Propofol Bolus Research Articles

Hemodynamic responses to 1 MAC desflurane inhalation during anesthesia induction with propofol bolus and remifentanil continuous infusion: a prospective randomized single-blind clinical investigation

BackgroundDesflurane is not recommended during anesthesia induction because of its sympathetic stimulation effect, particularly in patients with myocardial ischemic disease. To date, the hemodynamic response to 1 MAC desflurane inhalation in combination with remifentanil infusion during anesthesia induction has rarely been reported.MethodsThis investigation was designed to compare hemodynamic responses to 1 MAC desflurane (group D, n = 200) with sevoflurane (group S, n = 200) during anesthesia induction and endotracheal intubation in adult patients undergoing elective spine surgery. Subgroup analysis of the different age subgroups was also performed. With continuous infusion of remifentanil 0.1 μg/kg/min, anesthesia was induced with propofol bolus, and endotracheal intubation was performed after muscle relaxation. Heart rate (HR) and mean arterial blood pressure (MAP) were measured every minute for 5 min after anesthesia induction (T1-5) and after endotracheal intubation (T6-10).ResultsHR was significantly higher in group D (n = 182) than in group S (n = 173) at T3-10 except at T6 (1 min after intubation) (all P < 0.05). In the age-based subgroup analyses, which subdivided the group D and S into four subgroups based on patient’s age, the changes in HR from baseline values were significantly different between the coeval subgroups of patients in their 20–29 years and 30–39 years of age (all P < 0.05). MAP was reduced from baseline value, irrespective of group and age.ConclusionInhalation of 1 MAC desflurane during anesthesia induction with propofol bolus and remifentanil continuous infusion and during endotracheal intubation was more likely to induce elevations in HR more likely than 1 MAC sevoflurane, especially in younger patients.Trial registrationThis study was registered in the Clinical Research Information Service (CRIS, http://cris.nih.go.kr) of the Republic of Korea on Feb 12, 2016 (Registration No. KCT 0,001,813).

Evaluation of paradoxical effect of small dose ketamine as adjuvant in deep sedation for endoscopy patients

ABSTRACT Background This study tested the hypothesis that use of ketamine as an ‎adjuvant to propofol in the induction of deep sedation for ‎endoscopy patients could lead, paradoxically, to faster ‎emergence.‎ Methods We conducted a single-center, prospective randomized ‎controlled study on 154 adult ASA I or II patients‎, admitted for ‎gastrointestinal endoscopies‎. Patients were sedated with 25 µg ‎fentanyl and 1 mg/kg propofol bolus over 30 s. Patients ‎were divided into two groups: Group P (n = 77), sedated with ‎propofol only, and Group PK (n = 77), who received additionally a ‎single dose of ketamine (0.1 mg/kg) at induction. If the patient ‎moved or Ramsay Sedation Score (RSS) regressed to <4, ‎increments of 0.25 mg/kg of propofol were given. After the end ‎of the procedure, emergence from sedation was assessed with ‎modified Aldrete score, 5 and 10 m after admission to the ‎recovery room.‎ Results Adding a small dose of ketamine did not significantly achieve ‎deep sedation (RSS ≥4) more quickly or result in lesser ‎propofol increments. Patients who received ketamine showed a ‎statistically significant improvement in the Modified Aldrete ‎score when recorded 5 min after admission to the recovery ‎room (Group P 8.73 ± 1.02, Group PK 9.1 ± 0.96, P value = ‎‎0.02), but not after 10 min (Group P 9.03 ± 0.74, Group PK ‎‎9.21 ± 0.8, P value = 0.146).‎ Conclusion Inclusion of a small single dose of ketamine in the induction of sedation for gastrointestinal endoscopy significantly improves emergence from sedation.

Usefulness of supplemental parasternal block for sternal keloid excision under general anesthesia in a child status post multiple cardiac surgeries

