Richmond Agitation Sedation Score Research Articles

Efficacy of Nebulized Dexmedetomidine and Lignocaine Inhalation versus Lignocaine Alone as Premedication for Flexible Fiber-optic Bronchoscopy under Sedation: A Randomized Comparative Study.

Airway management is an integral part of general anesthesia, allowing ventilation and oxygenation and working as a mode for delivering anesthetic gases. Awake fiber-optic-guided intubation is an essential component of airway management in difficult cases. We aim to study the benefits of nebulized dexmedetomidine with lignocaine over lignocaine alone for anesthetizing the airway for flexible fiber-optic bronchoscopy. In the study, after written informed consent, 50 patients were randomly allocated into two equal groups of 25 each. The intervention group received dexmedetomidine with lignocaine nebulization, while the control group received lignocaine nebulization alone. Baseline pulse rate, blood pressure, and, at regular intervals, cough, sedation, and pain scores were recorded along with the patient satisfaction score. Parametric data were analyzed by the Student's t-test, while nonparametric data were analyzed by the Wilcoxon Mann-Whitney U test. Out of a total of 54 patients, 4 patients did not give consent to participate in the study. The demographic profile was comparable in both groups. The pulse rate was comparable in both groups throughout the procedure; however, 10 min after the procedure, the pulse rate in the lignocaine group was (mean ± standard deviation) 114.2 ± 11.52, while in the intervention group, it was 87.32 ± 7.24 with a P = 0.027. The mean blood pressure was comparable throughout the procedure. The cough score yielded a Z-score of -5.12 and a P < 0.00001 favoring the dexmedetomidine group. Similarly, Richmond agitation-sedation score and Visual Analog Scale (VAS) also favored the intervention group, with P < 0.00054 and P < 0.00001 in RASS and VAS, respectively. Patient satisfaction score analysis found a Z-score of -5.29 and a P < 0.00001. The overall results favored dexmedetomidine with lignocaine nebulization over lignocaine alone for anesthetizing airways for flexible fiber-optic bronchoscopy.

Postoperative Sedation in Free Microvascular Tissue Transfer in Head and Neck Cancer: A Comparison of Fentanyl and Morphine

Background and Aims: Head-and-neck cancer surgeries with microvascular free flap reconstruction require endotracheal tube retention for 24–48 h postoperatively. Many regimes have been used for analgesia and sedation. The efficacy of fentanyl and morphine for post-operative analgosedation was compared by evaluating the need for additional sedatives to achieve optimum sedation scores. The secondary objective included analgesia, haemodynamic stability and a re-exploration rate. Methods: This was an open-label prospective study. A sample size of 36 was calculated in each group with α = 0.05 and a power of 80% to detect a 50% difference between the groups. Ninety adult patients were allocated to receive either fentanyl (Group F) or morphine (Group M). The Richmond agitation sedation score, Behavioural pain scale score, requirement of rescue hypnotic drug, pulse rate, systolic and diastolic blood pressures and re-explorations were recorded postoperatively. Haemodynamic parameters and sedation were analysed by two-way repeated measures of analysis variances. Pain scores were analysed using the Chi-square test. Results: When titrating to optimal sedation, in Group M, more patients needed intravenous midazolam boluses (n = 42, 93.3%) as compared to Group F (n = 33, 73.3%) (P = 0.011). More subjects in Group M required propofol infusion (n = 15, 33.3%) than in Group F (n = 4, 8.9%) (P = 0.009). Mean behavioural pain scores were significantly higher in Group M (score 1: P = 0.005 and score 2: P =0.001). The difference in the mean systolic, diastolic blood pressure, pulse rate, respiratory rate and re-exploration rate between the two groups was statistically insignificant. Conclusion: For analgesia-based sedation of spontaneously breathing intubated patients after head-and-neck cancer reconstructive surgeries, fentanyl is more effective than morphine in terms of ease of titration, sedation quality and analgesia. Both are safe for post-operative sedation regarding haemodynamic stability, tube retention and maintenance of spontaneous respiration.

Incidence and risk factors of delirium in the intensive care unit of SIUT Karachi.

