Ramsay Sedation Scale Score Research Articles

The Opioid-sparing Effect of Intraoperative Dexmedetomidine Infusion After Craniotomy.

We conducted a randomized trial to evaluate the opioid-sparing effect of an intraoperative infusion of dexmedetomidine (DEX) after craniotomy. Sixty adult patients scheduled for craniotomy were divided randomly into group A (DEX infusion at 0.5 μg/kg/h for 10 min and then adjusted to 0.2 to 0.5 μg/kg/h from tracheal intubation to incision suturing) and group B (0.9% saline infusion). Additional intravenous injections and patient-controlled analgesia with morphine were used to control postoperative pain for verbal Numerical Rating Scale scores >4. Cumulative morphine consumption, Numerical Rating Scale pain score, and the Ramsay Sedation Scale score were evaluated at 1, 2, 4, 6, 8, 12, and 24 hours; the incidence of postoperative nausea and vomiting, agitation, and respiratory depression were recorded at 24 hours after surgery. Postoperative pain scores within 12 hours and Ramsay Sedation Scale scores within 6 hours of surgery were both significantly lower in group A than in group B (P<0.001). Patients in group A required 54.4%, 43.3%, and 31.4% less cumulative morphine consumption during the first 4, 12, and 24 hours, respectively. No patient in group A and 5 patients in group B presented agitation within 1 hour after surgery. Three patients in group A and 9 patients in group B showed pruritus (P<0.001). An intraoperative infusion of DEX reduced cumulative morphine consumption and adverse effects after craniotomy.

Oral clonidine and gabapentin suppress pressor response: A prospective, randomized, double blind study.

Background:Pressor response is a part of stress response caused by reflex sympathetic discharge due to direct laryngoscopy and tracheal intubation resulting in tachycardia, hypertension and arrhythmias. Both clonidine, and gabapentin administered orally can effectively blunt this detrimental hemodynamic response.Aim:To study the effect of oral clonidine to blunt the pressor response to direct laryngoscopy and to compare it with oral gabapentin. To observe for postoperative sedation and side effects if any.Settings and Design:Sixty patients of American Society of Anaesthesiologist Grade I and II scheduled for surgery under general anesthesia were considered in this prospective randomized double-blind study. They were randomly allocated into two groups of 30 each using computerized randomization.Materials and Methods:Group A was given oral clonidine 5 μg/kg and Group B was given oral gabapentin 800 mg. Both the drugs were given 90 min prior to surgery. Heart rate (HR) and blood pressure were monitored at baseline, 0, 1, 3, 5, 10, 15, and 30th min of laryngoscopy. Sedation was monitored by Ramsay Sedation Scale score and side effects were noted.Results:HR decreased in both groups at 0 and 1 min, increased at 3rd min and gradually decreased by 30th min. Statistically, significant difference was found between two groups at 1, 3, 5, 10, and 15th min (P < 0.05). Though there was no significant difference in systolic blood pressure, diastolic blood pressure and mean arterial pressure between the two groups, there was no rise in these parameters. Gabapentin produced more sedation than clonidine postoperatively, and few side effects were noted.Conclusion:Both oral clonidine and gabapentin are effective in obtunding pressor response to direct laryngoscopy, clonidine being better in terms of controlling HR. Gabapentin produces more postoperative sedation than clonidine.

Femoral nerve block prevents deep venous thrombosis of the lower extremity after knee arthroplasty: a single-center randomized controlled trial