Sir A 12-year-old boy weighing 60 kg, with history of tricuspid atresia, had undergone right modified Blalock–Thomas–Taussig shunt, and patent ductus arteriosus ligation on day 1 of life. One year later he underwent bidirectional Glenn shunt, and extra cardiac Fontan surgery was done at 6 years. He presented now with a thick keloid in the midline sternotomy scar for keloid excision. Current screening echo showed tricuspid atresia, normally related great arteries with normal ventricular flow and unobstructed Glenn and Fontan flow profiles. Intravenous midazolam 1 mg, fentanyl 100 mcg and ketamin 60 mg were given and incremental bolus of propofol 10 mg (total 20 mg) was given till loss of response to verbal commands and relaxation of jaw. Airway was then secured with size 3 proseal laryngeal mask airway (PLMA) and correct placement was ensured with regular endtidal carbon dioxide (ETCO2) waveforms. Parasternal block was then given under ultrasound guidance at third and fifth intercostal spaces 2 cm lateral to midline bilaterally. Spread of injected solution causing separation of pectoralis major muscle from the rib and external intercostal muscle confirmed deposition of drug in the correct plane (Fig. 1). Ten milliliter of 0.25% bupivacaine was injected at each site.Figure 1: Superficial parasternal-intercostal plane block.Anesthesia was maintained with sevoflurane (1.5–2%) in air oxygen mixture under spontaneous ventilation. Intraoperatively patient remained stable with heart rate 86-98/min, systolic blood pressure 90–100 mmHg, oxygen saturation 96–98% and ETCO2 32-40 mmHg and had received 500 ml of Ringer lactate. At the end of surgery, which lasted for 2 h, PLMA was removed when patient was awake. He had good postoperative analgesia. Anesthetic goals in a child post-Fontan surgery include adequate hydration, avoidance of hypoxia, hypercabia, and acidosis and preservation of spontaneous ventilation whenever possible. If general anesthesia is mandated, low inspiratory pressures and minimal positive end expiratory pressures are to be used [1,2]. Sternotomy produces considerable pain which increases with chest wall movement and reduces pulmonary function with higher risk of development of postoperative hypoxia, atelectasis, and pneumonia [3]. Parasternal block is commonly advocated to provide supplemental anaesthesia intraoperatively and for postoperative analgesia following median sternotomy, breast surgery and cardioverter-defibrillator implantation [4,5]. The nerve targeted is the anterior branches of intercostal nerves which enters intercostal and pectoralis major muscles and innervates the antero-medial region of chest wall. Local anesthetic is injected deep to pectoralis major muscle and superficial to intercostal muscles or between internal thoracic muscle and transverses thoracis muscle. Therefore, these blocks are essentially described as superficial or deep parasternal-intercostal plane blocks, depending on where the target nerves are blocked. The anatomical injection site differentiates these techniques though both techniques provide analgesia to the antero-medial chest wall [5]. Supplemental regional block helps to reduce dose requirement of anesthetic agents intraoperatively. Use of supplemental parasternal block enabled us to keep the child spontaneously breathing under general anaesthesia using PLMA with use of lesser doses of anesthetic agents, thereby minimising drug adverse effects which could be deleterious in the presence of cardiac diseases. It is concluded that supplemental parasternal block provides good intraoperative and postoperative analgesia following anterior midline chest wall surgeries.

916: BENZODIAZEPINE BOLUSES VERSUS PROPOFOL OR DEXMEDETOMIDINE INFUSIONS IN CRITICALLY ILL ADULT PATIENTS

Introduction: Critically ill patients who require mechanical ventilation (MV) are administered sedative medications to promote compliance with the ventilator and reduce anxiety and agitation. Previous studies have shown worse outcomes with benzodiazepine infusions compared to infusions of propofol or dexmedetomidine. There are limited studies evaluating boluses of benzodiazepines titrated to lighter depths of sedation in this population. The purpose of this study is to compare MV days in patients who received PRN benzodiazepine doses vs. continuous infusion of propofol or dexmedetomidine. Methods: This was a single center, retrospective study of patients admitted to the medical intensive care unit (ICU) at Denver Health Medical Center from 2016 to 2020 requiring MV and sedated with either continuous infusion of propofol or dexmedetomidine (Infusion) vs. boluses of midazolam or lorazepam (Bolus). The primary outcome for this study is duration of MV. Secondary outcomes include average RASS score while on MV, ICU length of stay (LOS), 90-day mortality, delirium incidence, and hypotension requiring vasopressors. Results: 101 patients were included in the analysis;(50 in the Bolus group and 51 in the Infusion group). There were no significant differences between baseline characteristics in the two groups. For the primary outcome, the duration of MV in the Bolus group was 1 day [IQR 1-3] vs. 2 days [IQR 1-3.5] (P=.297) in the Infusion group. In the Bolus group, ICU LOS was 4 [IQR 2-6] vs. 3 days [IQR 1-4], (P=.009). The average RASS score was -0.85 in the Bolus group vs. -0.99 in the Infusion group, (P=1.6). 90-day mortality was 24% in the Bolus group vs. 2%, (P=.001). The incidence of ICU delirium was 70% vs. 65%, (P=.57). 70% of patients in the Bolus group compared to 49% in the Infusion group required vasopressors, (P=.03). Conclusions: There was no difference in the duration of MV between patients who received continuous infusions of propofol or dexmedetomidine vs benzodiazepine bolus sedation strategy. However, use of PRN boluses was associated with an increase in ICU LOS, 90-day mortality, and vasopressor use. Limitations include a retrospective study design and confounding factors such as acuity of illness as well as hemodynamic instability at baseline. Further study is warranted to confirm findings.