Objective: To estimate the incidence and risk factors of delirium in intensive care unit (ICU) of Sindh Institute of Urology and Transplantation (SIUT), Karachi. Study Design: Cross-sectional study. Setting: The ICU of SIUT, Karachi, Pakistan. Period: February 2023 to August, 2023. Methods: Patients over 18 years of age who were admitted to the ICU for more than 24 hours were analyzed. Patient with Richmond agitation sedation score (RASS &gt;-2) were assessed for delirium using the confusion assessment method (CAM)-ICU method. Delirium subtypes were also evaluated. Domographic and clinical risk factors were evaluated for possible relationship with the existence of delirium. Results: Total 96 patient were enrolled in the study, 64 (66.7%) were male and 32 (33.3%) female. The mean age was 49.1±17.3 years. Mean RASS and CAM-ICU scores were 0.53±1.31 and 1.0±1.42 respectively. Delirium was present in 32 (33.3%) patients. It was noted that 45.4% patients had hypoactive delirium, 31.8% hyperactive delirium, and 22.7% mixed type. Patients aged 50 years or above had higher odds of delirium (OR: 0.41 [0.17-0.98], p=0.045), On multivariable regression model, BMI &lt;25 Kg/m2, coexistence of ischemic heart disease and chronic kidney disease, patients with septic shock, post-operative patients, need of sedation were significantly associated with higher odds of delirium. Conclusion: Delirium is a frequent condition in ICU patients, with a higher occurrence of hypoactive delirium. The leading risk factors associated with delirium were older age, ischemic heart disease, chronic kidney disease and use of sedative drugs.

The Effect of Music on Postoperative Agitation, Pain, and Opioid Use among Patients Undergoing Total Knee Replacement

BackgroundPostoperative pain and agitation is an ongoing issue among patients undergoing total knee replacement (TKR). Use of complementary therapies such as music may improve outcomes when combined with medical therapy. AimThe purpose of this quality improvement (QI) initiative was to evaluate postoperative use of classical music among adult patients who have undergone TKR on reported agitation, pain, and opioid use. DesignA prospective evidence-based QI initiative. SettingA midwestern hospital post-anesthesia care unit. ParticipantsPostoperative patients who had undergone TKR. MethodsClassical piano music was played postoperatively using an MP3 device. Adult patients who were undergoing TKR were consecutively offered music during their recovery period in the PACU. Agitation was measured using the Richmond Agitation Sedation Score (RASS). Patient perceived pain was measured on a scale of 0-10 with 0 being no pain and 10 being extreme pain. Opioid use was measured using the morphine milligram equivalents (MME). FindingsA total of (n=40) patients received music and (n=50) patients received standard care without music. RASS was significantly lower in the music group than in the baseline non-music group X2 (1, N = 89) = 17.8, p < .001. Patient reported pain scores were significantly lower in the music group, 3.98(SD = 2.71), compared to the baseline non-music group, 6.27(SD = 2.60). Opioid use was also significantly decreased in the music group to MME 9.51(SD = 8.62) compared to the baseline non-music group 13.38 (SD = 9.71). ConclusionMusic is an effective nonpharmacologic intervention in decreasing agitation, pain, and opioid use among patients undergoing TKR. These findings provide evidence for nurses to incorporate music as an adjunctive approach to enhance the patient's experience and improve outcomes.

Caffeine administration to treat oversedation after general anesthesia: A retrospective analysis

Study objectiveOur institution has adopted an informal practice of administering postoperative caffeine to expedite anesthesia recovery for patients with excessive sedation. This study aimed to determine whether caffeine administration was associated with improved sedation recovery and reduced risk of respiratory complications. DesignSingle-center, retrospective, observational study. SettingQuaternary medical center. PatientsWe included adult patients who were admitted to a postanesthesia recovery care unit (PACU) after general anesthesia and had evidence of postoperative sedation (Richmond Agitation Sedation Score [RASS] < 0). Patients were seen from May 5, 2018, through December 31, 2020. InterventionsPatients were categorized according to caffeine administration (0 vs 250 mg). MeasurementsSedation was measured with RASS. To account for potential confounding, binary and ordinal logistic regression with inverse probability of treatment weighting (IPTW) were used to compare RASS and episodes of severe respiratory complications within 48 h after PACU discharge. Main resultsWe identified 47,222 adult surgical patients with evidence of sedation in the PACU, and of these, 1892 (4.0%) were intravenously administered caffeine. Patients who received caffeine had more sedation in the PACU. In the IPTW-adjusted analysis, caffeine administration was associated with improved sedation scores after PACU discharge (ordinal logistic regression odds ratio [OR], 1.13 [95% CI, 1.00–1.28]; P = .04 for the first RASS score after PACU discharge) but increased risk of respiratory complications (OR, 2.99 [95% CI, 1.44–6.24]; P = .003) and emergency response team activation (OR, 7.18 [95% CI, 2.85–18.10]; P < .001). ConclusionsIn this observational study, caffeine administration during anesthesia recovery was associated with improved sedation scores. However, it was also associated with an increased risk of respiratory complications, possibly reflecting selection bias (ie, administering caffeine to higher-risk patients). Patients with signs of excessive sedation during anesthesia recovery may benefit from enhanced postoperative respiratory monitoring.