Background: The use of tourniquets in knee arthroplasty can promote the release of abundant neutrophil elastase from neutrophils, which increases the risk of deep venous thrombosis of the lower extremity. Advanced femoral nerve blocks can decrease the risk of deep venous thrombosis of the lower extremity after knee arthroplasty, but their mechanism of action remains unclear. We assume that the femoral nerve block can effectively suppress the inflammatory reaction and prevent deep venous thrombosis of the lower extremity after knee arthroplasty. Methods/Design: A total of 120 patients undergoing total knee arthroplasty under general anesthesia in the General Hospital of Ningxia Medical University of China will be enrolled in this single-center randomized controlled trial. These patients will be equally and randomly assigned to three groups. In the advanced femoral nerve block group, ultrasound-guided femoral nerve block will be conducted 30 minutes before surgery. In the conventional femoral nerve block group, ultrasound-guided femoral nerve block will be carried out at consciousness after surgery. In the intravenous analgesia group, an analgesia pump will be used to relieve pain after surgery. The primary outcomes will be the changes in the levels of serum thrombosis-related inflammatory factors (neutrophil elastase, thrombin-antithrombin III complex, D-dimers, C-reactive protein, tumor necrosis factor-α, interleukin-1, interleukin-6, and interleukin-8) immediately after entering the operating room; 30 and 60 minutes after application of the tourniquet; 30 minutes after removal of the tourniquet; and 12, 24 and 48 hours after surgery. The secondary outcomes measures will be the Ramsay Sedation Scale score, visual analogue scale score, times until initial and complete effect of the block, muscle strength rating, blood loss, and color Doppler ultrasound examination results of the lower extremity veins. Discussion: We hope to identify the clinical advantages of advanced femoral nerve block for total knee arthroplasty and determine whether deep venous thrombosis of the lower extremity after knee arthroplasty can be prevented by inhibiting the release of abundant neutrophil elastase and suppressing the inflammatory reaction. Trial registration: ClinicalTrial.gov identifier: NCT02411097; registered on 20 March 2015. Ethical approval: Written approval for this project was obtained from the Ethics Committee of the General Hospital of Ningxia Medical University of China. All patients or their family members will be informed of the protocols and will provide written informed consent. Our study is in accordance with the guidelines of the Declaration of Helsinki, formulated by the World Medical Association.

Dexmedetomidine combined with midazolam vs. dexmedetomidine alone for sedation during spinal anesthesia.

BackgroundDexmedetomidine is a useful sedative agent for spinal anesthesia. However, it has been reported that dexmedetomidine decreases heart rate in a dose-dependent manner. In the current study, we compared the administration of a bolus dose of midazolam and bolus loading of dexmedetomidine over 10 min with the goal of identifying an additional method of sedation.MethodsNinety patients classified as American Society of Anesthesiologists physical status I–II who were undergoing spinal anesthesia were divided into two groups. In the midazolam and dexmedetomidine combined group (group MD), 10 min after bolus loading of 0.05 mg/kg midazolam, 0.5 µg/kg/h dexmedetomidine was continuously infused. In the dexmedetomidine group (group D), 1 µg/kg dexmedetomidine was infused over 10 min, and then 0.5 µg/kg/h dexmedetomidine was continuously infused.ResultsAt 10 min, the sedation depth of the two groups was almost equal. In both groups, the bispectral index was within the optimal score range of 55–80 and the Ramsay Sedation Scale score was within the optimal range of 3–5. Satisfaction with sedation for both patient and surgeon did not differ between the two groups. At 10 min, heart rate was significantly lower (P < 0.010) in group D and mean blood pressure was significantly lower (P < 0.010) in group MD. The prevalence of bradycardia, hypotension, and hypoxia did not differ statistically between the two groups (P = 0.714, P = 0.089, P = 0.495, respectively).ConclusionsMidazolam bolus and dexmedetomidine continuous infusion (the regimen of group MD) may be an additional sedation method for patients who have severe bradycardia.

Postoperative Pain Control with Epidural Catheter after Posterior Lumbar Spine Fusion

