Risk Of Respiratory Depression Research Articles

Awake Endospine Disektomi pada Pasien Lumbar Spinal Stenosis karena Hernia Nucleus Pulposus

Lumbar spinal stenosis (LSS) are symptoms from degradation canalis spinalis vertebrae’s size which pressured nerve inside it. Based on its cause, there are two types of LSS, congenital and degenerative. The patient can experience an unpredictable pain phase as well as a stable phase without pain. Bulging of intervertebralis disc or HNP is one of degenerative LSS. HNP disease is one of the causes of low back pain and is a major health problem. HNP prevalention is 1-2 % from population. One of therapy use to medicate LSS is endospine discectomy. This operation done with general anesthesia (GA) or neuroaxial anesthesia (spinal, epidural). GA preferably used because it caused less side effect like airway obstruction or neural injury. Dexmedetomidine has a sedative effect without the risk of respiratory depression and has an analgesic effect. It can be used to awake endospine methods in dissectomy. In this case report, the writer did awake endospine method to accommodate operator so they could know level of pain and motoric function of patient durante operation.

The Physiology and Maintenance of Respiration: A Narrative Review.

Chronic pain is one of the most common reasons adults seek medical care and is often managed with opioid analgesics; however, opioids may cause respiratory depression by suppressing various components of respiration. Respiration is the physiological process that facilitates gas exchange and is mediated through the proper function of and communication among central neural control (respiratory drive), sensory input systems, the lungs, and the muscles involved in respiration. Normal respiratory function can be dampened with the use of central nervous system (CNS) depressants and/or underlying health conditions. Patients with chronic pain are often exposed to CNS depressants other than opioids, including benzodiazepines, barbiturates, nonbenzodiazepine sedative-hypnotics, and ethanol, which can function synergistically with opioids to increase the risk of respiratory depression. Some patients may also have underlying health issues, such as obstructive sleep apnea, that can be exacerbated with the use of opioids and other CNS depressants and further contribute to respiratory depression. Clinicians should have a thorough understanding of respiration, recognize how various CNS depressants suppress it, and take necessary steps to mitigate the risk of opioid-induced respiratory depression by collaborating with a multidisciplinary team (i.e., sleep and pain specialists), choosing appropriate medications, and educating patients on the proper use and storage of opioids.

Postoperative respiratory depression after hysterectomy.

To investigate if sex-specific physiologic characteristics could impact postoperative respiratory depression risks in women, we studied incidence and risk factors associated with postoperative respiratory depression in a gynecologic surgical cohort. Only hysterectomies performed under general anesthesia from 2012 to 2017 were included to minimize interprocedural variability. Respiratory depression was defined as episodes of apnea, hypopnea, hypoxemia, pain-sedation mismatch, unplanned positive airway pressure device application, or naloxone administration in the post-anesthesia care unit. Multivariable logistic regression was used to explore the association with clinical characteristics. From 1974 hysterectomies, 253 had postoperative respiratory depression, yielding an incidence of 128 (95% confidence interval [CI], 114–144) per 1000 surgeries. Risk factors associated with respiratory depression were older age (odds ratio 1.22 [95% CI 1.02–1.46] per decade increase, p=0.03), lower body weight (0.77 [0.62–0.94] per 10 kg/m2, p = 0.01), and higher intraoperative opioid dose (1.05 [1.01–1.09] per 10 mg oral morphine equivalents, p = 0.01), while sugammadex use was associated with a reduced risk (0.48 [0.30–0.75], p = 0.002). Respiratory depression was not associated with increased hospital stay, postoperative complications, or mortality. Postoperative respiratory depression risk in women increased with age, lower weight, and higher intraoperative opioids and decreased with sugammadex use; however, it was not associated with postoperative pulmonary complications.