Perioperative Implementation of Low-Dose Pregabalin in an Enhanced Recovery After Cardiac Surgery Protocol: A Pre-Post Observational Study

Determine the effect of low-dose pregabalin in the perioperative enhanced recovery after cardiac surgery protocol. Pre-post observational study. Tertiary care hospital. Patients undergoing off-pump coronary artery bypass graft procedures. Pregabalin 75 mg BID for 48 hours postoperatively versus no pregabalin in a perioperative setting. Perioperative opioid use, pain scores, length of stay, time to extubation, and mortality were all measured. Descriptive data were presented as mean (SD), median (IQR), or N (%). Ordinal and continuous data used the t-test or Kruskal-Wallis test. Categorical data were compared between groups using the chi-square test or Fisher's exact test, as appropriate. Low-dose pregabalin administration (75 mg twice daily for 48 hours after surgery) was associated with a clinically significant reduction in opioid consumption on postoperative day 0 by 30.6%, with a median requirement of 318 (233, 397) morphine milligram equivalents (MME) in the pregabalin group compared with 458 (375, 526) MME in the control group (p < 0.001). There was no significant difference in pain scores between the groups with the exception at 0-to-12 hours, during which the pregabalin group had greater pain scores (median 3.32 [1.65, 4.36] v 2.0 [0, 3.25], p=0.013) (Table 3). Moreover, there was no significant difference in pain scores on postoperative day 1 (p=0.492), day 2 (p=0.442), day 3 (p=0.237), and day 4 (p=0.649). The difference in average Richmond Agitation Sedation Score scores was also not statistically significant between groups at 12 hours (p=0.954) and at 24 hours (p=0.301). The pregabalin group had no increased incidence of adverse events or any significant differences in intensive care unit length of stay, time to extubation, or mortality. In this evaluation of perioperative pregabalin administration for patients requiring cardiac surgery, pregabalin reduced postoperative opioid use, with significant reductions on postoperative day 0, and without any significant increase in adverse reactions. However, no differences in intensive care unit length of stay, time to extubation, or mortality were noted. The implementation of low-dose perioperative pregabalin within an Enhanced Recovery After Cardiac Surgery protocol may be effective at reducing postoperative opioid use in the immediate postoperative period, and may be safe with regard to adverse events. Ideal dosing strategies have not been determined; thus, further randomized control trials with an emphasis on limiting confounding factors need to be conducted.

Effect of Using Midazolam and Propofol in Low Doses for Intraoperative Nausea and Vomiting Prevention in Pregnant Women Underwent Cesarean Section under Regional Anesthesia

Aim: To investigate if and how severe intraoperative nausea and vomiting occur following elective cesarean sections performed under spinal anesthesia using sub-hypnotic dosages of midazolam and propofol.&#x0D; Study Design: Clinical trial.&#x0D; Methodology: The current study was conducted at the Gynecology and Obstetrics Department of a Teaching Hospital in Baghdad, Iraq. The study included 90 full-term pregnant women with single viable fetuses who underwent elective C/S by spinal anesthesia and were randomly assigned to one of three groups: group A included 30 women who received propofol, group B included 30 women who received midazolam, and Group C included 30 women who received placebo. The Bellville scoring score was used to assess nausea and vomiting. The Richmond Agitation Sedation Score (RASS) was used to assess sedation intraoperatively.&#x0D; Results: Patients in group C had the highest prevalence of nausea and vomiting (56.7%), which was significantly different from groups A (16.7%, P=0.001) and B (13.3%, P=0.001); however, there was no statistically significant difference between groups A and B (P= 0.717). The group B patients had the highest prevalence of drowsiness (20%), which was substantially different from group C (3.3%, P=0.044), whereas there were no statistically significant differences between groups A and B (P= 0.278) or A and C (P= 0.3).&#x0D; Conclusion: Low doses of midazolam or propofol administered after cesarean section (after the umbilical cord has been clamped) can lessen intraoperative nausea and vomiting without significantly lowering blood pressure or heart rate, with midazolam being more effective than propofol in this regard.

