ventilation to patients who sometimes need this lifesaving technology. By attending this workshop, delegates would be able to understand the various indications, NIV options, modes of delivery, effective monitoring, and analysing failures which will definitely go a long way in providing this care more effectively with less failure.All the workshops are led by trained educators who are experienced practicing paediatric intensivists, neonatologists, and pulmonologists with an extensive NIV experience. To make learning fun and to encourage participation, high-quality learning materials and skill stations have been tailored to the needs of each group. This methodology has been successfully used to train the next generation of clinical champions.

Pediatric headache and neuroimaging: experience of two tertiary centers.

Headache is a frequent complaint in children and adolescents. Decision-making for neuroimaging should take into account the cost and the need for sedation in young children. To evaluate the yield of MRI in pediatric headache patients seen in two large tertiary hospitals. Data were retrospectively collected from patient records (n = 613) and neuroimaging reports. Headache was classified according to International Headache Society guidelines. There were 346 children with imaging studies (MRI n = 281, CT n = 65). Of patients who had at least one MRI study, 29% demonstrated an abnormal finding. Findings altering the management were obtained in 21 (7%) patients: the majority (n = 17, 80%) had headache for less than 3months. On the other hand, four patients with headache longer than 3months (19%) and 12 patients with normal neurological examination (57%) had significant MRI results affecting management. None of the children in whom the diagnosis of migraine could be made on clinical grounds (n = 40) had a significant MRI finding. Neuroimaging should be performed selectively in children with headache seen in pediatric neurology clinics, especially in headache of short duration (< 3months) and features atypical for migraine. A normal neurological examination should not reassure the clinician.

Utility of local anesthesia for open carpal tunnel release in patients with psychiatric diagnoses

PurposeCarpal tunnel release, one of the most commonly performed procedures in Veterans Affairs (VA) medical centers, is often performed under local anesthesia alone. In this patient population, there is an increased prevalence of psychiatric disorders. Our hypothesis is that there is no difference in operating time, request for sedation, or complications in the veteran population with or without a recognized psychiatric history. MethodsA retrospective cohort study was performed at a VA medical center from January 2013 to January 2017 by the senior surgeon (E.S.L). Patients were divided into two groups: patients with no known psychiatric history (n = =33) and patients with an active psychiatric diagnosis (n = =25), including post-traumatic stress disorder, anxiety disorder, bipolar disorder, depression, substance abuse, or panic disorder. Primary endpoints included operation time, time in operating room, request for sedation, and complication rates. ResultsFifty-nine percent of patients successfully underwent wide-awake hand surgery, while 41% requested sedation. Patients with no known psychiatric history had a 45.5% rate of requesting sedation compared to 36% in those with a psychiatric diagnosis. No patients converted from wide-awake surgery to sedation. There was no statistically significant difference in operation time, time in the operating room, need for sedation, or complication rate between all groups. ConclusionsWide-awake hand surgery is an excellent technique that can be safely used in patients with a history of psychiatric illness. Without the need for monitored anesthesia care, the cost for carpal tunnel releases done in military medical centers could decrease dramatically. Type of StudyPrognostic Level of EvidenceLevel II

The risk of unfavorable outcomes in critically ill patients during interhospital transportation in Tyumen Region

The objective : assessment of the risk of unfavorable outcomes in critically ill patients based on the experience of interhospital transportation in Tyumen Region. Methods . The results of 338 patients’ transportation from hospitals of the Tyumen Region for 4 months of 2018 were studied. To assure the group homogeneity, exclusion criteria were used (in order to assess changes in hemodynamic parameters, patients with upcoming or recently performed cardiac surgery, those who had acute myocardial infarction in the last 6 months, were excluded from the study, as well as children under 14 years old, whose hemodynamic parameters depended on the age). Results . Interhospital evacuation of patients at night was statistically significantly associated with lower systolic blood pressure, lower Glasgow coma score, and more often required artificial pulmonary mechanical ventilation (APV) on the way. Conclusions . The severity of the condition of patients undergoing interhospital transfer is closely associated with the state of three systems: respiratory, cardiovascular and central nervous systems. With unfavorable assessment of functions of these systems, the risk of deterioration of the patient's condition during evacuation can accelerate. Tests of these systems’ functions should be the basis of the scales aimed to assess the transportation risk. It was found that impaired consciousness and the need for sedation correlated with condition severity (r = 0.46; p = 0.03) and the need for artificial pulmonary ventilation (r = 0.55; p = 0.05), and if the decision on APV was not made in due time it could serve as a signal to start mechanical ventilation during transportation. Interhospital evacuation at night often requires APV, which in the absence of the timely decision about the patient’s intubation can lead to a deterioration of the condition directly associated with transportation (t = 2.19; p = 0.03) and the increased risk of critical incidents.