670 DEXMEDETOMIDINE SEDATION FOR PULMONARY VEIN ISOLATION PROCEDURE

Abstract Background Peri-procedural anesthesia for catheter ablation of atrial fibrillation (AF) varies from conscious sedation to general anesthesia. Current guidelines do not suggest any specific strategy, thus the choice between different protocols is mainly driven by local expertise, operator and/or patient preference and availability of a dedicated anesthesiology team. Propofol is often the drug of choice despite the risk of respiratory depression. Few data have recently reported operator-directed nurse-administered dexmedetomidine (DEX) sedation as an effective and safe strategy. Aim of the study To evaluate the outcomes of operator-directed nurse-administered DEX sedation in AF ablation (pulmonary vein isolation-PVI). Method Between May 2022 and August 2022, 41 consecutive patients (male 83%, median age 64 years, IQR 57-71) with drug-refractory paroxysmal (n.27;66%) or persistent AF (n.14;34%) underwent first PVI procedure under DEX sedation. Our sedation protocol consisted of continuous intravenous administration of DEX (0.2–0,7 µg/kg/hr) titrated throughout the procedure to achieve mild to moderate sedation (Modified Observer's Assessment of Alertness and Sedation Scale 2-3). A single dose of Ondansetron (4 mg) was administered in the beginning of procedure. Adjunctive doses of fentanyl (cumulative dose 50-100 µg) were administered before the beginning of radiofrequency (RF) delivery and in case of inadequate control of the pain. A low dose propofol bolus (&amp;lt;1mg/kg) was eventually added for electrical cardioversion (ECV). Sedation-related complications were evaluated, including sustained hypoxemia (SpO2 &amp;lt;90%), need of anesthesiologist support and persistent hypotension (SBP &amp;lt; 90 mmHg). The day after the procedure, patients’ satisfaction and pain (0-100 scale) were assessed by a standardized questionnaire. Results Pulmonary vein isolation was performed either with Low Power Long Duration (LPLD, n.17;41,46%) or High-Power Short Duration (HPSD, n.24;58,54%) RF protocol. Median procedure time was 135’ (IQR 110-170’). Median DEX dose was 0,30 µg/kg/hr (IQR 0,27-0,33 µg/kg/hr). Median fentanyl dose was 75 µg (IQR 50-100 µg). In patients needing for ECV (n. 16; 39%), median propofol dose was 60 mg (IQR 47,5–105 mg). Thirteen patients (31,7%) had one or more significant risk factor (obesity, severe heart failure, pulmonary comorbidity, coronary artery disease) for anesthesia-related complications. Median pain scale value was 20 (IQR 10-50). Majority of patients (90,2%, n.37) reported mild to moderate pain (pain &amp;lt;60/100) during the procedure and satisfaction was overall high (median value 90, IQR 80-100), with a 90,2% of patients declaring a satisfaction of 60/100 or more. These results were independent from baseline characteristics (sex, age, AF type, HF, CAD, pulmonary comorbidity, obesity) and procedural aspects (LPLD vs HPSD, procedure time, need for ECV). A strong linear correlation was found between patients’ satisfaction and reported pain (r=-0,59). Only 1 (2,4%) sedation-related complication occurred, consisting in sustained post procedural hypotension treated with volume repletion. Conclusions in our experience, dexmedetomidine (DEX) sedation protocol during catheter ablation of atrial fibrillation is associated to high patients’ satisfaction and no respiratory complications. It seems to be also feasible in patients at higher risk for anesthesia-related complications (severe heart failure, BMI &amp;gt; 30 kg/m2), generally excluded from previous studies.