Sub-hypnotic dose of midazolam is effective in reducing intraoperative nausea and vomiting during cesarean sections under spinal anesthesia

Background &amp; Objectives: Intra and postoperative nausea and vomiting under regional anesthesia is a common problem in cesarean sections. Globally, the incidence has been documented to be from 40−80%, and various drugs have been used to control it. We aimed to determine if a subhypnotic dose of midazolam will be effective to reduce intraoperative nausea and vomiting during an elective cesarean section under spinal anesthesia.&#x0D; Methodology: A randomized interventional study was done through a period of 6 months from March 11, 2019 to September 11, 2019 and included 100 full term pregnant women undergoing elective cesarean sections (CS) under spinal anesthesia. The participants were allocated to one of two groups: Midazolam group (received midazolam 1 mg bolus then 1.0 mg/h infusion after umbilical cord clamping), and placebo group (received normal saline). Bellville score was used to evaluate nausea and vomiting (N/V). The hemodynamic parameters were monitored at three-minute intervals.&#x0D; Results: No statistically significant differences were noted between study groups regarding mean arterial pressure, heart rate and total ephedrine used in the two groups. Intraoperative nausea and vomiting were recorded midazolam (81.6%) with a significant association between prevention of intraoperative N/V and receiving midazolam. Insignificant association was noticed between the level of sedation and receiving midazolam.&#x0D; Conclusion: Administration of low dose of midazolam during cesarean sections under spinal anesthesia can lessen intraoperative nausea/vomiting without significantly effect on blood pressure or heart rate and without any negative side effects.&#x0D; Abbreviations: BMI – Body Mass Index; CS - Cesarean Section; LA – Local Anesthesia; N/V - Nausea/Vomiting; RASS - Richmond Agitation Sedation Score SA - Spinal Anesthesia&#x0D; Key words: Nausea; Vomiting; Anesthesia, Spinal; Midazolam; Cesarean Section&#x0D; Citation: Ibrahem IG. Sub-hypnotic dose of midazolam is effective in reducing intraoperative nausea and vomiting during cesarean sections under spinal anesthesia. Anaesth. pain intensive care 2023;27(4):485−489; DOI: 10.35975/apic.v27i4.2087&#x0D; Received: October 12, 2022; Reviewed: May 16, 2023; Accepted: June 23. 2023

Dexmedetomidine as Conduit for Non-Invasive Ventilation (NIV) Compliance in COVID-19 and Chronic Obstructive Pulmonary Disease (COPD) Patients in Intensive Care Unit (ICU) Setting: Case Series.

Non-compliance to the non-invasive ventilation (NIV) mask in a distressed hypoxemic patient is not an unusual finding, especially in desaturated coronavirus disease(COVID-19)or chronic obstructive pulmonary disease(COPD)patients with respiratory distresswho require ventilatory support to improve oxygenation. Failure to achieve success with the non-invasive ventilatory support with the tight-fitting mask led to emergent endotracheal intubation. This was inview to avert consequences such as severe hypoxemia and subsequent cardiac arrest. Sedation is an important component of ICU management for noninvasive mechanical ventilation to improve NIV compliance/tolerance.Including the various sedatives used, such as fentanyl, propofol, or midazolam, the most suitable agentto be used asa primary/solesedative still remains unclear.Dexmedetomidineprovidinganalgosedationwithout significant respiratory depression facilitates better tolerance of NIV mask application. This case series is a retrospective analysis of patients in whom dexmedetomidine bolus followed by infusion was observed to facilitate compliance to NIV with the tight-fitting mask.Herein, a case summary of six patients with acute respiratory distresswho weredyspnoic, agitated havesevere hypoxemia were put on NIV with dexmedetomidine infusion is being reported. They were extremely uncooperative as their RASS score (Richmond Agitation-Sedation score) was + 1 to +3, not allowing the application of the NIV mask. Due to their poor compliance with to use of the NIV mask,proper ventilation could not be achieved. Dexmedetomidine infusion (0.3 to0.4mcg/kg/hr) was used after a bolus dose (0.2-0.3 mcg/kg).The RASS Score of our patients was +2 or +3 before this intervention which became -1 or -2 after including dexmedetomidine in the treatment protocol.The low dose dexmedetomidine bolus and infusion thereafter showed to improvethepatient'sacceptance of the device. Oxygen therapy with this was shown to improve patient oxygenation by allowing the acceptance of the tight-fitting NIV face mask.In conclusion, this case series serves as evidence of the use of dexmedetomidine as an effectivetherapy to calm the agitated desaturatedpatient, thereby facilitating non-invasive ventilation in COVID-19 and COPD patients and promoting better oxygenation. This may, in turn, avoid endotracheal intubation for invasive ventilation and the associated complications.