Benefits of Silent DWI MRI in Success Rate, Image Quality, and the Need for Secondary Sedation During Brain Imaging of Children of 3–36 Months of Age

Silent T1W and T2W magnetic resonance imaging (MRI) can be used to study myelination in children, but the success rate of silent diffusion-weighted imaging is unknown. This study aimed to evaluate the success rate and image quality of silent MRI for the brain of children. This was a retrospective study of 3-36-month children who underwent silent or conventional brain MRI at the People's Hospital of Northern Jiangsu from 01/2015 to 02/2018. The success rates were compared. The acoustic noise of each sequence was measured using a decibel meter. The signal-to-noise ratio and contrast-to-noise ratio of the diffusion-weighted imaging, T2W, and T1W sequences were analyzed. Subjective image quality (lesion delineation, visibility, gray-white differentiation, and overall diagnostic usefulness) was determined. The success rate of silent MRI (n = 443) was higher than that of conventional MRI (n = 391) (97.7% vs. 88.2%, p < 0.001). The acoustic noise of all silent sequences was lower than that of the conventional sequence (all p < 0.05). Silent sequences showed decreased signal-to-noise ratio vs. conventional sequences but increased contrast-to-noise ratio (all p < 0.05). Lesion delineation was not significantly different. Lesion visibility and gray-white differentiation of all silent sequences were higher (all p < 0.05). The overall diagnostic usefulness of the silent group was higher (p < 0.001). Silent MRI can effectively improve the success rate of MRI in children of 3-36 months. Noise is reduced, and the overall diagnostic usefulness is higher than that of conventional MRI. Silent MRI is more suitable for children's brain scan than conventional MRI.

Initial clinical experience with high-pitch dual-source CT as a rapid technique for thoraco-abdominal evaluation in awake infants and young children

To evaluate dual-source high-pitch computed tomography (HPCT) imaging of the chest and abdomen as a rapid scanning technique to obtain diagnostic-quality imaging evaluation of infants and young children without sedation. Fifty-three paediatric patients (age 24.1±2 months) who underwent chest or abdomen HPCT (≥1.5) and standard pitch CT (SPCT, <1.5) on a dual-source 128-row multidetector CT system were included in the study. Image quality assessment was performed by two paediatric radiologists for diagnostic confidence, image artefacts, and image noise. Objective image noise was measured. Most of the CT examinations were performed in children who were >1 year old (n=15 and n=20) followed by ≤1 year old (n=8 and n=10) in SPCT and HPCT, respectively. The mean radiation dose (SSDE) from HPCT was 1.96±1 mGy compared to 2.2±1 mGy for SPCT (p=0.3). No major artefacts were reported and overall image quality of all HPCT examinations was acceptable diagnostically. In addition, objective image noise values were not significantly different between HPCT compared with SPCT (11±3 versus 11±5, p=0.7). Ultra-fast, HPCT can be performed without the need for sedation as a potential alternative to anaesthetised magnetic resonance imaging in infants and young children.

Peri‐operative considerations for sedation‐analgesia during cataract surgery: a narrative review

Cataract surgery is usually of short duration and is associated with minimal pain when employing topical or regional anaesthesia. Patient education regarding the peri-operative process may help alleviate anxiety and avoid the need for sedation. However, sedation may be required, and we discuss the various options. Many consider that pre-operative fasting is necessary due to the risk of aspiration but fasting may not be required if minimal sedation is administered. If the use of sedatives, hypnotics or analgesics is required, then their associated adverse events should be considered.

Feasibility of sedation on demand in Taiwan using water exchange and air insufflation: A randomized controlled trial.