The Perils of a Pandemic: Challenges Faced by Addiction Services

Back to table of contents Previous article Next article Clinical & ResearchFull AccessThe Perils of a Pandemic: Challenges Faced by Addiction ServicesSanya Virani, M.D., M.P.H., Souparno Mitra, M.D.Sanya ViraniSearch for more papers by this author, M.D., M.P.H., Souparno MitraSearch for more papers by this author, M.D.Published Online:6 Aug 2020https://doi.org/10.1176/appi.pn.2020.8a26AbstractPsychiatrists who treat people with substance use disorders have been helped by relaxed treatment regulations, but that’s not enough.The coronavirus pandemic engulfed New York City’s health care system for a number of months. The downstream effects not only became evident across hospitals that found it necessary to redeploy several physicians to critical care units but also in outpatient services that functioned in a very limited capacity to meet patient needs. Addiction services were also significantly impacted, and opioid treatment programs (OTPs) were confronted with complex challenges that included requiring patients to present daily to receive maintenance doses of methadone. Inpatient rehab units were closed, and the process of converting them to COVID units seemed to lack planning and strategy, leaving many patients in the lurch for services.Patients struggling with opioid use disorders are already at risk for respiratory depression, and some are confined and sometimes find themselves in prisons or homeless shelters. Because they are in close contact with others, sthey are especially vulnerable to COVID-19. To prevent people in need from being denied essential services, the Substance Abuse and Mental Health Services Administration announced blanket exceptions in late March for maintenance patients to receive upward of 14 to 28 daily take-home doses, depending on each patient’s stability in treatment. Clinically stable patients can be dispensed 28-day medication supplies.Several accommodations are in effect to initiate patients on buprenorphine via telepsychiatry, waiving the requirements for initial physical examinations. Patients on methadone, however, must still have in-person evaluations.iStock/William Rodrigues dos SantosClearly, not all challenges are being circumvented. With emergency departments overflowing and primary care clinics slowly opening up, not only has it become practically impossible to get medical clearance for patients requesting detox, but psychiatrists also find themselves dealing with many such requests. Queues at methadone clinics have gotten longer, thereby defeating the purpose of physical distancing. The shutting down of liquor stores in April brought on additional concerns about patients going into life-threatening alcohol withdrawal.With uncertainties still looming large around COVID-19, the field of addiction psychiatry is at the start of a road fraught with many challenges: underserved patients at risk for overdosing or withdrawing and services overly reliant on technology that is unable to fully substitute one-on-one interactions for this subset of patients. At the crux of it all, we have to make the most of the resources we have, rise to the current occasion, and plan strategically for a future with limited capacity.The pandemic has shown us the importance of contingency plans in effect to provide addiction services to address the needs of patients. Some of these measures could be expanded to include risk stratification of patients in OTPs, permitting extended durations for medication refills, and developing a workflow for medically clearing patients so that they can be ready for initiation or maintenance of treatment in detox and rehab units that could even be managed virtually. A guideline for disaster management operations could be established by the governing bodies of associations. Preparedness with respect to these facilities may enable a more efficient and safe functioning of addiction facilities in the wake of future crisis situations. ■Sanya Virani, M.D., M.P.H., is a fellow in addiction psychiatry at the Yale School of Medicine and is the resident-fellow member trustee-elect on APA’s Board of Trustees. Souparno Mitra, M.D., is a PGY-1 psychiatry resident at Bronxcare Health Systems in Bronx, N.Y. ISSUES NewArchived

Palliation of chronic breathlessness with morphine in patients with fibrotic interstitial lung disease \u2013 a randomised placebo-controlled trial

BackgroundPatients suffering from fibrotic interstitial lung diseases (fILD) have a poor prognosis and a high symptom burden. Palliative treatment includes relief of symptoms such as breathlessness. There is no evidence-based treatment for chronic breathlessness but opioids are often used despite concerns due to the hypothetical risk of respiratory depression. This study investigated the effect of oral morphine drops in patients with fILD on chronic breathlessness and safety.MethodsIn a double-blinded placebo-controlled study, 36 patients with fILD were randomised to either four daily doses of 5 mg of oral morphine drops or placebo for 1 week. Endpoints and safety parameters were obtained at baseline, at follow-up after 1 h and 1 week.ResultsThe primary endpoint, the visual analogue score (VAS) of dyspnea was reduced by 1.1 ± 0.33 cm in the morphine group at follow-up compared to baseline (P < 0.01), whereas the reduction was 0.35 ± 0.47 cm in the placebo group. However, the difference between the two groups was not statistically significant (p = 0.2). Oral morphine drops did not affect respiratory frequency, pulse rate, blood pressure, peripheral saturation or the 6-min walk test. More patients treated with morphine reported constipation, nausea and confusion.ConclusionOral administration of morphine drops, 20 mg a day, in patients with fILD did not significantly reduce dyspnea VAS score during 1 week compared to placebo. Oral morphine did not induce respiratory depression, but was related to an increased risk of constipation, nausea and confusion.Trial registrationThe trial is registered in clinicaltrials.gov (Identifier: NCT02622022). Registered 4 December 2015.