681: THE IMPACT OF CLONIDINE ON TACHYCARDIA, HYPERTENSION, AND AGITATION POST-DEXMEDETOMIDINE INFUSION

Introduction: Dexmedetomidine is frequently used as a sedative in the pediatric intensive care unit (PICU) despite limited data on the risk factors, manifestations, and treatment of withdrawal. Clonidine is often utilized to treat withdrawal based on mechanism of action, but data showing efficacy is lacking. We hypothesized that patients treated with clonidine would have less agitation, hypertension, and tachycardia. Methods: This retrospective observational cohort study took place in a 30-bed PICU over a two year period. Data was collected on all intubated patients receiving dexmedetomidine infusions except patients on clonidine prior to admission and those receiving end of life comfort care. Variables of interest collected via electronic medical record included maximum infusion rate, days on infusion, infusion wean duration, exposure to other sedatives, treatment with clonidine during weaning, Withdrawal Assessment Tool 1 (WAT-1) scores, heart rate and blood pressure changes from pre-wean baseline, and presence of agitation, as measured by Richmond Agitation Sedation Score greater than 0. Variables were compared with non-parametric tests (all data median [IQR]). Results: While there was a significant difference in the maximum infusion rates of dexmedetomidine in the clonidine group (n=17, 1.6 mcg/kg/hr [1.2-2.0]) compared to the no clonidine group (n=13, 1.0 mcg/kg/hr [0.8-1.4]; p= 0.01), there was no significant difference in days on infusion (9.0 [7.0-11.0] vs. 5.0 [5.0-11.5]; p= 0.17) or infusion wean duration (1.0 [1.0-2.0] vs. 1.0 [1.0-2.5] days; p= 0.87). There was no difference in presence of agitation (8 [47%] vs. 7 [54%], p= 0.71), presence of delirium (6 [35%] vs. 5 [39%]; p= 0.93), WAT-1 scores greater than 3 (8 [47%] vs. 7 [54%]; p= 0.70), a heart rate elevation >15 bpm (14 [82%] vs. 10 [77%]; p= 1.0), or at least two episodes of a systolic blood pressure increase above 10 mmHg over baseline (10 [59%] vs. 11 [85%]; p= 0.23) in the first 24 hours post infusion. Conclusions: In this small cohort of patients treated with prolonged dexmedetomidine infusions, clonidine administration was not associated with reduced agitation, WAT-1 scores, or heart rate and/or blood pressure changes post infusion.

Novel insights on association and reactivity of Bispectral Index, frontal electromyogram, and autonomic responses in nociception-sedation monitoring of critical care patients

BackgroundAssessing nociception and sedation in mechanically ventilated patients in the ICU is challenging, with few reliable methods available for continuous monitoring. Measurable cardiovascular and neurophysiological signals, such as frontal EEG, frontal EMG, heart rate, and blood pressure, have potential in sedation and nociception monitoring. The hypothesis of this explorative study is that derived variables from the aforementioned signals predict the level of sedation, as described by the Richmond Agitation-Sedation score (RASS), and respond to painful stimuli during critical care.MethodsThirty adult postoperative ICU patients on mechanical ventilation and receiving intravenous sedation, excluding patients with primary neurological disorders, head injury, or need for continuous neuromuscular blockage. Bispectral Index (BIS), EMG power (EMG), EMG-derived Responsiveness Index (RI), and averaged blood pressure variability (ARV) were tested against RASS measurements. The aforementioned variables together with blood pressure and Surgical Pleth Index (SPI) were explored before and after painful stimuli (for example bronchoscopy, or pleural puncture) at varying RASS levels, to test variable responsiveness.ResultsBIS, EMG, and RI predicted RASS levels with a prediction probability (PK) of 0.776 for BIS, 0.761 for EMG, and 0.763 for RI. In addition, BIS, EMG, and ARV demonstrated responsiveness to painful stimuli during deep sedation (RASS score ≤ -3).ConclusionVariables derived from EEG and EMG are associated with sedation levels, as described by the RASS score. Furthermore, these variables, along with ARV, react with consistency to painful stimuli during deep sedation (RASS -5 to -3), offering novel tools for nociception-sedation monitoring of mechanically ventilated ICU patients requiring deep sedation.

The effect of active distraction compared to midazolam in preschool children in the perioperative setting: A randomized controlled trial

PurposeThe primary purpose of this study was to compare the effect of active distraction to midazolam as a non-pharmacological method of reducing preoperative anxiety in preschool children. A secondary purpose was to compare emergence delirium, sedation/agitation, and length of stay between groups. Design and methodsPreschool children (N = 99) scheduled for elective surgery participated in this 2-group randomized controlled trial: the active distraction (tablet) group (n = 52) had unlimited playtime with a tablet and the midazolam group (n = 47) were medicated approximately 10 min before mask induced anesthesia. Data were collected using the modified Yale Preoperative Anxiety Scale, Pediatric Anesthesia Emergence Delirium scale, and Richmond Agitation Sedation Score. Length of stay (LOS) was measured in minutes from PACU admission to discharge. Wilcoxon rank sum, Pearson's chi square, and Fischer's exact tests were used in analysis. ResultsPreschool children (3–5 years old), predominantly male (61%) and White (85%) presented for ear, nose, throat, ophthalmology, urology, and general surgery at a pediatric surgical center within a large Midwestern hospital. There was no significant difference in anxiety, emergence delirium, or sedation/agitation scores between midazolam and tablet groups. Children assigned to the tablet group had shorter LOS (p = 0.021). ConclusionActive distraction with a tablet as an anxiolytic was as effective as midazolam for pre-school aged children with no side effects and reduced length of stay. Practice implicationsPreoperatively, non-pharmacological methods such as active distraction with a tablet should be considered for preschool children as an alternative to medication.