Introduction Pain management after posterior spinal fusion surgeries is a challenging topic. Epidural analgesia (CEA) technique has been developed to resolve some deleterious effects related with conventional intravenous patient-controlled analgesia (IV-PCA) method. However, studies are scanty in adult lumbar deformity patients. We hypothesized that CEA would be beneficial in adult lumbar deformity patients and conducted a study to observe effectiveness and safety of the procedure with a special consideration of the catheter level. Patients and Methods Forty-six patients scheduled for elective posterior lumbar spine fusion, in one spine-center clinic, were enrolled into the study. Three patients' dataset about pain control and/or sedation status were inconclusive and they were excluded from the final analysis. Pain and sedation status were evaluated with VAS and Ramsay sedation scales, respectively. Epidural catheter was inserted under direct visualization intraoperatively. Results There were 43 patients in the final analysis. Twenty-one patients had epidural catheters at or below the L2 level, 22 patients had their catheters above the predefined level. There was significant difference between the groups only in the 24th hour VAS scores. Patients with catheters of higher level location in the spinal canal, had higher VAS scores at the immediate postoperative period, however VAS scores in this group lessened more than the lower level catheter group at the 24th hour. Ramsay sedation scale score was significantly slightly higher in the patients with lower level catheters than the other group at 0 and the 2nd hour. Conclusion Continuous epidural analgesia is an effective and safe method in controlling postoperative pain in adult lumbar deformity patients treated with PSF method. Higher placement of epidural catheter in the spinal canal causes more pain at the beginning; however, drug release at this level has more effect over pain than lower levels.

Comparison of the analgesic effects of paracetamol and tramadol in lumbar disc surgery.

To compare the postoperative analgesic efficacy and side effects of paracetamol and tramadol in patients undergoing lumbar disc surgery. Group P (paracetamol group) was given 1 g of paracetamol intravenously 30 min before the end of the operation and 1 g each day at 6-h intervals. Group T (tramadol group) was given 1.5 mg/kg of tramadol as a loading dose and patient-controlled analgesia for 1 day. Hemodynamic parameters, modified Aldrete score, Ramsay sedation scale score, patient satisfaction scale (PSS) score, visual analog scale (VAS) score, nausea/vomiting scale score, and additional analgesic needs/times were recorded. PSS scores were significantly higher in Group T (P < 0.05). The total analgesic consumption was significantly higher in Group P. There were no significant differences in the VAS scores at any time points. Twenty-one patients in Group P and 8 patients in Group T needed additional analgesia (P < 0.05). The first additional analgesic time was earlier in Group P, and pain was more evident at the 15th minute and at hours 2 and 6 (P < 0.05). Paracetamol alone was not able to provide effective analgesia. Tramadol was more effective in the treatment of postoperative pain after lumbar disc surgery.

Premedication dilemmas, is Pregabalin the answer?

Objective:Laryngoscopy and intubation are associated with sympathetic stimulation which can prove deleterious in patients with cardiovascular compromise; so, various methods have been tried to obtund this pressor response. In this study, we have assessed the efficacy of pregabalin in attenuating the pressor response to laryngoscopy and intubation.Methods:This prospective randomized study included 80 patients with American Society of Anesthesiologists physical status grades I-II, in the age group of 18–60 years of age. The patients were randomized into two groups of 40 patients each. Group A received the placebo orally, 90 min prior to surgery. Group B received 150 mg of pregabalin orally, 90 min prior to surgery. These patients were assessed in terms of sedation with Ramsay sedation scale (RSS). In the operation theatre, the heart rate (HR), systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation recorded at baseline and 1, 3, 5, and 10 min after intubation. The rate pressure product (RPP) was calculated for these time intervals. In the postoperative period, patients were assessed for complications like dizziness, nausea, and blurred vision. Statistical analysis was performed using Chi-square and ANOVA tests.Findings:The group receiving 150 mg of pregabalin as premedication was found to be adequately sedated at 1 h post-premedication with 52% patients having a RSS score of 3 compared to 4% with the same RSS score in the placebo group (P < 0.0001). Hemodynamics was more stable post-intubation with significant stability in the HR (P = 0.002) and RPP (P = 0.004) in the pregabalin group.Conclusion:Pregabalin when given as a premedication provides adequate sedation and obtunds the pressor response seen with intubation.