Completion of colonoscopy without sedation eliminates sedation cost and complications. Reported in the United States and Europe, on-demand sedation is not routine practice in Taiwan. Water exchange (WE), characterized by infusion and nearly complete removal of infused water during insertion, reduces insertion pain compared to air insufflation (AI) during colonoscopy. We evaluated the feasibility of on-demand sedation in Taiwan. In a randomized controlled trial of WE vs AI colonoscopy, we also aimed to determine if WE augmented the implementation by reducing insertion pain and decreasing sedation requirement. This prospective patient-blinded study randomized patients to AI or WE (75 patients/group) to aid insertion. The primary outcome was the proportion of patients completing without sedation. In the AI and WE groups, 76.0% and 93.3% (P=0.006) completed without need for sedation, respectively. The WE group had lower insertion pain score (mean [SD]) (4.0 [2.9] vs 2.1 [2.6], P<0.001), lower doses of propofol (25.7 [52.7] mg vs 9.1 [35.6] mg, P=0.012), and less time in the recovery room (3.4 [7.4] vs 1.5 [5.5], P=0.027) than the AI group. Patient satisfaction scores and willingness to repeat if needed in the future were similar. On-demand sedation was feasible in Taiwan. The completion rate without sedation was high in patients (76.0% with standard AI) open to the option (no prior intent to receive the standard of full or minimal sedation). WE augmented the implementation by reducing insertion pain and decreasing sedation requirement without adversely affecting patient satisfaction or willingness to repeat.

¿Cuál es el volumen tidal ideal en pacientes ingresados en UCI sin SDRA que requieren ventilación mecánica más de 24 horas?

La protección pulmonar en los pacientes críticos sometidos a ventilación mecánica, es uno de los objetivos que persiguen los facultativos cuando utilizan esta herramienta terapéutica; que, pese a todos sus beneficios y su uso extendido, no está exenta de efectos adversos. El apoyo ventilatorio en el Síndrome de Distrés Respiratorio Agudo (SDRA) consta de una serie de medidas, entre las que se incluye el volumen tidal (VT) bajo. Pero, ¿qué ocurre con aquellos pacientes que precisan más de 24 horas de ventilación mecánica sin criterios de SDRA? ¿Cuál es su VT recomendado? La evidencia científica apoya que la ventilación con VT bajo se asocia a la disminución del número de complicaciones respiratorias en comparación con VT alto (si bien, los ensayos clínicos preexistentes comparaban volúmenes bajos de 6 ml/kg vs volúmenes muy altos, de más de 10 ml/kg) (1)(2). Por contra, los VT bajos pueden incrementar la necesidad de sedación, aumentan la tasa de asincronía entre el paciente y el ventilador e incluso algunos trabajos hablan de que podría aumentar el riesgo de delirio.(3) El objetivo principal del estudio fue determinar si una estrategia de ventilación con VT bajo es más efectiva que una estrategia de VT intermedio en función del número de días libres de ventilación en el día 28 en los pacientes vivos tras la aleatorización. ABSTRACT Which is the ideal tidal volume for patients in ICU without ARDS who need mechanical ventilation more than 24h? Invasive ventilation, one of the most frequently applied strategies in the intensive care unit (ICU), is increasingly recognized as a potentially harmful intervention. There is evidence that lung-protective ventilation using low tidal volumes improves survival in patients with acute respiratory distress syndrome (ARDS), but it is less certain whether tidal volume restriction benefits patients without ARDS. Two randomized clinical trials found tidal volume reduction to be associated with a lower number of pulmonary complications in patients without ARDS, and 2 individual patient data meta-analyses suggested that tidal volume reduction may shorten the time spent on the ventilator and duration of stay in the ICU and hospital. However, the use of low tidal volumes could lead to an in- creased need for sedation because of higher respiratory rate or patient-ventilator asynchrony and, possibly, self- inflicted lung injury due to compensatory injurious inspiratory efforts. In addition, it has been suggested that low tidal volumes may increase the risk of delirium. The Protective Ventilation in Patients Without ARDS (PReVENT) trial was conducted to test whether a ventilation strategy using low tidal volumes is superior to a ventilation strategy using intermediate tidal volumes with respect to the number of ventilator-free days and alive at day.

Neonatal Head Ultrasound: A Review and Update-Part 1: Techniques and Evaluation of the Premature Neonate.

Ultrasound of the infant brain has proven to be an important diagnostic tool in the evaluation of neonatal brain morphology and pathology since its introduction in the late 1970s and early 1980s. It is a relatively inexpensive examination that can be performed in the isolette in the neonatal intensive care unit. There is no radiation exposure and no need for sedation. This article will discuss gray scale and Doppler techniques and findings in normal head ultrasounds of premature neonates. It will discuss intracranial pathologies noted in such neonates and their neurodevelopmental outcome.

Evidence-Based Review and Discussion Points

Evidence-Based Review and Discussion Points

Intranasal Ketamine Use in Pediatric Emergency Departments

To reduce the need for intravenous sedation, a pediatric emergency department began using intranasal (IN) ketamine in patients aged ≥6 months.