Deconstructing delirium in the post anaesthesia care unit.

The course of neuro-cognitive recovery following anaesthesia and surgery is distinctive and poorly understood. Our objective was to identify patterns of neuro-cognitive recovery of the domains routinely assessed for delirium diagnosis in the post anaesthesia care unit (PACU) and to compare them to the cognitive recovery patterns observed in other studies; thereby aiding in the identification of pathological (high risk) patterns of recovery in the PACU. We also compared which of the currently available tests (3D-CAM, CAM-ICU, and NuDESC) is the best to use in PACU. This was a post hoc secondary analysis of data from the Alpha Max study which involved 200 patients aged over 60 years, scheduled for elective surgery under general anaesthesia lasting more than 2 h. These patients were assessed for delirium at 30 min following arrival in the PACU, if they were adequately arousable (Richmond Agitation Sedation Score ≥ −2). All tests for delirium diagnosis (3D-CAM, CAM-ICU, and NuDESC) and the sub-domains assessed were compared to understand temporal recovery of neurocognitive domains. These data were also analysed to determine the best predictor of PACU delirium. We found the incidence of PACU delirium was 35% (3D-CAM). Individual cognitive domains were affected differently. Few individuals had vigilance deficits (6.5%, n = 10 CAM-ICU) or disorganized thinking (19% CAM-ICU, 27.5% 3D-CAM), in contrast attention deficits were common (72%, n = 144) and most of these patients (89.5%, n = 129) were not sedated (RASS ≥ −2). CAM-ICU (27%) and NuDESC (52.8%) detected fewer cases of PACU delirium compared to 3D-CAM. In conclusion, return of neurocognitive function is a stepwise process; Vigilance and Disorganized Thinking are the earliest cognitive functions to return to baseline and lingering deficits in these domains could indicate an abnormal cognitive recovery. Attention deficits are relatively common at 30 min in the PACU even in individuals who appear to be awake. The 3D CAM is a robust test to check for delirium in the PACU.

Prospective comparison of acupuncture with sham acupuncture to determine impact on sedation and analgesia in mechanically ventilated critically ill patients (PASSION study): protocol for a randomised controlled trial

IntroductionSedation and analgesia are recommended to be employed in the intensive care unit (ICU) to enhance patient comfort and safety, facilitate mechanical ventilation and reduce oxygen demands. However, the increasing...

Comparing Efficacy of Intravenous Dexmedetomidine and Lidocaine on Perioperative Analgesic Consumption in Patients Undergoing Laparoscopic Surgery.

Perioperative pain management is a major challenge for anaesthesiologists. IV lidocaine and dexmedetomidine have been utilised for peri-operative pain management. To analyse the effects of intraoperative intravenous lignocaine/dexmedetomidine on pain relief, opioid consumption, peri-operative hemodynamic and side-effect profiles/unique interactions in patients undergoing laparoscopic surgeries. Prospective, interventional, single-centric, double-blind, randomised, active-controlled, Helsinki protocol-compliant clinical study was conducted on 90 ASA I/II class patients aged 18-60 yrs. This Patients were block-randomised to Group-L (2% Lignocaine), Group-D (dexmedetomidine) and Group C (Control/Placebo/0.9% normal saline). Hemodynamic were noted at pre-defined time frames intra-/post-operatively. Post-operative VAS score and Richmond Agitation Sedation Score monitoring was done. Demographic parameters of were comparable. Mean intra-operative fentanyl consumption amongst the three groups were 20.5 ± 20.05 mcg, 26.5 ± 17.57 mcg and 46.83 + 21.31 mcg (Group-L, Group-D, Group-C; P value Group-L vs Group-D:0.22, Group L/D vs Group C: <0.0001). Group-D exhibited the lower heart rates and MAP (P < 0.05). Extubation- First rescue analgesic phase was comparable for the Group-C and Group-L (59.17 ± 46.224 min vs 61.64 ± 53.819 min) and significantly greater in Group-D (136.07 + 55.350 min; P < 0.0001). Both Dexmedetomidine and lignocaine can be useful intra-operative pain relief adjuncts. Dexmedetomidine delayed First rescue analgesic and total analgesic consumption more than lignocaine. Dexmedetomidine patients exhibited bradycardia intraoperatively more than the other groups. we recommend, Dexmedetomidine in the intra-operative phase and lignocaine in the post-operative phase can be an alternative in patients who are poor candidates for post-operative opioids/sedation/contraindicated regional anaesthesia regimes.