A methodology to explore ventilatory chemosensitivity and opioid-induced respiratory depression risk

Reported incidence of postoperative opioid-induced respiratory depression (OIRD) ranges from 0.5-41% and is not reliably predicted by traditional risk factors. This study tests a new methodology to investigate ventilatory chemosensitivity as a new potential risk factor and explore OIRD distribution across sleep and wakefulness. Preoperative patient ventilatory chemosensitivity was quantified by hypercapnic ventilatory responses with (HCVRREMI, effect site concentration 0.7 or 2.0 ng/mL) and without (HCVRBL) remifentanil during hyperoxia and hypoxia. Postoperative opioid consumption was recorded during hospital stays. OIRD frequency was the primary outcome of the study, detected as incidences of respiratory rate < 60% of baseline, minute ventilation < 60% of predicted value, pulse oximetry [Formula: see text] < 90% (breathing room air) or 92% (supplemental O2), transcutaneous Pco2 > 50 mmHg, and central and obstructive apnea/hypopnea. Sleep stages were recorded until the first postoperative morning to determine the OIRD sleep distribution as the secondary outcome. The methodology was feasible in implementation and posed no obstacles to standard care. In the nine patients studied (2 females, mean age 65 ± 7.5 yr), remifentanil depressed HCVR to a highly variable degree. High OIRD frequency was generally observed with lower HCVRREMI. OIRD predominantly occurred during light sleep. This study supports ventilatory chemosensitivity as an important predictor of OIRD, lending a new perspective to classify risk for OIRD and detailing a methodology in which to pursue this investigation for future studies.NEW & NOTEWORTHY Our new and noteworthy methodology allows for exploration of preoperative ventilatory chemosensitivity, measured as the hypercapnic ventilatory response (HCVR), as a risk factor for postoperative opioid-induced respiratory depression (OIRD). This feasible and reliable methodology produced preliminary data that showed highly variable depression of HCVR by remifentanil, predominance of OIRD during light sleep, and potentially negative correlation between OIRD frequency generally and HCVR measurements when measured in the presence of remifentanil. Although the results are preliminary in nature, this novel methodology may guide future studies that can one day lead to effective clinical screening tools.

Efficacy of dexamethasone vs dexmedetomidine as an adjuvant for brachial plexus block- A randomised control trial

The brachial plexus block is an easy and relatively safe procedure for upper limb surgeries though there are different approaches to it, it is a block of roots, divisions and cords of the brachial plexus, out of which supraclavicular approach is most widely used method for anaesthesia and preoperative pain management in surgery below shoulder joint. It is performed at the trunk level where the plexus is presented most compactly. Another advantage is that it can be performed with the patient’s arm in any position to provide excellent anaesthesia for elbow, forearm and hand surgery.Various local anaesthetic agents are used for Brachial Plexus Block but most commonly used drugs are; Bupivacaine, and Lignocaine. Bupivacaine is long acting whereas Lignocaine is short acting drug. Novel adjuncts studied to date include butorphanol, buperonorphine, dexamethasone, Clonidine, Neostigmine, Tramadol, Midazolam, Dexmedetomidine etc.Dexmedetomidine is an anxiolytic sedative and analgesic agent, it is a selective α2 – adrenoreceptor agonist and is approximately 8 times more potent than clonidine. It was superior to clonidine also in quality for anesthesia in tourniquet tolerance, and postoperative analgesia and it is notable for its ability to provide sedation without risk of respiratory depression and can provide cooperative or semi arousable sedation.The mechanism by which αadrenergic receptor agonists produce analgesia is likely to be multifactorial. Peripherally αadrenergic agonists produce analgesia by reducing the release of norepinephrine and αreceptor independent inhibitory effect on nerve fibre action potential. Recent pre-clinical and clinical studies show that the glucocorticoid dexamethasone appears to be effective as adjuvant to local anesthetics since it posses anti-inflammatory and analgesic properties. In addition, perineural injection of steroid does influence post operative analgesia. This study was done to compare the adjuvant effect of dexamethasone and dexmedetomidine, when aded with local anesthetics in Supraclavicular brachial plexus block.It was a prospective randomized control trial conducted for 18 months in LLR hospital Kanpur. 90 patients of ASA grade 1 and 2 aged more than 18 yrs of either sex were included and Thirty patients were randomly divided in each of the three groups and observations were made regarding hemodynamic changes such as HR, MAP, SPO2 and onset of sensory, motor block and duration of motor, sensory effect. Student t test and analysis of variance were the methods used for analysis. Additions of injection dexamethasone and injection dexmedetomidine with lignocaine markedly prolonged duration of sensory and motor block however duration of injection dexmedetomidine was found to be longer as compared to dexamethasone.Dexmedetomidine has longer duration of motor and sensory effect when used as an adjuvent as compared to dexamethasone.