Effects of lidocaine and esmolol infusions on hemodynamic changes, analgesic requirement, and recovery in laparoscopic cholecystectomy operations

ObjectiveWe compared the effects of lidocaine and esmolol infusions on intraoperative hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery in laparoscopic cholecystectomy surgery. MethodsThe first group (n=30) received IV lidocaine infusions at a rate of 1.5mg/kg/min and the second group (n=30) received IV esmolol infusions at a rate of 1mg/kg/min. Hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery characteristics were evaluated. ResultsIn the lidocaine group, systolic arterial blood pressures values were lower after the induction of anesthesia and at 20min following surgical incision (p<0.05). Awakening time was shorter in the esmolol group (p<0.001); Ramsay Sedation Scale scores at 10min after extubation were lower in the esmolol group (p<0.05). The modified Aldrete scores at all measurement time points during the recovery period were relatively lower in the lidocaine group (p<0.05). The time to attain a modified Aldrete score of ≥9 points was prolonged in the lidocaine group (p<0.01). Postoperative resting and dynamic VAS scores were higher in the lidocaine group at 10 and 20min after extubation (p<0.05, p<0.01, respectively). Analgesic supplements were less frequently required in the lidocaine group (p<0.01). ConclusionIn laparoscopic cholecystectomies, lidocaine infusion had superiorities over esmolol infusions regarding the suppression of responses to tracheal extubation and postoperative need for additional analgesic agents in the long run, while esmolol was more advantageous with respect to rapid recovery from anesthesia, attenuation of early postoperative pain, and modified Aldrete recovery (MAR) scores and time to reach MAR score of 9 points.

Comparison of Midazolam and Propofol for Sedation in Pediatric Diagnostic Imaging Studies

Objective: This study aims to compare the efficacy of propofol and midazolam in terms of adverse effect potentials and to determine the appropriate strategy for pediatric procedural sedation. Methods: A total of 200 pediatric patients (aged < 14 years) undergoing diagnostic procedures were recruited for this nonrandomized prospective controlled cohort study. The patients were assigned to 2 treatment arms: either propofol (Group 1: IV bolus dose of 2 mg/kg during a 2-minute period, IV maintenance dose of 100 mcg/kg/min) or midazolam (Group 2: IV bolus dose of 0.15 mg/kg during a period of 2 to 3 minutes) to achieve sedation. Demographic data, body weight, and clinical status of the patients were evaluated and recorded. The vital signs and sedation levels (ie, Ramsay sedation scale scores) were evaluated and recorded, as well as the complications detected and medications administered in 10-minute intervals throughout the sedation procedure. Findings between the study arms were compared. Results: Arterial blood pressures decreased significantly in both groups (P = 0.001). The patients in Group 1 experienced a greater difference in diastolic blood pressure (P = 0.001) than those in Group 2. Sedation scores in Group 1 were more favorable (P = 0.014) and reached the appropriate sedation level in a shorter time than those in Group 2 (P = 0.010). Likewise, recovery time of patients was shorter in Group 1 than in Group 2 (P = 0.010). Hypoxia was found to be more common in the propofol group, but the difference was not significant (P = 0.333). Conclusion: Propofol seems to be more effective, achieve the appropriate sedation level more quickly, and provide a faster onset of sedation than midazolam in pediatric procedural sedation and analgesia. Propofol is preferred for imaging studies (computed tomography and magnetic resonance imaging) to reduce the occurrence of undesired motion artefacts. Although both drugs are safe to use for sedation before pediatric imaging procedures, propofol is preferred with appropriate preparation.

Dexmedetomidine versus midazolam for sedation in upper gastrointestinal endoscopy

To investigate the efficacy and safety of sedation with dexmedetomidine in upper gastrointestinal endoscopy. Patients with ASA physical status I-II undergoing elective upper gastrointestinal endoscopy were randomly allocated to receive dexmedetomidine or midazolam for conscious sedation. Continuous peripheral oxygen saturation (SpO2), heart rate, mean arterial pressure (MAP), Ramsay Sedation Scale (RSS) and numeric rating scale pain scores were recorded before, during and after the procedure. Patients completed a post-procedure satisfaction questionnaire. Patients in the midazolam group (n = 30) experienced a significant decrease in MAP during sedation compared with pre-sedation values. Patients in the dexmedetomidine group (n = 30) had significantly higher SpO2 and RSS scores during sedation than those in the midazolam group. Overall satisfaction was higher in the dexmedetomidine group than the midazolam group. There were no clinically significant complications in either group. Dexmedetomidine has a good safety profile and is an effective sedative for use in upper gastrointestinal endoscopy.