Point Prevalence of Delirium and Its Subtypes in the Patients Admitted with Acute Coronary Syndrome in Cardiac ICU and Its Impact on Mortality

Objective: To measure the point prevalence of delirium in the patients admitted to the cardiac ICU with acute coronary syndromes, with particular attention to the most commonly noted delirium and the impact on ICU mortality and length of ICU stay.&#x0D; Study Design: Prospective cohort study.&#x0D; Place and Study Duration: National Institute of Cardiovascular Diseases, Karachi Pakistan, from Mar and Jul 2021.&#x0D; Methodology: Consecutive adult patients with age &gt;18 years admitted to the cardiac ICU after acute coronary syndromes were assessed for delirium using the confusion assessment method (CAM)-ICU tool and Richmond agitation sedation score (&gt;-3). The types of delirium were also assessed.&#x0D; Results: 201 patients were enrolled, half of patients with ST-elevation MI (51.2%) and shock (45.8%). Delirium was identified in 71 (35.3%) patients, 30 (42.2%) had hypoactive delirium and 41 (57.7%) had hyperactive delirium. In multivariable regression, independent risk factors for delirium were: sepsis 3.19 (1.15-8.87), uremia 4.12 (1.18-14.46), mechanical ventilation 7.58 (1.2-47.99), and non-invasive ventilation 8.55 (2.9-25.2). Overall mortality was 35 (17.4%); 27/71 (38%) vs. 8/130 (6.2%); p 0.001 in patients with and without delirium, respectively. In multivariable regression, delirium was an independent risk factor for mortality at 7.12 (2.16-2.23). The mean ICU stay was 7.772.36 days vs. 3.91.44 days; p 0.001 for patients with and without delirium.&#x0D; Conclusion: The deleterious effect of delirium in terms of higher morbidity and mortality cannot be overemphasised. Hypoactive delirium is as common as the hyperactive type, with the same mortality risk. Assessment for delirium is mandatory for all patients admitted..............

The utilization of procedural sedation and analgesia at the University Teaching Hospital of Kigali, Rwanda

Introduction: In the Emergency Department (ED), safe and effective Procedural Sedation and Analgesia (PSA) is essential. The professional performing procedural sedation has to be prepared to handle any potential adverse effects. Medications are used according to their availability and based on the physician’s experience and preference. Despite the common occurrence of procedural sedation in the ED, it has not previously been studied in Rwanda. The study aimed to describe procedural sedation and analgesia utilization and common adverse events at Rwanda's University Teaching Hospital of Kigali (UTH-K) ED.Methods: This study is a prospective observational study of procedural sedations done at UTH-KED. The effectiveness of sedation was evaluated using the Richmond Agitation Sedation Score (RASS) during sedation. The pain scale was assessed before and after the procedure. Categorical data were analyzed for significant differences using Chi-squared (X) tests and continuous data with Mann-Whitney (MW) tests.Results: Two hundred fifty-one patients were recruited. Seventy-two percent (72%) of patients were male with a median age of 32 years (IQR 23to 40). The most commonly used analgesics included morphine (78%) and tramadol (17%), with ketamine least used (1%). A common adverse event was hypoxia (36%), followed by hallucination (8%). No adverse events were observed in 47% of procedures. Conclusion: Our study findings suggest that although sedation in our low-resource setting did not result in serious adverse outcomes for patients, there was a much higher incidence of minor adverse events (especially hypoxia) than in higher-resource settings.