A preliminary assessment of vital-signs-integrated patient-assisted intravenous opioid analgesia (VPIA) for postsurgical pain

BackgroundWe developed a Vital-signs-integrated Patient-assisted Intravenous opioid Analgesia (VPIA) analgesic infusion pump, a closed-loop vital signs monitoring and drug delivery system which embodied in a novel algorithm that took into account patients’ vital signs (oxygen saturation, heart rate). The system aimed to allow responsive titration of personalized pain relief to optimize pain relief and reduce the risk of respiratory depression. Moreover, the system would be important to enable continuous monitoring of patients during delivery of opioid analgesia.MethodsNineteen patients who underwent elective gynecological surgery with postoperative patient controlled analgesia (PCA) with morphine were recruited. The subjects were followed up from their admission to the recovery room/ ward for at least 24 h until assessment of patient satisfaction on the VPIA analgesic infusion pump.ResultsThe primary outcome measure of incidence of oxygen desaturation showed all patients had at least one episode of oxygen desaturation (< 95%) during the study period. Only 6 (31.6%) patients had oxygen desaturation that persisted for more than 5 min. The median percentage time spent during treatment that oxygen saturation fell below 95% was 1.9%. Fourteen (73.7%) out of 19 patients encountered safety pause, due to transient oxygen desaturation or bradycardia. The patients’ median [IQR] pain scores at rest and at movement after post-op 24 h were 0.0 [2.0] and 3.0 [2.0], respectively. The average morphine consumption in the first 24 h was 12.5 ± 7.1 mg. All patients were satisfied with their experience with the VPIA analgesic infusion pump.ConclusionsThe use of VPIA analgesic infusion pump, when integrated with continuous vital signs monitor and variable lockout algorithm, was able to provide pain relief with good patient satisfaction.Trial registrationThis study was registered on clinicaltrials.gov registry (NCT02804022) on 28 Feb 2016.

Tu1092 OPTIMAL SEDATION FOR THE GASTROINTESTIINAL ENDOSCOPY WITH THE COMBINATION OF INTERMEDIATE - ACTION AND RAPID- ACTION AGENT