Arousal Time from Sedation during Spinal Anaesthesia Given with Propofol and Midazolam for Elective Infraumbilical Surgeries

Background: Arousal time is variable after sedation with spinal anesthesia after infraumbilical surgeries. Propofol and midazolam have been studied individually using the Observer’s Assessment of Awareness/Sedation (OAA/S) score and different other ways. So this present study was designed to compare the arousal time of sedation for propofol and midazolam using OAA/S scores.&#x0D; Materials and methods: A total of 60 patients were randomly assigned to receive either propofol (Group A, n =30) or midazolam (Group B, n = 30). All patients of Group A received bolus of propofol (1 mg/kg) followed by infusion at 3 mg/kg/h, Group B received bolus of midazolam (0.05 mg/kg), followed by infusion at 0.06 mg/kg/h. OAA/S score was noted at beginning and again during recovery. The time to achieve OAA/S score 5 was noted. Changes of pulse rate, O2 saturation and satisfaction score were noted.&#x0D; Results: Among the 60 patients gender distributions where male and female distributed evenly. Age group distributions revealed more patients were gathered in age group 31- 40 years and &gt;51 years. Regarding physical status most of the patients were at ASA physical status 1. It was found that propofol had better outcome than midazolam in terms of arousal time score and patient’s satisfaction score after surgery.&#x0D; Conclusions: A shorter arousal time from sedation during spinal anaesthesia can be achieved using propofol than arousal time with midazolam.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.21 (2); July 2022; Page 18-21

USE OF BISPECTRAL INDEX (BIS) FOR MONITORING OF SEDATION AND TOTAL INTRAVENOUS ANESTHESIA (TIVA) IN PEDIATRIC PATIENTS UNDERGOING COLONOSCOPY

The objectives of this study were to determine whether there was a correlation between bispectral index (BIS) and Ramsey Sedation Scale (RSS) in regard to the type of sedation and total intravenous anesthesia (TIVA) during colonoscopy procedures in children, and to assess the utility of ketamine and propofol combination (ketofol) for this kind of procedures at children’s age. In our prospective study, 40 ASA I-II patients, 3 to 17 years of age, were randomly divided into two groups of 20 patients each. After premedication with atropine and midazolam, sedation was induced with propofol and fentanyl in Group PF, whereas in Group PK propofol and ketamine were used for induction. Both groups were further divided into two subgroups depending on whether anesthesia was maintained with intermittent doses or continuous infusion of propofol. Ketamine and/or fentanyl were administered as bolus doses. Heart rate (HR), peripheral oxygen saturation (SpO2), RSS and BIS values of all patients were recorded every 5 minutes throughout the colonoscopy procedures. The strongest degree of correlation between RSS and BIS existed when sedation or TIVA was maintained by the boluses of propofol and fentanyl. The use of ketamine significantly reduced the doses of propofol and fentanyl. BIS can be monitored in all pediatric patients in whom sedation and TIVA are administered during colonoscopy, but the effect of different anesthetics on the EEG signal should be considered in order to adequately assess the depth of sedation and anesthesia.Key words: awareness, monitoring, child, anesthetics, endoscopy

Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study

BackgroundCirculatory and respiratory depression are common problems that occur in propofol alone sedation during gastroscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during Endoscopic retrograde cholangiopancreatography (ERCP) or colonoscopy. However, it is still unknown the median effective dose (ED50) of propofol when combined with lidocaine intravenously. This study aimed to compare the ED50 of propofol with or without intravenous lidocaine for inserting gastrointestinal endoscope successfully.MethodsFifty nine patients undergoing gastroscopy or gastrointestinal (GI) endoscopy were randomly divided into control group (Group C, normal saline + propofol) or lidocaine group (Group L, lidocaine + propofol). Patients were initially injected a bolus of 1.5 mg/kg lidocaine in Group L, whereas equivalent volume of 0.9% saline in Group C. Anaesthesia was then induced with a single bolus of propofol in all subjects. The induction dose of propofol was determined by the modified Dixon’s up-and-down method, and the initial dose was 1.5 mg/kg in both groups. The primary outcome was the ED50 of propofol induction dose with or without intravenous lidocaine. The secondary outcomes were the induction time, the first propofol bolus time (FPBT: from MOAA/S score ≤ 1 to first rescue bolus propofol), and adverse events (AEs: hypoxemia, bradycardia, hypotension, and body movements).ResultsTotally, 59 patients were enrolled and completed this study. The ED50 of propofol combined with lidocaine was 1.68 ± 0.11 mg/kg, significantly reduced compared with the normal saline group, 1.88 ± 0.13 mg/kg (P = 0.002). There was no statistical difference in induction time (P = 0.115) and the FPBT (P = 0.655) between the two groups. There was no significantly difference about the AEs between the two groups.ConclusionThe ED50 of propofol combined with intravenous lidocaine for successful endoscope insertion in adult patients, was 1.68 ± 0.11 mg/kg significantly reduced compared with the control group.Trial registrationChinese Clinical Trial Registry, No: ChiCTR2200059450. Registered on 29 April 2022. Prospective registration. http://www.chictr.org.cn.