Diabetes mellitus in association with hepatic encephalopathy in patients with hepatitis C virus cirrhosis: correlation with ICU outcome

Background There is growing evidence to support the concept that hepatitis C virus (HCV) infection is a risk factor for developing type 2 diabetes mellitus (T2DM) and that diabetes control could affect the prognosis of hepatic encephalopathy.Objective To study the relation between type of DM and HCV cirrhosis and to report any relationship between the outcome of hepatic encephalopathy and the glycemic control in the period before precipitation of encephalopathy.Patients and methods A total of 30 selected diabetic, HCV cirrhotic patients with age ranging from 43 and 70 years (mean, 55.87 years), admitted to the ICU for hepatic encephalopathy, were prospectively enrolled in this study. Cirrhosis was evaluated according to Child classification, whereas encephalopathy was evaluated according to West Haven criteria as well as Richmond agitation sedation score. Glycated hemoglobin was used to assess the glycemic control in the period before precipitation of encephalopathy.Results T2DM was more prevalent than type 1 in association with HCV (83.3% T2DM and 16.7% T1DM). Diabetes control plays no role in increasing the severity of cirrhosis (nonsignificant, with P & 0.249). The diabetic HCV cirrhotic patients admitted for hepatic encephalopathy had shorter ICU stay when DM was well-controlled medically in the period before precipitation of encephalopathy (P & 0.001). Moreover, the mortality was decreased markedly in association with diabetes control (P & 0.01).Conclusion HCV viremia had a higher risk of T2DM than T1DM. Diabetes control has no role in increasing the severity of HCV cirrhosis. In HCV cirrhotic diabetic patients, well- controlled DM could improve the ICU outcome (shorter ICU stay and less mortality) when admitted for hepatic encephalopathy.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial

To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30days (DF/CF-ICU-30) using multivariate linear regression. A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0years vs 40.5 ± 17.0years [p < 0.001]). Mean DF/CF-ICU-30days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Effect of acupuncture on analgesia and sedation in elderly patients with severe pneumonia during invasive mechanical ventilation

To observe the analgesic and sedative effects of acupuncture in elderly patients with severe pneumonia during invasive mechanical ventilation. A total of 188 elderly patients with severe pneumonia were randomly divided into an observation group and a control group, 94 cases in each group. Both groups were treated with routine nursing and treatment of severe pneumonia such as invasive mechanical ventilation, analgesia and sedation. Based on these, the observation group was treated with acupuncture at Neiguan (PC 6), Hegu (LI 4), Yintang (GV 29) and Baihui (GV 20), twice a day until the mechanical ventilation was offline. The critical care pain observation tool (CPOT) score and Richmond agitation-sedation score (RASS) were observed before treatment and 0.5 h after analgesia and sedation; the average time of reaching the standard, the reaching standard rate of shallow sedation and analgesia within 0.5 h and 72 h as well as the dosage of analgesic and sedative drugs and compilations were compared between the two groups. The mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and blood oxygen saturation (SpO2) were observed before treatment and 0.5 h, 1 h and 2 h after analgesia and sedation. The levels of partial pressure of blood oxygen (PaO2), partial pressure of carbon dioxide (PaCO2) and lactic acid (Lac) were observed before treatment and 12 h, 24 h, 48 h, 72 h, 96 h, 120 h and 144 h after analgesia and sedation. The white blood cell (WBC), neutrophil percentage (NEUT%), high-sensitivity C-reactive protein (hs-CRP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatinine (Cr) were observed before treatment and 72 h after analgesia and sedation. The tracheal intubation time and ICU hospitalization time were compared between two groups. At the time point of 0.5 h after treatment, the CPOT and RASS scores in the two groups were lower than those before treatment (P<0.05); the average time of reaching the standard in the observation group was shorter than that in the control group (P<0.01); the 30 min reaching standard rates of CPOT and RASS scores as well as the rate of reaching the shallow sedation and analgesia within 72 h in the observation group were higher than those in the control group (P<0.01, P<0.05). The dosage and duration of dexmedetomidine, propofol and butorphanol in the observation group were less than those in the control group (P<0.05), and the occurrence times of hypotension, respiratory depression, bradycardia, constipation as well as average tracheal intubation time and average ICU hospitalization time in the observation group were less than those in the control group (P<0.05). After 0.5 h, 1 h and 2 h of treatment, the HR and RR were lower than those before treatment in the two groups (P<0.05), MAP and SpO2 were higher than those before treatment in the two groups (P<0.05); the MAP 0.5 h after treatment in the observation group was higher than that in the control group (P<0.05); the HR after 1 h and 2 h of treatment in the observation group was lower than that in the control group (P<0.05). Compared before treatment, the levels of PaCO2 and Lac were reduced and the levels of PaO2 were increased 12 h, 24 h, 48 h, 72 h, 96 h, 120 h and 144 h after treatment in both groups (P<0.05); compared before treatment, the WBC, NEUT%, hs-CPR, ALT and Cr were reduced 72 h after treatment in the two groups (P<0.05), and the hs-CRP in the observation group was lower than that in the control group (P<0.05). Acupuncture has analgesic and sedative effect in elderly patients with severe pneumonia during invasive mechanical ventilation, which could reduce the dosage of sedative and analgesic drugs and the occurrence of complications, improve blood oxygen, and has good safety.