Since 1989, we have performed the gastrointestinal endoscopy with sedation of 2 agents combination (diazepam/thiopental sodium). In 1997, we changed diazepam to midazolam in order to decrease the risk of respiratory depression. Since 2010, we have used propofol instead of thiopental sodium in order to decrease the risk of cough from sputum. Furthermore, recently, we have changed the ration of midazolam and propofol in order to decrease the awakening time. It was uncertain whether midazolam predominant/propofol or midazolam/propofol predominant is more effective and safer. To evaluate prospectively effectiveness and safety of midazolam predominant or propofol predominant (The plasma half time of diazepam, midazolam, thiopental sodium, and propofol are 28 - 35 hour, 120 minute, 2.8 minute, and 2.6minute, respectively.) In diagnostic endoscopy, 200 patients were randomly assigned to 2 groups (2015 October - 2016 March). No significant difference was observed between the two groups in patients characteristic. Both combination agents were given intravenously by the skilled nurse. Midazolam predominant method: Midazolam and propofol were administered intravenously at a stating dose of 0.12mg/Kg and 0.4mg/Kg of body weight, respectively. Sedation was maintained by administering a bolus of 10mg propofol every time the patient’s resistance was noted. Propofol predominant method: At a stating dose of 0.033mg/Kg and 1.0mg/Kg of body weight, respectively. Bolus: 10mg. The primary end-points were the relief rate of discomfort by questionnairing to 200 patients and the safety of sedation by using SPO2 pulse oximeter . Respiratory depression was defined as decrease in oxygen saturation < 90 % for > 20 sec. Severe respiratory depression was defined as the necessity of mask ventilation or the interruption of endoscopic procedure. The perfect relief rate of discomfort and anxiety were same (99% vs 100%). The respiratory depression rate were not significantly difference (23% vs 18%). Severe respiratory depression rate were not significantly difference (1% vs 0 %). However, the rate of cough from sputum significantly decreased (19% vs 9%). Furthermore, the awaking time were shorter in propofol predominant group (80.7min. vs 60.6min). The sedation with the combination of intermediate - action agent and rapid - action agent is very effective. Propofol predominant method is safer than Midazolam predominant method and has faster awaking time.

In Response.

I sincerely thank the authors for describing an experienced-based technique to support the safe tracheal intubation of patients with suspected or confirmed coronavirus disease (COVID-19).1 Their suggestion to use a delayed sequence technique in selected patients is a valuable addition to the “Recommendations for endotracheal intubation of COVID-19 patients.”2 Specifically, they suggest that agitated and uncooperative patients be sedated with ketamine during the preoxygenation phase, to gain their cooperation while minimizing the risk of respiratory depression and cardiovascular instability. The authors describe a difficult and high-stakes scenario. An agitated and uncooperative patient with COVID-19 represents a considerable safety risk to the airway management team. Dislodgement of or damage to personal protective equipment can expose health care providers to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. In addition, movement of glasses, goggles, or a face shield can lead to fogging or an obstructed view, which makes tracheal intubation more difficult. Thus, it may be desirable to optimize conditions by sedating certain patients before tracheal intubation. Additional suggestions from others include using a 2-handed technique with the hands in the VE position when using a self-inflating bag-valve-mask device during preoxygenation,3 cross-checking team members’ personal protective equipment (particularly when managing agitated patients), having all needed materials prepared in advance, and knowing the patients’ code status.4 I applaud the authors and others for sharing their lived experiences as we learn together to support patients and each other during the COVID-19 pandemic. Beverley A. Orser, MD, PhDDepartments of Anesthesiology and Pain Medicine and PhysiologyUniversity of TorontoToronto, Ontario, CanadaDepartment of AnesthesiaSunnybrook Health Sciences CentreToronto, Ontario, Canada[email protected]

Propofol versus placebo (with rescue with ketamine) before less invasive surfactant administration: study protocol for a multicenter, double-blind, placebo controlled trial (PROLISA)

BackgroundOne major limitation for less invasive surfactant administration (LISA) is the difficulty in providing sedation before this procedure and the competitive risk of respiratory depression versus avoidance of intubation for most sedative or analgesic drugs used in this context.The objective of this study is to compare the need for mechanical ventilation within 72 h of life following premedication with propofol, versus placebo (rescue with ketamine), for the LISA procedure in preterm neonates born before 32 weeks gestational age (wGA).MethodsProLISA is a phase III, non-inferiority, multicenter, double blind, randomized, placebo controlled trial designed according to the SPIRIT Statement. Neonates born before 32 wGA in 12 geographically dispersed Neonatal Intensive Care Units in France needing surfactant will be included from September 2019 to September 2022. A sample of 542 patients is needed. The neonate is randomized to the intervention (propofol) or control placebo group. Open label rescue treatment with ketamine is possible in both groups if FANS (Faceless Acute Neonatal pain Scale) is ≥6. To guide drug administration, FANS is scored before attempting laryngoscopy. Once an adequate score has been obtained, LISA is performed according to a standardized protocol. The primary outcome is the need for mechanical ventilation within 72 h of life. Secondary outcomes are tolerance of the procedure, pain evaluation, hemodynamic and neurologic parameters after the intervention, morbidities before discharge and neurodevelopmental assessment at 2 years of age.DiscussionThis paper describes the first multicenter, double-blind, randomized, placebo-controlled trial on this topic and will provide crucial information to support implementation of the LISA procedure.Trial registrationClinicalTrials.gov: NCT04016246. Registered 06 June 2019, N°EUDRACT: 2018–002876-41.