Dexmedetomidine decreases the requirement of ketamine and propofol during burns debridement and dressings.

Background and Aims:Dexmedetomidine (Dex), a highly selective α2-adrenoreceptor agonist, is used for sedation management in various clinical settings and shows anaesthetic-sparing effect. Our aim was to study the effects of Dex on requirements of propofol, ketamine, and intraoperative haemodynamic variations during burns debridement and dressing changes, and compare its effectiveness and safety with combination of ketamine and propofol.Methods:Sixty adult patients posted for elective debridement and dressing were included in the study. Thirty patients received Dex (intramuscular)(IM) 1 μg/kg, 1 h before shifting to the operation theatre while the other thirty did not. Anaesthesia was induced with propofol and ketamine followed by adjusted infusion to achieve a Ramsay Sedation Scale score (RSS) of six in all patients. Intraoperatively haemodynamic parameters were recorded at regular intervals of 5, 15, 30, 45, and 60 min. The mean data between the groups were compared by unpaired t test and medians by Mann-Whitney U test. Within group analysis was performed by using repeated measures ANOVA. P < 0.05 was considered significant.Results:The dose requirement of ketamine and propofol in Dex group was significantly lower when compared to control group (100.5 ± 17.58 mg vs. 231.5 ± 60.39 mg (P < 0.0001) and 127.7 ± 15.47 mg vs. 254 ± 59.22 mg (P < 0.0001) respectively). Additionally, recovery time was lower in the Dex group as compared to the control group, 9.57 ± 1.50 min vs. 11.53 ± 2.56 min (P = 0.0006). Haemodynamic variations were also significantly lower in the Dex group as compared to the control group.Conclusion:Dexmedetomidine (1 μg/kg IM) reduced the requirement of propofol and ketamine, with more stable intraoperative haemodynamics.

Dexmedetomidine versus midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography: An open-label randomised controlled trial

Background:Traditionally, midazolam has been used for providing conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP). Recently, dexmedetomidine has been tried, but very little evidence exists to support its use.Objective:The primary objective was to compare haemodynamic, respiratory and recovery profile of both drugs. Secondary objective was to compare the degree of comfort experienced by patients and the usefulness of the drug to endoscopist.Study Design:Open-label Randomised Controlled Trial.Methods:Subjects between 18 and 60 years of age with American Society of Anaesthesiologist Grade I-II requiring ERCP were enrolled in two groups (30 each). Both groups received fentanyl 1 μg/kg IV at the beginning of ERCP. Group M received IV midazolam (0.04 mg/kg) and additional 0.5 mg doses until Ramsay Sedation Scale (RSS) score reached 3-4. Group D received dexmedetomidine at loading dose of 1 μg/kg over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4. The vital parameters (heart rate (HR), blood pressure (BP), respiration rate, SpO2), time to achieve RSS 3-4 and facial pain score (FPS) were compared during and after the procedure. In the recovery room, time to reach modified Aldrete score (MAS) 9-10 and patient and surgeon's satisfaction scores was also recorded and compared. Any complication during or after the procedure were also noted.Results:In Group D, patients had lower HR and FPS at 5, 10 and 15 min following the initiation of sedation (P<0.05). There was no statistically significant difference in BP and respiratory rate. The procedure elicited a gag response in 29 (97%) and 7 (23%) subjects in Group M and Group D respectively (P<0.05). MAS of 9-10 at 5 min during recovery was achieved in 27 (90%) subjects in Group D in contrast to 5 (17%) in Group M (P<0.05). Dexmedetomidine showed higher patient and surgeon satisfaction scores (P<0.05).Conclusion:Dexmedetomidine can be a superior alternative to midazolam for conscious sedation in ERCP.