The effect of intravenous lidocaine on propofol dosage in painless bronchoscopy of patients with COPD.

BackgroundWe tested the hypothesis that intravenous (IV) lidocaine reduces propofol requirements in painless bronchoscopy in patients with chronic obstructive pulmonary disease (COPD).MethodsA total of 93 patients who underwent bronchoscopy were included in this randomized placebo-controlled study. The patients were randomly divided into two groups. After the IV doses of nalbuphine, patients were given a bolus of propofol, which was titrated if necessary until loss of consciousness. Then patients were given IV lidocaine (2 mg/kg then 4 mg/kg/h) or the same volume of saline. The primary endpoint was the propofol requirements. Secondary endpoints were the incidence of hypoxemia, the incidence of cough during glottis examination, the systolic blood pressure (SBP) and heart rate (HR) during bronchoscopy procedures, the bronchoscopist's comforts, and the time for wakefulness before recovery.ResultsLidocaine infusion resulted in a significant reduction in propofol requirements (p < .0001), and the incidence of hypoxemia (p = .001) and cough (p = .003) during examination decreased significantly in the lidocaine group. During the examination, the fluctuation of SBP and HR was significantly lower than that in the control group, and the difference was statistically significant (p < .05). Bronchoscopist's comforts were higher in the lidocaine group (p < .001), and time for wakefulness (p < .001) were significantly lower in the lidocaine group.ConclusionIn painless bronchoscopy in patients with COPD, IV infusion of lidocaine resulted in a reduction in propofol dose requirements and reduce the incidence of adverse events.

Adding Low-Dose Propofol to Limit Anxiety during Target-Controlled Infusion of Remifentanil for Gastrointestinal Endoscopy: Respiratory Issues and Safety Recommendations.

Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients’ characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses.

Air Medical Casualty Evacuation in High Altitude: An Experience of 100 Cases in High Altitude and Hilly Terrain of Northern India

Objectives: This article describes the on ground challenges faced by the medical care team deployed for transferring critically ill patients by air from remote locations of the high altitude and hilly terrain to definitive health care facility. Methods: All intubated critical patients requiring definitive and super specialty medical care, transferred by air from high altitude hilly terrain to tertiary care hospital during Jan 2016 to Dec year 2020, analyzed in this retrospective study. Results: The total duration of flight was between 40 – 150 min and average being 83 min. Twenty four patients were transferred by fixed wing aircraft and rest 76 by helicopters. All patient were given sedation in form of injection fentanyl 1mcg/kg in dividing doses and boluses of propofol 10 mg intravenously during transfer. The most common change noticed was fall in oxygen saturation with incidence almost 100% of the patients. The mean fall in saturation was 17.29%. Four patients required injection atropine for bradycardia which resulted with decrease of Saturation of peripheral oxygen (SpO2). Conclusion: Transferring a critically ill patient by road to distant medical centers is often not an option because of losing the golden hour of the medical care. Here comes the importance of aeromedical evacuation for a timely transfer for early medical attention. But shifting the critical patients through aerial mode requires planning and poses a variety of challenges. Keywords: Air­evacuation, High altitude, Air ambulance

The hemodynamic stability of remimazolam compared with propofol in patients undergoing endoscopic submucosal dissection: A randomized trial.

ObjectiveHypotension is common in propofol anesthesia. Whether remimazolam could reduce intraoperative hypotension remains unknown. We therefore tested the primary hypothesis that remimazolam reduces the incidence of intraoperative hypotension compared with propofol in adult patients undergoing endoscopic submucosal dissection (ESD) surgery.Materials and methodsWe conducted a prospective trial to compare patients who received either remimazolam or propofol bolus induction and thereafter intravenous infusion. The hemodynamic parameters were measured using CNAP® Monitor 500 system. Our primary analysis was to compare the incidence of hypotension defined as systolic blood pressure below 90 mmHg between remimazolam and propofol during the whole anesthesia period.ResultsThe incidence of hypotension decreased by 50%, from 67.9% in propofol group to 32.1% in remimazolam group (p < 0.01). Patients received less amount of intraoperative phenylephrine in the remimazolam group than the propofol group (0 [0–40] μg vs. 80 [0–200] μg, p < 0.01). Time-weighted average and cumulative time of hypotension was lower in remimazolam group compared with propofol group (p < 0.05). Cardiac output continuously measured by CNAP was preserved much better in remimazolam group compared with propofol group (p = 0.01), while systemic vascular resistance did not differ between the groups. The median time from discontinuation until full alertness was 4 [3–11.8] min in the remimazolam group compared with 15 [12.0–19.8] min in the propofol group (p < 0.01).ConclusionRemimazolam has better hemodynamic stability than propofol in adult patients undergoing ESD surgery. The benefits of remimazolam on hemodynamic stability and hypotension prevention may be partly contributed to its better preservation of cardiac output.Clinical Trial Registration[http://www.chictr.org.cn/com/25/showproj.aspx?proj=61104], identifier [ChiCTR2000037975].