Effects of oxycodone and diazepam alone and in combination on operant nociception.

Developing effective analgesics with fewer unwanted side effects is a pressing concern. Due to a lack of effective nonopioid options currently available, an alternative approach termed opioid-sparing evaluates the ability of a coadministered drug to reduce the amount of opioid needed to produce an antinociceptive effect. Opioids and benzodiazepines are often coprescribed. Although this approach is theoretically rational given the prevalent comorbidity of chronic pain and anxiety, it also has inherent risks of respiratory depression, which is likely responsible for the substantial percentage of fatal opioid overdoses that have involved benzodiazepines. Moreover, there have been no clinical trials to support the effectiveness of this drug combination nor has there been corroborative preclinical evidence using traditional animal models of nociception. The present studies examined the prescription µ-opioid analgesic oxycodone (0.003-0.1 mg/kg) and the prototypical benzodiazepine anxiolytic diazepam (0.03-1.0 mg/kg), alone and in combination, using an animal model of pain that examines the restoration of conflict-related operant behavior as evidence of analgesia. Results documented significant dose-related increases in thermal threshold following oxycodone treatment. Diazepam treatment alone did not produce significant antinociception. In combination, diazepam pretreatment shifted oxycodone functions upward in a dose-dependent manner, but the additive effects were limited to a narrow dose range. In addition, combinations of diazepam and oxycodone at higher doses abolished responding. Taken together, though intriguing, these findings do not provide sufficient evidence that coadministration of an anxiolytic will result in clinically relevant opioid-sparing for pain management, especially when considering the inherent risks of this drug class combination.

Independent Validation in a Large Privately Insured Population of the Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose.

To assess the generalizability of the overdose or serious opioid-induced respiratory depression risk index (VHA-RIOSORD), created by Zedler et al., using claims data from a large private insurer. A retrospective nested case-control analysis of health care claims data. Commercially insured individuals with a claim for an opioid prescription between October 1, 2014, and September 30, 2016 (N = 1,431,737). An overdose or serious opioid-induced respiratory depression (OSORD) occurred in 1,097 patients. Ten controls were selected per case (N = 10,970). Items and the assignment of point values to predictors were consistent with those determined by Zedler et al. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution. All 15 items of the VHA-RIOSORD were used to determine a member's risk of OSORD. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 90% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C-statistic was 0.88. Consistent with the findings of its developers, the VHA-RIOSORD performed well in identifying members of a large private insurance company who were medical users of prescription opioids at elevated risk of overdose or life-threatening respiratory depression, those most likely to benefit from preventive interventions.

Melatonin is useful alternative for sedation in children undergoing auditory brainstem responses testing.

Auditory brainstem responses testing (ABRs) is frequently required to assess auditory function in children. It is done usually in outpatient fashion and requires deep sleep to avoid artefacts. Sedation method used for the test should allow a deep sleep while avoiding general anaesthesia that requires special monitoring, dedicated staff and operating room availability. For this purpose, several sedation methods have been used, with the risk of respiratory depression and sides effects. We aim to assess the efficacy and the usefulness of melatonin in sedation for children undergoing auditory brainstem responses testing. We calculated success rate of complete bilateral ABR, sleep delay and quality of sleep of 247 children referred for ABR testing. Two hundred six children (83.4%) successfully underwent both ears testing. The delay to sleep was variable with a mean of 32min. The quality of sleep was described as continuous in 156 infants (75.7%) and discontinuous in 50 infants (24.27%) requiring either simple nursing or a second dose of melatonin 30min later.Conclusion: Melatonin has the advantages of inducing natural sleep and reducing sleep delay without adverse effects or respiratory depression risk. It is efficient and useful sedation method for ABRs in an outpatient setting. What Is Known? • Auditory brainstem responses test is the most used objective test to assess auditory function in children and requires deep sleep to avoid artefacts. • Melatonin is an endogenous pineal hormone used for sedation in electrophysiological testing and magnetic resonance imaging. What Is New? • 83.4% of children in our study successfully performed a bilateral ABR under melatonin-induced sleep with continuous sleep in 75.7%. • The use of melatonin to induce sleep for ABR tests is useful in an outpatient setting and it is a good alternative to general anaesthesia in Morocco.