Patient-controlled sedation with propofol/remifentanil versus propofol/alfentanil for patients undergoing outpatient colonoscopy, a randomized, controlled double-blind study.

Context:Many techniques are used for sedation of colonoscopies. Patient-controlled sedation (PCS) is utilizing many drugs or drug combinations.Aims:The aim of this study is to compare the safety and feasibility of propofol/remifentanil versus propofol/alfentanil given to sedate patients undergoing outpatient colonoscopies through a patient-controlled technique.Settings and Design:Controlled randomized and double-blind study.Materials and Methods:A total of 80 patients were randomly divided into two groups; PA group received a combination of propofol/alfentanil and PR group received propofol/remifentanil combination. Patients were monitored for heart rate (HR), blood pressure (BP), oxygen saturation, and Ramsay sedation scale (RSS). Times of the following events were recorded; initiation of sedation, insertion and removal of the colonoscope, recovery and discharge. Five intervals were calculated; time to sedation, procedure time, postprocedure time, procedure room time, and postanesthesia care unit (PACU) time. Endoscopist and patient satisfaction scores were obtained.Statistical Analysis Used:Unpaired Student's t-test was used to compare between the two groups. Paired Student's t-test was used to compare baseline readings with readings after 30 min of sedation in the same group when needed.Results:Both groups showed slowing of the HR and decrease in mean arterial BP. HR and mean arterial BP were significantly lower 5 and 10 min after initiation of sedation in PR group when compared with PA group. Both HR and mean arterial BP returned to presedation readings 30 min after initiation of sedation in PR group but not in PA group. No differences between the two groups concerning oxygen saturation, RSS, endoscopist and patient satisfaction scores. Postprocedure and PACU times were significantly prolonged in PA group.Conclusion:PCS with either remifentanil/propofol or alfentanil/propofol for patients undergoing outpatient colonoscopy is safe and feasible. Remifentanil/proofol has more beneficial advantages in this setting secondary to its more rapid clearance.

Comparison on dosage and effect of postoperative analgesia between patients of Uygur and Han nationalities after spinal surgery

Objective To compare dosage and effects of postoperative analgesia between patients of Uygur and Han nationalities after spinal surgery.Methods Ninty-four ASA Ⅰ or Ⅱ patients(47 Uygur nationality,47 Han nationality) undergoing posterior laminectomy,discectomy interbody pedicle fixation operation under general anesthesia were divided into two groups (U and H).The patients in both groups received fentanyl patient-controlled intravenous analgesia after surgery.Visual analog scale (VAS),Ramsay sedation scale score,the vital signs at 6,12,24,48 h after operation and the total consumption of fentanyl,the total number and the valid number of pressing patient-controlled analgesia (PCA) pump,the adverse effects at 48 h after operation were recorded and compared.Results There were no difference in the mean artery pressure (MAP),pulse oxygen saturation(SpO2),Ramsay score and VAS score at the time points of patients between two groups (P＞0.05).The total consumption of fentanyl,the total number and the valid number of pressing PCA pump (times) in group U were (1 203±217) pg,(21.8±6.8),(13.2±3.0) respectively.It was significantly higher than those of group H,which were (793±138) μg,(12.5±3.2),(7.9±2.6) respectively.Compared with group H (15％),the occurrence rate of postoperative nausea and vomiting in group U (27％)was significantly higher (P＜0.05).Condusions There is a significant difference in the total consumption of fentanyl between Uygur and Han nationalities.The influence of nationality on recommended dosage of fentanyl should be considered. Key words: Race; Fentanil ; Postoperative analgesia

Ketamine/propofol versus fentanyl/propofol for sedating obese patients undergoing endoscopic retrograde cholangiopancreatography (ERCP)