Anestesia total intravenosa en Tortuga (Chelonoidis carbonaria) sometido a plastrotomía para enterotomía: Reporte de caso

Chelonians are gradually more present in the routine of non-conventional animals in veterinary clinics, centers and hospitals, demanding vast knowledge of capable professionals to provide specialized care. In this way, the anesthesia of reptiles becomes even more challenging, since their anatomical and physiological characteristics are different when compared to other animal groups. The present study aimed to report the anesthetic techniques and procedures used in a specimen of a 10-year-old Red-footed tortoise (Chelonoidis carbonaria), weighing 1.54 kg. The chelonian was submitted to plastrotomy and enterotomy to remove foreign bodies. In his anamnesis, it was found that the animal had penile prolapse, constipation and severe tenesmus for four days. The radiographic evaluation revealed five radiopaque, amorphous and irregular structures in the colic region, which ranged from 2.04 cm to 0.50 cm, and after an unsuccessful attempt at conservative treatment, surgical treatment was chosen. As pre-anesthetic medication, dexmedetomidine (30 ug/kg), methadone (1 mg/kg), dextroketamine (10 mg/kg) and midazolam (1 mg/kg) were used. Subsequently, induction was performed with propofol (2.5 mg/kg) in the subcarapacial venous sinus, followed by venous access in the jugular vein with a 24G catheter and administration of an intravenous bolus of propofol (5 mg/kg). After muscle relaxation, the animal was intubated using a number 2.0 endotracheal tube (uncuffed) and continuous infusion of propofol at a rate of 100 ug/kg/min for anesthetic maintenance. Intraoperative analgesia was performed by coccygeal epidural block with lidocaine without vasoconstrictor (0.2 mL/5 cm of carapace). Among the physiological parameters monitored, heart and respiratory rate, capnography and cloacal temperature stand out, which remained stable throughout the anesthetic period. At the end of the procedure, dexmedetomidine and midazolam were reversed with atipamezole (0.03 mg/kg) and flumazenil (0.01 mg/kg), respectively. His extubation occurred 20 minutes after the end of the surgical procedure, and his post-anesthetic recovery was uneventful.

Postoperative propofol bolus treatment did not affect recovery time in patients with emergence agitation after sevoflurane anesthesia in pediatric patients undergoing strabismus surgery: Prospective nonrandomized case-control study.

The incidence of emergence agitation (EA) after sevoflurane anesthesia is high, especially in pediatric strabismus surgery. However, research thus far has focused on the pharmacological prophylaxis of EA and administering drugs to pediatric patients without EA is problematic. The purpose of this study was to determine whether the use of propofol after sevoflurane anesthesia affects recovery time in patients with EA. After obtaining informed written consent, 113 children (aged 2-12 years) with the American Society of Anesthesiologists physical status of I or II who underwent strabismus surgery were enrolled. Patients were divided into 2 groups; upon arrival at the postanesthetic care unit (PACU), patients who had EA (pediatric anesthesia emergence delirium [PAED] scale score ≥14) were treated with 1.0 mg/kg 1% propofol (group P: n = 30). Patients who did not have EA (PAED scale score <14, group C: n = 83) were taken care of in the PACU without propofol administration. There was no difference in the PAED scale scores between the 2 groups from 10 minutes to discharge from the PACU (P > .05). There was no difference in PACU stay time between the 2 groups (P > .05). We concluded that propofol administration for intense EA alleviated EA symptoms and prevented an increase in the duration of PACU stay due to EA in children undergoing strabismus surgery under sevoflurane anesthesia.

Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial

BackgroundOur objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. MethodsWe conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.m−2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL−1 plus 0.5 μg.mL−1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg−1 plus 0.5 mg.kg−1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. ResultsThe median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0‒0) vs. 0 (0‒0) (p = 0.239) and 1 (0‒1) vs. 3 (1‒4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group ‒ 2 (0‒2) vs. 1 (0‒1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 µg.kg−1.min−1 vs. 195 ± 44 µg.kg−1.min−1 (p = 0.040)). ConclusionsDuring colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

The Effectiveness of Three Regimens of Sedation for Children Undergoing Magnetic Resonance Imaging: A Clinical Study.