Gabapentinoids: pharmacokinetics, pharmacodynamics and considerations for clinical practice.

The gabapentinoids are often recommended as first-line treatments for the management of neuropathic pain. The differing pharmacodynamic and pharmacokinetic profiles can have implications for clinical practice. This article has summarised these key differences. In addition to their use in managing neuropathic pain, gabapentinoids are increasingly being used for off-label conditions despite the lack of evidence. Prescription rates for off-label conditions have overtaken that for on-label use. Similarly, the use of gabapentinoids in the perioperative period is now embedded in clinical practice despite conflicting evidence. This article summarises the risks associated with this increasing use. There is increasing evidence of the potential to cause harm in vulnerable populations such as the elderly and increasing prevalence of abuse. The risk of respiratory depression in combination with opioids is of particular concern in the context of the current opioid crisis. This article describes the practical considerations involved that might help guide appropriate prescribing practices.

Evaluation of bispectral index monitoring efficacy in endoscopic patients who underwent retrograde cholangiopancreatography and received sedoanalgesia.

IntroductionBispectral index (BIS) monitoring provides an objective, non-invasive measurement of the level of consciousness in a sedated patient.AimIn this prospective study, we aimed to investigate the hypothesis that risk of respiratory depression could be reduced and the desired level of sedation with minimal doses of propofol could be achieved by using BIS monitoring in endoscopic retrograde cholangiopancreatography (ERCP) procedures.Material and methodsSixty patients in the ASA 1–2 category, who were scheduled for an ERCP with sedation, were randomly divided into two groups. The procedure was performed, and sedation was administered so that the patient’s Ramsay Sedation Score (RSS) would be 4–5 in the first group (group 1) and the patient’s BIS value would be 65–75 in the second group (group 2). Cardiopulmonary complications, the total duration of the procedure, and the total amount of propofol administered were recorded.ResultsThe mean SpO2 measurements at the third minute, fifth minute, and 10th minute were higher in the BIS group (p < 0.001) (p < 0.05). The mean number of respirations during the third, fifth, 10th, and 15th minute of sedation was significantly higher in the RSS group than in the BIS group (p < 0.05). There was no difference between the groups in terms of recovery time, total propofol amount, and additional doses of bolus propofol.ConclusionsBIS monitoring during sedation with propofol for ERCP did not reduce total propofol use, but it may be an efficient guide for the timing of additional dose administration, which could reduce the risk of respiratory depression, and it could be used safely as an objective method in the follow-up of level of sedation.

Incidence of Respiratory Depression After Epidural Administration of Morphine for Cesarean Delivery: Findings Using a Continuous Respiratory Rate Monitoring System

(Int J Obst Anesth. 2019;38:32–36) Epidural morphine is widely used for postcesarean analgesia. However, because of the risk of respiratory depression after neuraxial administration of morphine, the American Society of Anesthesiologists (ASA) recommends frequent respiratory rate monitoring in the 24 hours after administration. This has typically been assessed through intermittent manual counting of the respiratory rate—a practice that is prone to observer error and does not allow continuous monitoring. Using this technique has resulted in documented rates of respiratory depression after epidural or intrathecal morphine administration of 0% to 0.9%.This study aimed to estimate the incidence of respiratory depression using the Nellcor respiratory rate monitoring system, which allows continuous monitoring, in patients who received 3 mg of epidural morphine for postcesarean analgesia.

Intranasal fentanyl for pain management during screening for retinopathy of prematurity in preterm infants: a randomized controlled trial.