ObjectiveThis study was conducted to compare two techniques of sedation for obese patients undergoing ERCP, using either ketofol or fentanyl–propofol as regards propofol consumption, recovery time, patients’ satisfaction, and sedation-related adverse events.Materials and methodsTwo hundred obese patients were randomly allocated to one of two groups; ketamine/propofol (ketofol) group KP (n = 100) or fentanyl/propofol group FP (n = 100). The level of sedation was adjusted to achieve a Ramsay Sedation Scale (RSS) score of 5.ResultsTotal dose of propofol consumed was significantly higher in group FP compared with group KP (97.08 ± 23.31 mg and 57.71 ± 16.97) mg. Recovery time was slightly longer in group KP compared with group FP (11.19 ± 2.59 min and 9.43 ± 1.23 min, respectively), time needed to achieve Aldrete Recovery Scale Score of 9 was comparable in both groups, and sedation-related side effects as hypotension, bradycardia, apnea, and reduction of SpO2 were more significant in the FP group.In conclusionKetamine/propofol combination 1:4 provided better sedation quality than fentanyl/propofol combination with less side effects and can be safely used for sedating obese patients undergoing ERCP.

Tu1257 The Ramsay Sedation Scale Score Is a Poor Predictor of Abnormal Ventilation During Endoscopy Using Moderate Sedation

Abnormal ventilation during endoscopic sedation can be identified by the occurrence of hypoxemia detected during pulse oximetry, but only if the patient is not on supplemental oxygen. Patients at moderate sedation levels are presumed to have intact ventilation and airway protection reflexes. Clinical assessment scales, such as the Ramsay Sedation Scale (RSS) are often used during endoscopy to monitor whether a patient is at moderate or deep levels of sedation. It is unclear how such scales perform in predicting the occurrence of abnormal ventilation during endoscopy.

Comparison of topical tramadol and ketamine in pain treatment after tonsillectomy

The primary objective of this study is to evaluate the effects of topically applied ketamine or tramadol on early postoperative pain scores in children undergoing tonsillectomy. The secondary aim of the study is to assess nausea, vomiting, difficulty in swallowing, and sore throat characteristics of the patients. Tonsillectomy surgery is frequently associated with postoperative pain, which usually requires substantial consumption of analgesics including opioids. Safe and effective post-tonsillectomy pain control is still a clinical dilemma, in spite of the use of various surgical and anesthetic techniques. A total of 60 children, aged between 4 and 10years, scheduled for tonsillectomy, were randomly assigned to one of three groups. Study drugs were administered to both tonsillar fossae for 5min. In 5ml artificial saliva, Group K (n=20) received 0.4ml (20mg) ketamine and Group T (n=20) received 0.8ml tramadol HCl solution. Group C (n=20) received only 5ml saline as a control. Ramsay Sedation Scale and FACES PRS Score, nausea, vomiting, difficulty in swallowing, and sore throat were evaluated. There was no difference among the groups in terms of baseline characteristics, including age, sex, and ASA profile (P>0.05 for all). Systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, respiratory rate, and saturation of peripheral oxygen (SpO2 ) values were not significantly different among the groups in all time points (P>0.05 for all). There was a statistically significant difference among the groups according to Ramsay Sedation Scales in 40th minute (P<0.001). There were statistically significant differences among the groups in terms of Wong-Baker FACES Pain Rating Scale Score in all time points (P<0.004 for all). There was a statistically significant difference among the groups in terms of rescue analgesia necessity in 5th and 10th minute (P<0.001 and P=0.003). There was a statistically significant difference among the groups in terms of sore throat in 5th and 10th minute (P<0.001 for both). Neither rescue analgesia necessity nor sore throat characteristics was different between the Group T and Group K in all time points. Topical tramadol and ketamine seem to be safe, effective, and easy analgesic approach for decreasing tonsillectomy pain.