Magnetic resonance imaging (MRI) under sedation requires faster recovery for early discharge and feeding resumption in children with neuropsychiatric disorders. The use of dexmedetomidine alone results in delayed recovery. Propofol, when used alone, can cause hypotension and respiratory depression. A new regimen for sedation was evaluated by exploiting the properties of these drugs, to allow faster recovery with minimal adverse events. One hundred and fifty children aged 2-12 years requiring MRI were randomly allocated to these three groups. Group P (n = 50) received propofol bolus at 2 mg.kg-1 over 10 min followed by infusion at 100 μg.kg-1.min-1. Group D (n = 50) received dexmedetomidine bolus of 2 μg.kg-1 over 10 min followed by infusion at 1 μg.kg-1.h-1. Group PD (n = 50) received propofol bolus at 2 mg.kg-1 over 10 min followed by dexmedetomidine infusion at 1 μg.kg-1.h-1. Recovery characteristics were noted. Recovery following sedation in Group PD (15 ± 7.0 min) and Group P (17.35 ± 7.4 min) were comparable and significantly (P = 0.03) lesser than Group D (27.58 ± 8.09 min). Emergence delirium scores were significantly less in Group PD (5 ± 1.08) and Group D (5.6 ± 2.4), unlike scores in Group P (9 ± 2.43). About 79.5% (39/49) of children in Group P, 88.2% (45/51) of children in Group D, and 86% (43/50) of children in Group PD completed MRI without any movement. Seven (14.58%) in Group P, 2 (4%) in Group D, and 5 (10.20%) in Group PD required rescue sedation. The regimen with propofol bolus and dexmedetomidine infusion provided adequate sedation and better recovery characteristics in children aged 2-12 years without systemic complications, as compared to the use of either agent alone.

Analgesia and Sedation in Critically Ill Patients With Burns.

Analgesia and Sedation in Critically Ill Patients With Burns.

Evaluation of the Efficacy of Propofol-Magnesium Sulfate Combination for Sedation in Paediatric Magnetic Resonance Imaging of Brain.- a Randomized Controlled Trial

Background and Aims: The key to successful sedation for pediatric magnetic resonance imaging (MRI) is to keep the child completely immobile while ensuring rapid recovery. We compared the efficacy of propofol-midazolam and propofol-magnesium sulfate sedation for MRI of the brain in the paediatric population. Methods: Total 60 paediatric patients, aged 1 to 8 years awaiting for MRI brain were randomly allocated into two groups. Group I patients received midazolam 0.05mg/kg and Group II patients received magnesium sulfate 30 mg/kg infusion in the preinduction room. In the MRI room all patients were sedated with 1-2 mg/kg bolus and 100 ug/kg/min infusion of propofol. The two groups were compared for sedation characteristics like discharge time, total number of additional propofol boluses, agitation scores, haemodynamic parameters and adverse events. Fisher exact test was used for all quantitative data. Results: Induction time, scan quality, requirement of additional propofol boluses and awakening time were comparable for the groups (P&gt;0.05). There was no statistically significant incidence of airway instrumentation between both groups (p=0.14)). Heart rate remained on lower normal side, 20 minutes after induction in Group II (P&lt;0.00). Incidence of emergence agitation was significantly lower in Group II (P&lt;0.01). The discharge time was shorter in Group II (41.03 ± 8.39 min versus 32.83 ± 5.97 min; P&lt;0.001). Conclusion: Propofol-magnesium sulfate sedation is a better alternative to propofol-midazolam combination for paediatric brain MRI, as it provides a shorter discharge time and a lower incidence of emergence agitation.

Isoelectric Electroencephalography in Infants and Toddlers during Anesthesia for Surgery: An International Observational Study.