To study the efficacy of intranasal fentanyl as an adjunct for pain management during screening for retinopathy of prematurity (ROP) in preterm infants. In this single center, double blinded, randomized controlled trial, preterm neonates between 30 and 34 weeks postmenstrual age received either intranasal fentanyl (2 mcg/kg) or intranasal normal saline through a mucosal atomization device 5 min prior to the first ROP-screening examination. Both the groups received standard pain relief strategies (oral sucrose, 0.5% proparacaine eye drops and physical containment). The primary outcome was premature infant pain profile-revised (PIPP-R) score during the screening. A total of 111 infants were enrolled. PIPP-R score during the retinal examination was significantly lower in the fentanyl group (8.3 versus 11.5, mean difference: 3.2 (2.46-4.06), P < 0.001). There was no significant difference in the incidence of adverse effects. Intranasal fentanyl significantly reduced the pain associated with retinal examination without increasing the risk of respiratory depression. Large RCTs are required to verify the efficacy and safety of intranasal fentanyl for acute procedural pain in neonates. CTRI/2017/12/011016.

Impact of Timing of Preprocedural Opioids on Adverse Events in Procedural Sedation.

The risk of respiratory depression is increased when opioids are added to sedative agents. In our recent multicenter emergency department (ED) procedural sedation cohort, we reported a strong association between preprocedural opioids and sedation-related adverse events. We sought to examine the association between timing of opioids and the incidence of adverse sedation outcomes. We conducted a secondary analysis of a prospective cohort of children aged 0 to 18years who received sedation for a painful procedure in six Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was timing of opioid administration, adjusted for age, opioid type, preprocedural and sedation medications, and procedure type. Outcomes were 1) oxygen desaturation, 2) vomiting, and 3) positive pressure ventilation (PPV). Of the 6,295 children in the original cohort, 1,806 (29%) received a preprocedural opioid. Patients receiving preprocedural opioids had a higher incidence of oxygen desaturation (risk difference= 4.3%, 95% confidence interval [CI]= 2.9% to 5.8%), vomiting (risk difference2.0%, 95% CI= 0.7% to 3.3%), and PPV (risk difference= 1.5%, 95% CI= 0.7% to 2.3%). Multivariable regression with timing of opioids modeled as a restricted cubic spline revealed the risk for each outcome was highest when opioids were administered in the 30minutes prior to sedation. Timing of opioid administration was statistically significantly associated with oxygen desaturation and vomiting (p<0.0001) but not with PPV (p=0.113). Timing of opioids was significantly associated with the risk of oxygen desaturation and vomiting. Being aware of this increased risk will help clinicians prepare for sedation and the potential need for patient rescue.

Sufentanil versus fentanyl for pain relief in labor involving combined spinal-epidural analgesia: a systematic review and meta-analysis of randomized controlled trials

To systematically compare the efficacy and safety of sufentanil versus fentanyl for pain relief in labor involving combined spinal-epidural analgesia (CSEA), a systematic review and meta-analysis of randomized controlled trials targeting parturients requesting labor analgesia was conducted. The primary outcome measure was visual analog scale scores assessed at 10, 15, 30, and 60 min after intrathecal injection. Secondary outcomes included duration of spinal analgesia, incidence of side effects in parturients, and neonatal Apgar scores. Twelve randomized controlled trials, including data from 881 patients fulfilled the inclusion criteria. No clinically meaningful differences in pain reduction after intrathecal injection were found between the two analgesics. Sufentanil extended the duration of spinal analgesia by 25.40 min (95% CI 21.82 to 28.98min; p < 0.00001) compared with fentanyl. The risk for pruritus, nausea, and vomiting among parturients was 82% for those using sufentanil (relative risk 0.82 [95% CI 0.67-0.99]; p = 0.04) and 48% for those using fentanyl (relative risk 0.48 [95% CI 0.29-0.80]; p = 0.005). Both the synthesis results and sensitivity analysis demonstrated no differences in the risk for respiratory depression between parturients using sufentanil versus fentanyl. The neonates in sufentanil group exhibited higher Apgar scores than the fentanyl group 5 min after delivery (weighted mean difference 0.10 [95% CI 0.05-0.16]; p = 0.0002). Existing evidence suggests that compared with fentanyl, sufentanil used for analgesia in combined spinal-epidural during labor is more effective in extending the duration of spinal analgesia, and may be safer for the infant. There was overall low clinical and statistical heterogeneity among the included studies. For all outcomes, variations caused by heterogeneity across trials were acceptable. Thus the findings of this meta-analysis may provide additional evidence for future clinical practices of pain relief in labor involving CSEA. Stronger evidence supporting this conclusion will require data from more high-quality and multicenter randomized controlled trials.