Middle Ear Effusion in Mechanically Ventilated Patients: Effects of the Nasogastric Tube

Middle ear effusion (MEE) is rare among adults, but has a higher incidence among ICU patients. The aim of this study was to analyze the effect of nasogastric tube (NGT) on MEE and to assess other predisposing factors. Prospective observational study, carrying out an otoscopic examination and tympanometry in 100 mechanically ventilated patients. Immittance testing was carried out within 24 hours of ICU admission and every 72 hours until ICU discharge. In a case of persisting pathologic curve at the moment of discharge from ICU, there was a follow-up examination every 3 days until middle ear function was restored. In addition to descriptive variables, we recorded placement (left or right nostril) and diameter (12, 16, or 18 French) of the NGT. A Cox regression analysis was performed, adjusted for the days since ICU admission. A total of 535 tympanometry studies were carried out, of which 352 were normal and 183 observations presented MEE. We observed that 12 and 16 French NGTs were not significantly associated with abnormal middle ear function, whereas 18 French NGT was significantly associated with MEE (odds ratio 2.54, 95% CI 1.42-4.55; P = .01). Other variables independently associated with pathological tympanogram curves were Ramsay Sedation Scale score ≥ 4 (odds ratio 2.42, 95% CI 1.65-3.55; P = .01) and orotracheal intubation (odds ratio 5.72, 95% CI 3.40-9.60; P = .01). No intracranial infection or long-term disabilities were identified. MEEs and tympanometric alterations are frequent in intubated patients (32% in our study). To prevent these complications, they should receive NGTs with a diameter lower than 18 French, when feasible.

Dexmedetomidine for sedation of patients undergoing elective surgery under regional anesthesia

BackgroundDexmedetomidine may be useful as a sedative agent. However, it has been reported that dexmedetomidine decreases systemic blood pressure, heart rate, and cardiac output in a dose-dependent manner. The purpose of this study was to determine the appropriate dose of intravenously administered dexmedetomidine for sedation.MethodsForty-five American Society of Anesthesiologists physical status I-II patients under spinal anesthesia received dexmedetomidine 1 µg/kg intravenously as a loading dose. The patients were randomly allocated to one of three groups for maintenance dose: Group A (0.25 µg/kg/hr), Group B (0.50 µg/kg/hr), and Group C (0.75 µg/kg/hr). The hemodynamic variables and the Ramsay Sedation Scale (RSS) score were recorded for all patients. The numbers of patients who developed hypotension, bradycardia, or inadequate sedation necessitating further drug treatment were also recorded.ResultsSystolic blood pressure, heart rate, and SpO2 were decreased, and RSS score was increased significantly at both 20 min and 40 min after injection of dexmedetomidine in the three study groups compared to baseline, without significant differences between the groups. The prevalence of hypotension, but not that of bradycardia or adjunctive midazolam administration, exhibited a positive correlation with the dose of dexmedetomidine.ConclusionsIntravenous injection of dexmedetomidine 1 µg/kg followed by continuous administration at infusion rates of 0.25, 0.50, or 0.75 µg/kg/hr produced adequate levels of sedation. However, there was a tendency for the incidence of hypotension to increase as the dose increased. To minimize the risk of hemodynamic instability, a dose of 0.25 µg/kg/hr may be the most appropriate for continuous administration of dexmedetomidine.

Optimal drug dosing control for intensive care unit sedation by using a hybrid deterministic–stochastic pharmacokinetic and pharmacodynamic model

SUMMARYIn clinical intensive care unit practice, sedative/analgesic agents are titrated to achieve a specific level of sedation. The level of sedation is currently based on clinical scoring systems. Examples include the motor activity assessment scale, the Richmond agitation–sedation scale, and the modified Ramsay sedation scale. In general, the goal of the clinician is to find the drug dose that maintains the patient at a sedation score corresponding to a moderately sedated state. This is typically done empirically, administering a drug dose that usually is in the effective range for most patients, observing the patient's response, and then adjusting the dose accordingly. However, the response of patients to any drug dose is a reflection of the pharmacokinetic and pharmacodynamic properties of the drug and the specific patient. In this paper, we use pharmacokinetic and pharmacodynamic modeling to find an optimal drug dosing control policy to drive the patient to a desired modified Ramsay sedation scale score. Copyright © 2012 John Wiley &amp; Sons, Ltd.