Intraoperative isoelectric electroencephalography (EEG) has been associated with hypotension and postoperative delirium in adults. This international prospective observational study sought to determine the prevalence of isoelectric EEG in young children during anesthesia. The authors hypothesized that the prevalence of isoelectric events would be common worldwide and associated with certain anesthetic practices and intraoperative hypotension. Fifteen hospitals enrolled patients age 36 months or younger for surgery using sevoflurane or propofol anesthetic. Frontal four-channel EEG was recorded for isoelectric events. Demographics, anesthetic, emergence behavior, and Pediatric Quality of Life variables were analyzed for association with isoelectric events. Isoelectric events occurred in 32% (206 of 648) of patients, varied significantly among sites (9 to 88%), and were most prevalent during pre-incision (117 of 628; 19%) and surgical maintenance (117 of 643; 18%). Isoelectric events were more likely with infants younger than 3 months (odds ratio, 4.4; 95% CI, 2.57 to 7.4; P < 0.001), endotracheal tube use (odds ratio, 1.78; 95% CI, 1.16 to 2.73; P = 0.008), and propofol bolus for airway placement after sevoflurane induction (odds ratio, 2.92; 95% CI, 1.78 to 4.8; P < 0.001), and less likely with use of muscle relaxant for intubation (odds ratio, 0.67; 95% CI, 0.46 to 0.99; P = 0.046]. Expired sevoflurane was higher in patients with isoelectric events during preincision (mean difference, 0.2%; 95% CI, 0.1 to 0.4; P = 0.005) and surgical maintenance (mean difference, 0.2%; 95% CI, 0.1 to 0.3; P = 0.002). Isoelectric events were associated with moderate (8 of 12, 67%) and severe hypotension (11 of 18, 61%) during preincision (odds ratio, 4.6; 95% CI, 1.30 to 16.1; P = 0.018) (odds ratio, 3.54; 95% CI, 1.27 to 9.9; P = 0.015) and surgical maintenance (odds ratio, 3.64; 95% CI, 1.71 to 7.8; P = 0.001) (odds ratio, 7.1; 95% CI, 1.78 to 28.1; P = 0.005), and lower Pediatric Quality of Life scores at baseline in patients 0 to 12 months (median of differences, -3.5; 95% CI, -6.2 to -0.7; P = 0.008) and 25 to 36 months (median of differences, -6.3; 95% CI, -10.4 to -2.1; P = 0.003) and 30-day follow-up in 0 to 12 months (median of differences, -2.8; 95% CI, -4.9 to 0; P = 0.036). Isoelectric events were not associated with emergence behavior or anesthetic (sevoflurane vs. propofol). Isoelectric events were common worldwide in young children during anesthesia and associated with age, specific anesthetic practices, and intraoperative hypotension.

Penile Prosthesis Now An In office Procedure: A Single Center Experience In The US

ABSTRACT Introduction Inflatable penile prosthesis (IPP), an implantable device for treatment of ED, historically have always been done in a hospital setting or outpatient setting. These surgeries are now done more frequently around the world as an in-office procedures. With the increase risk of COVID infections and the improvement of IPP technique we began performing this procedure in the office under local and total intravenous anesthesia. Objective To present the nuances of office based 3 piece penile prosthesis and the outcome data for the feasibility of in-office implants while minimizing complications. Methods A retrospective chart review was performed on the 10 IPP patients who had surgery in the office based setting in our clinic. The age ranges varied from 34-58 years of age. All pateints who opted for IPP in the office were screened for any and history of pelvic surgery, renal failure, cardiac stents or heart failure. Preoperatively, Antibiotics used were Vancomycin, Amikacin and oral Fluconazole and oral Neurontin for analgesia. All patients had a preoperative COVID nasal swab or had the vaccine prior to surgery. Intraoperatively Vancomycin, Amikacin and Fluconazole were used for irrigation and implant prep. Smaller table sets with stacking sterile field was used with headlights and loupes. IV sedation was used with the assistance of an anesthesiologist who used Propofol for sedation. A propofol bolus was given prior to entering the space of retzius. The patients also received a penile and pudendal block with a mixture of 1% Lidocaine, 0.5% Marcaine and 1mg Solumedrol for post-op pain management. Postoperatively, Neurontin and Tylenol were given PO and Toradol was given IV. Results Of the 10 patients selected, 0 patients had infections we had even with a drain being in place 2 patients suffered a hematoma. 1 patient suffered urinary retention, resolving after 24 hours. Patients were cleared for device use between 5 to 8 weeks. 1 patient's implant was recalled; however, the patient did not have a desire for re-operation and has the device and works around the valve. The average procedure time was 53.5 minutes. Incision size range was 1.7 cm to 2.5 cm in length.Drains were placed in all patients for 24 to 48 hours with out puts of 90-160cc. Patients were discharged after 90 minutes in recovery phase. Conclusions Office based penile prosthesis is safe and feasible in the post COVID world. Nuances such was headlights, loupes and adequate block-aid and sterile field efficiency with preloading and stacking are a necessity. With careful patient selection, in-office implantable penile prosthesis implant can be a safe feasible alternative for patients that have severe ED, have gone through alternative therapies, but either cannot afford and or insurance does not cover this procedure. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast