Safety Of Sedation Research Articles

Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy: a cohort study.

Remimazolam is a novel ultra-short-acting sedative, but its safety and adverse events (AEs) in high-risk patients in the intensive care unit (ICU) setting remain unknown. This was a single-center, retrospective study that compared remimazolam to propofol and midazolam in patients undergoing upper gastrointestinal endoscopy. The primary outcome was the incidence of treatment-related AEs. The secondary outcomes were the time to extubation, the length of ICU stay, and the average cost of sedative per case. Of the 88 patients analyzed, 47 were treated with remimazolam (mean dose, 7.90±4.84 mg), and 41 were treated with propofol (21.19±17.98 mg) or midazolam (3.08±2.17 mg). There was no statistically significant difference in the average duration of the endoscopic procedure (35.89±13.37 min vs. 44.51±21.68 min, P=0.133) or the time to extubation (15.00±9.75 h vs. 20.59±18.71 h, P=0.211) in the remimazolam group (group I) compared to the propofol or midazolam group (group II). ICU stays (5.40±2.93 d vs. 4.63±3.31 d, P=0.072) and treatment-related AEs (48.61% vs. 51.38%, P=0.056) were similar between groups. The average cost of sedative per case was significantly lower in the group I than in the group II (RMB 16.07±10.58 yuan vs. RMB 24.37±15.46 yuan, P=0.016). Remimazolam-based sedation was noninferior to the classic sedatives and had lower average cost per case, indicating that it may be used as a promising sedative for high-risk patients during endoscopic procedures in the ICU setting.

Safety and efficacy of target controlled infusion administration of propofol and remifentanil for moderate sedation in non-hospital dental practice.

Fearful and anxious patients who find dental treatment intolerable without sedative and analgesic support may benefit from moderate sedation. Target controlled infusion (TCI) pumps are superior to bolus injection in maintaining low plasma and effect-site concentration variability, resulting in stable, steady-state drug concentrations. We evaluated the safety and efficacy of moderate sedation with remifentanil and propofol using TCI pumps in non-hospital dental settings. A prospective chart review was conducted on 101 patients sedated with propofol and remifentanil using TCI pumps. The charts were completed at two oral surgeons and one general dentist's office over 6 months. Hypoxia, hypotension, bradycardia, and over-sedation were considered adverse events and were collected using Tracking and Reporting Outcomes of Procedural Sedation (TROOPS). Furthermore, patient recovery time, sedation length, drug dose, and patient satisfaction questionnaires were used to measure sedation effectiveness. Of the 101 reviewed sedation charts, 54 were of men, and 47 were of women. The mean age of the patients was 40.5 ±18.7 years, and their mean BMI was 25.6 ± 4.4. The patients did not experience hypoxia, bradycardia, and hypotension during the 4694 min of sedation. The average minimum Mean Arterial Pressure (MAP) and heartbeats were 75.1 mmHg and 60.4 bpm, respectively. 98% of patients agreed that the sedation technique met their needs in reducing their anxiety, and 99% agreed that they were satisfied with the sedation 24 hours later. The average sedation time was 46.9 ± 55.6 min, and the average recovery time was 12.4 ± 4.4 min. Remifentanil and propofol had mean initial effect-site concentration doses of 0.96 µ/ml and 1.0 ng/ml respectively. The overall total amount of drug administered was significantly higher in longer sedation procedures compared to shorter ones, while the infusion rate decreased as the procedural stimulus decreased. According to the results of this study, no patients experienced adverse events during sedation, and all patients were kept at a moderate sedation level for a wide range of sedation times and differing procedures. The results showed that TCI pumps are safe and effective for administering propofol and remifentanil for moderate sedation in dentistry.

Effect of Intravenous Injection of Remazolam on Stress Response and Analgesic Effect in Patients with Transurethral Resection of the Prostate: A Single-Centre Study.

The reasonable selection of anaesthesia methods and drugs is the key to ensuring the perioperative safety of patients with the transurethral resection of the prostate (TURP). The effect of intravenous remazolam injection on stress response and analgesic effect in patients with transurethral prostate cancer electrotomy were explored. The medical records of 160 patients with prostatic hyperplasia who underwent TURP in Tianjin hospital from November 2020 to November 2022 were selected for retrospective analysis. Five patients who did not meet the study conditions were excluded, and 155 patients were finally included. According to anaesthesia schemes, the patients were divided into the observation group (OBG, n = 76, routine surgical anaesthesia and intravenous remazolam injection) and control group (COG, n = 79, routine surgical anaesthesia). Postoperative eye-opening times were recorded for both groups. The groups were compared in terms of anaesthetic effects, stress indexes, haemodynamic indexes, and use of postoperative analgesic drugs at different times, and adverse reactions were observed. The anaesthesia onset time and eye-opening time in the OBG were shorter than those in the COG (p < 0.001). The heart rate and mean arterial pressure of the OBG during anaesthesia induction were higher than those in the COG (p < 0.001). The OBG showed significantly lower noradrenaline and cortisol levels than the COG 1, 12 and 24 h after surgery (p < 0.001). The time of first pressing in the analgesic pump in the OBG was later than that in the COG, and the total consumption of sufentanil was less than that in the COG (p < 0.001). The total incidence of adverse reactions in the OBG was lower than that in the COG (p < 0.05). Intravenous remazolam injection provides safe and effective sedation and analgesia for patients on TURP and reduces the occurrence of stress responses and adverse reactions. However, cases involved in this study were all from a single centre, and multi-centre research and verification are needed.

A Survey on Procedural Sedation and Analgesia for Pediatric Facial Laceration Repair in Korea

Background Most children with facial lacerations require sedation for primary sutures. However, sedation guidelines for invasive treatment are lacking. This study evaluated the current status of the sedation methods used for pediatric facial laceration repair in Korea. Methods We surveyed one resident in each included plastic surgery training hospital using face-to-face interviews or e-mail correspondence. The health care center types (secondary or tertiary hospitals), sedation drug types, usage, and dosage, procedure sequence, monitoring methods, drug effects, adverse events, and operator and guardian satisfaction were investigated. Results We included 45/67 hospitals (67%) that used a single drug, ketamine in 31 hospitals and chloral hydrate in 14 hospitals. All health care center used similar sedatives. The most used drug administered was 5 mg/kg intramuscular ketamine (10 hospitals; 32%). The most common chloral hydrate administration approach was oral 50 mg/kg (seven hospitals; 50%). Twenty-two hospitals (71%) using ketamine followed this sequence: administration of sedatives, local anesthesia, primary repair, and imaging work-up. The most common sequence used for chloral hydrate (eight hospitals; 57%) was local anesthesia, administration of sedatives, imaging work-up, and primary repair. All hospitals that used ketamine and seven (50%) of those using chloral hydrate monitored oxygen saturation. Median operator satisfaction differed significantly between ketamine and chloral hydrate (4.0 [interquartile range, 4.0-4.0] vs. 3.0 [interquartile range, 3.0-4.0]; p <0.001). Conclusion The hospitals used various procedural sedation methods for children with facial lacerations. Guidelines that consider the patient's condition and drug characteristics are needed for safe and effective sedation.

Preprocedural Nebulisation with 4% Lignocaine and Ketofol Sedation during Endoscopic Retrograde Cholangiopancreatography Procedure for Abolition of Gag Reflex: A Randomised Double-blinded Study

Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) is preferably carried out under deep sedation with propofol alone or with adjuncts to reduce the dose of propofol thereby reducing the intraprocedural complications and improving the patient and endoscopist acceptance of the procedure. There is no consensus on the ideal dose of ketamine as adjunct to propofol to be used in such scenario. Aim: To evaluate the sedation characteristics, abolition of gag reflex and haemodynamic profile of the patients undergoing ERCP under ketofol sedation, with or without 4% lignocaine prenebulisation. Materials and Methods: This randomised double-blinded study was undertaken in Indra Gandhi Medical College, Shimla, from September 2018 to October 2019. Patients of American Society of Anesthesiologists (ASA) physical class I, II and III aged between 25 to 65 of both sexes posted for routine ERCP were included. In group 1, patients were nebulised with 6 cc normal saline, and group 2 with 6 cc 4% lignocaine 15 min prior to procedure in the recovery room. Entropy-guided ketofol induction (ketamine and propofol used in 1:2 concentration) was used, followed by propofol infusion at the rate of 8 mL/ hr. Gag reflex, hemodynamic and sedation characteristics were observed peri and postoperatively. Results: The mean time to onset of sedation and duration of recovery room stay were comparable in both the groups. Total mean dose of propofol and ketamine used was 105.67 mg, 55.33±18.75 mg in group 1 and 101.83 mg, 48.67±15.588 mg in group 2. Gag reflex was similarly obtunded and endoscopists’ rating of the procedure were similar in both the groups perioperatively (p-value &gt;0.05). Conclusion: Target controlled entropy guided infusion with ketofol is an effective drug combination to achieve all aspects of safe sedation practice in ERCP procedure.

Comparing the anti-nociceptive, sedative and clinicophysiological effects of epidural detomidine, detomidine-lidocaine and lidocaine in donkeys.

Epidural analgesia using the alpha-2 agonist detomidine (DE), alone or in combination with lidocaine (LD), is frequently employed for standing surgical procedures in horses, but its use has not been evaluated in donkeys. In a randomised controlled prospective trial, 24 healthy adult donkeys were assigned to four groups (n = 6), each receiving 40μg/kg of DE, 0.22mg/kg of LD, combined DE and LD (DELD) or 0.9% sterile normal saline epidurally. After epidural injection of each treatment, the onset, degree and duration of sedation and anatomical extension of anti-nociception were observed. DE and DELD treatments resulted in complete bilateral analgesia with loss of sensation in the tail, perineum, inguinal area, chest and the caudal aspect of the upper pelvic limb, and extended distally to the dorsal metatarsal area. DE and DELD resulted in a significantly (p < 0.05) longer duration of anti-nociception (110 ± 15.4min and 141.6 ± 14.7min, respectively) than LD (75.8 ± 4.9min). The DELD duration of sedation was significantly (p < 0.05) longer than the DE duration (118.3 ± 19.4min and 108.3 ± 7.5min, respectively). The current study's main limitation is using only one dose of DE. DE and DELD produced a very effective, safe and acceptable sedative and analgesic effect in the perineal and inguinal regions of donkeys.

To Compare the Safety and Efficacy of Conscious Sedation with Dexmedetomidine and Propofol Infusion for Endoscopic Discectomy.

Endoscopic discectomy is a minimally invasive, day care spine surgery. Patient comfort is of utmost importance as it is performed under local anaesthesia and in prone position. Propofol and dexmedetomidine are titrable and short-acting and commonly used for conscious sedation. The objectives of the study are to study the effect of dexmedetomidine and propofol infusion on cardiorespiratory parameters and to evaluate the efficacy of dexmedetomidine and propofol infusion for conscious sedation. This is a prospective, randomized, patient-blinded study. Sixty adult patients were randomly recruited to 2 groups of 30 each, to receive an infusion of dexmedetomidine or propofol, titrated to bispectral index score 70-80. The intra-operative cardiorespiratory parameters and level of sedation, postoperative visual analogue scale score, time to discharge from post-anaesthesia care unit, and patient satisfaction were monitored. Both groups were comparable with respect to demographic parameters and surgical duration. The heart rate was significantly lower with dexmedetomidine whereas the intraoperative mean arterial pressure was higher with dexmedetomidine. Though the level of intraoperative sedation was higher with propofol, the respiratory parameters were comparable. Postoperative visual analogue scale score was significantly higher with propofol. Dexmedetomidine and propofol provide adequate sedation without any cardiorespiratory compromise when used for conscious sedation for minimally invasive spine surgeries performed in prone position. Dexmedetomidine provides an added advantage of postoperative analgesia and better patient satisfaction.

Anesthesia outcomes in lysosomal disorders: CLN3 and GM1 gangliosidosis.

Natural history studies of pediatric rare neurometabolic diseases are important to understand disease pathophysiology and to inform clinical trial outcome measures. Some data collections require sedation given participants' age and neurocognitive impairment. To evaluate the safety of sedation for research procedures, we reviewed medical records between April 2017 and October 2019 from a natural history study for CLN3 (NCT03307304) and one for GM1 gangliosidosis (NCT00029965). Twenty-two CLN3 individuals underwent 28 anesthetic events (age median 11.0, IQR 8.4-15.3 years). Fifteen GM1 individuals had 19 anesthetic events (9.8, 7.1-14.7). All participants had the American Society of Anesthesiology classification of II (8/47) or III (39/47). Mean sedation durations were 186 (SD=54; CLN3) and 291 (SD=33; GM1) min. Individuals with GM1 (6/19, 31%) were more frequently prospectively intubated for sedation (CLN3 3/28, 11%). Minor adverse events associated with sedation occurred in 8/28 (28%, CLN3) and 6/19 (32%, GM1) individuals, frequencies within previously reported ranges. No major adverse clinical outcomes occurred in 47 anesthetic events in pediatric participants with either CLN3 or GM1 gangliosidosis undergoing research procedures. Sedation of pediatric individuals with rare neurometabolic diseases for research procedures is safe and allows for the collection of data integral to furthering their understanding and treatment.

To ascertain the plasma concentration of propofol to achieve bispectral index-guided sedation using a target-controlled infusion in patients undergoing elective surgeries under neuraxial anaesthesia.

Sedation improves patient satisfaction, comfort and acceptance of regional anaesthesia. Propofol using bispectral index (BIS)/target-controlled infusion (TCI) system can be an optimal method of sedation, as it combines objective measurement of sedation using BIS along with maintenance of a steady plasma concentration of propofol with the TCI device. The aim of this study was to ascertain the dose and safety of propofol using BIS/TCI system for sedation in patients undergoing surgeries under neuraxial anaesthesia. One hundred and seven adult patients, undergoing elective surgical procedures under spinal or combined spinal epidural anaesthesia, were recruited. Propofol infusion was started with TCI at an initial target plasma concentration (Cpt) of 1.2 μg/mL, and after equilibration between Cpt and effect site concentration (Ce), propofol was then adjusted in increments and/or decrements of 0.2 μg/mL in order to maintain a BIS value between 60 and 80. The average time to reach BIS = 80 after starting infusion was 7.32 ± 3.13 minutes. The objective was to calculate mean Cpt value maintaining BIS between 60 and 80 and to observe recovery time and complications. Mean Cpt value was 1.13 ± 0.17 mg/mL with 95% confidence interval (1.10-1.16 μg/mL). In 85% of patients, a BIS value of 60-80 was maintained at Cpt ≤ 1.2 μg/mL. No patient had severe complications requiring stoppage of infusion. Propofol sedation using BIS/TCI system can provide safe and convenient sedation during neuraxial anaesthesia at very low plasma concentration, Cpt ≤ 1.2 μg/mL in majority of patients. There were no periprocedural complications, and recovery was rapid.

A different state of mind: developing a mental health simulation programme for foundation doctors in Scotland

The new Foundation Curriculum 2021 for Doctors in Training (DiT) in the United Kingdom calls for an increased focus on developing mental health-related skills [1], bringing them into parity with physical health. The importance of developing the core clinical skills needed to work with patients who have mental illness is now well-recognised within medical education [2,3]. In collaboration with NHS Education Scotland (NES), we piloted a half-day programme of immersive high-fidelity simulation in Psychiatry for foundation year one (FY1) doctors working in NHS Lothian. Scenario design was by a core group consisting of simulation faculty and Foundation programme directors who were consultant psychiatrists and acted as content experts. The intended learning outcomes (ILOs) for these sessions were constructively aligned with key presentations set out in the revised Foundation Curriculum. The scenarios considered the limitations of practice for an FY1, particularly in regard to mental health law. The three immersive scenarios developed included management of an aggressive patient with delirium, challenging communication with relatives, and management of a depressed patient. Scenarios were based in general wards to maximise fidelity with FY1 experience. 18 sessions were run for FY1 doctors at the three main acute hospital sites in NHS Lothian to ensure equitable access. Participants completed a pre-session evaluation to determine their perceived ability to perform key skills, including assessment of a patient who has self-harmed, a patient with depressive symptoms, assessment of capacity and use of mental health legislation, use of verbal de-escalation, safe sedation, and how to take a collateral history. Assessments were made on a Likert scale and were repeated immediately following the session. We plan to repeat this questionnaire three months following the session. A total of 68 FY1 doctors attended the pilot sessions. When considering the percentage of participants who felt prepared or very prepared, substantial improvements were seen in all assessed domains following the session ( Percentage of candidates who reported feeling either prepared or very prepared to carry out they key skills included in the pilot sessions We have demonstrated that immersive simulation-based education can be used to improve knowledge and confidence in core aspects of psychiatry. With support from NES, we aim to offer this session to all FY1s in Scotland. 1. UK Foundation Programme (2021) UK Foundation Programme. 2. Piot MA, Dechartres A, Attoe C, Jollant F, Lemogne C, Layat Burn C, Rethans JJ, Michelet D, Cross S, Billon G, Guerrier G. Simulation in psychiatry for medical doctors: a systematic review and meta‐analysis. Medical Education. 2020;54(8):696–708. 3. Piot MA, Attoe C, Billon G, Cross S, Rethans JJ, Falissard B. Simulation training in psychiatry for medical education: a review. Frontiers in Psychiatry. 2021;12:658967.

Abstract 11905: Dexmedetomidine for Sedation During Epicardial Ablation for Ventricular Tachycardia: A Single-Center Experience

Introduction: Epicardial ablation of ventricular tachycardia (VT) is mainly performed under general anesthesia (GA). However, GA lowers blood pressure, may interfere with arrhythmia induction, and the use of muscle relaxants precludes identification of the phrenic nerve. Moreover, an anesthesiologist's is required during GA for the whole procedure, which may not always be possible. Hypothesis: The aim of there study was to evaluate the feasibility and safety of epicardial VT ablations under conscious sedation using dexmedetomidine. Methods: Between 2018 and 2022, all patients who underwent epicardial VT ablation under dexmedetomidine infusion were prospectively enrolled. All patients received premedication with paracetamol 1 g (acetaminophen 10 mg/ml) and ketorolac 30 mg. Sedation protocol included an i.v. bolus of midazolam (0.03-0.05 mg/kg) followed by continuous infusion of dexmedetomidine (0.2-0.7 mcg/kg/h). In addition, an i.v. fentanyl bolus (0.7-1.4 mcg/kg) was given for short-term analgesia, followed by a second dose after 30-45 minutes. Sedation-related complications were: hypoxia (S02&lt;90%), severe hypotension (MAP&lt;60 mmHg), and bradycardia (HR &lt;45 b/m). Results: Seventy-one patients with drug-refractory recurrent VT underwent epicardial or endo-epi ablation under conscious sedation. Standard percutaneous sub-xiphoid access was attempted in all patients. in 2 patients the procedure was switched to GA because of intractable pain during epicardial catheter's manipulation. Data from 69 patients were analyzed. Mean age was 65.4±12.1 years and 66.6% of patients were males. Forty-seven patients (68.1%) had non-ischemic cardiomyopathy, 13 patients (18.9%) had ischemic-cardiomyopathy, and 9 patients (13%) had myocarditis. Procedural-related complications occurred in five patients (7.2%), one transient phrenic nerve palsy, two pericarditis, and two vascular complications. No severe adverse events related to the sedation occurred. Conclusions: Prompt availability of anesthesia support remains crucial for epicardial VT ablation. Continuous infusion of dexmedetomidine in addition to midazolam and fentanyl seems to be a safe and effective sedation protocol in patients undergoing epicardial VT ablation.

Efficacy and Safety of the Remimazolam-Alfentanil Combination for Sedation During Gastroscopy: A Randomized, Double-blind, Single-center Controlled Trial

Propofol infusion is a popular single drug of choice for sedation in the gastrointestinal endoscopy suite. Drug combinations are more beneficial than single-drug regimens in gastroscopy sedation. However, the cardiopulmonary complications of propofol sedation raise concern. Remimazolam is a novel, ultra-short-acting benzodiazepine sedative, and alfentanil is a weak opioid. During endoscopic procedures, remimazolam is an effective and safe sedative procedure. No synergistic effect has been reported when remimazolam was combined with alfentanil in gastroscopy sedation. Here, we evaluated the effective dose, sedative efficacy, and safety of the remimazolam-alfentanil combination in gastroscopy sedation and compared the results with those of the propofol-alfentanil combination. This study was conducted in two parts. In Part 1, Dixon's up-and-down method (sequential distribution) was adopted for determining the 95% effective dose (ED95) (95% CI) and 95% CI of remimazolam combined with 5 µg/kg alfentanil. In Part 2, after obtaining the predictive remimazolam ED95, 161 patients were randomized into the remimazolam group (remimazolam-alfentanil) and the propofol group (propofol-alfentanil). The effectiveness of the drug combinations was measured according to successful sedation parameters. Changes in vital signs and the appearance of adverse events were used to assess the safety of drug combinations. Evaluation of patient and physician satisfaction was included as quality indicators of treatment. Baseline demographic and clinical characteristics were comparable between the 2 parts of the study. The ED95 of remimazolam in inhibiting a positive response to gastroscopy placement into the pharyngeal cavity was 0.33 mg/kg (95% CI, 0.289 to 1.023). The procedure success rate was 97.53% in the remimazolam group and 97.50% in the propofol group. The difference in the success rate of the procedure between the remimazolam and propofol groups was 0.03% (95% CI, -2.5 to 2.4). However, the incidence of injection pain, hypotension, respiratory depression, and dizziness was lower in the remimazolam group compared with the propofol group (P < 0.05). Furthermore, patients from the propofol group were more likely to be drowsy, and their work efficiency was reduced the day after leaving the hospital, whereas patients in the remimazolam group were less affected (P < 0.05). The ED95 of remimazolam was 0.33 mg/kg when it was combined with alfentanil (5µg/kg) for gastroscopy sedation. The sedation strategy of remimazolam-alfentanil has noninferior efficacy, fewer adverse effects, and a better postoperative recovery process than propofol-alfentanil for patients undergoing gastroscopy. Chinese Clinical Trials Registry identifier: ChiCTR2100051565.

Safety and Efficacy of Sedation During Emergency Endoscopy for Upper Gastrointestinal Bleeding: A Propensity Score Matching Analysis

Background and AimThis study aimed to compare patients with and without sedation during emergency endoscopy for upper gastrointestinal bleeding (UGIB) and to clarify the safety and efficacy of sedation in emergency endoscopy.MethodsWe retrospectively collected 389 patients who underwent emergency endoscopy for UGIB at Ureshino Medical Center from 2016 to 2021. Patients were divided into two groups: sedation group during emergency endoscopy and nonsedation group. Clinical characteristics, patient status on admission, and UGIB etiology were evaluated. Treatment outcomes and adverse events were evaluated using propensity score matching (PSM), and risk factors for mortality from UGIB were investigated using Cox multivariate analysis.ResultsThe sedation group was significantly younger, composed of a higher proportion of males, and had chronic liver disease. Blood pressure and hemoglobin level on admission were significantly higher in the sedation group. The main cause of bleeding was peptic ulcer, which was significantly higher in the nonsedation group. PSM created 133 matched pairs. The success rate of endoscopic hemostasis was similar in both groups, and procedure time was significantly shorter in the sedation group than in the nonsedation group (17.6 ± 10.0 versus 20.2 ± 10.2 min, P = 0.04). There were no significant differences in adverse events between groups. Cox multivariate analyses revealed that red blood cell transfusion [hazard ratio (HR) 4.45, P < 0.02] and rebleeding (HR 3.30, P = 0.03) were associated with increased risk of 30-day mortality from UGIB.ConclusionsSedation reduced the procedure time during emergency endoscopy for UGIB. Sedation during emergency endoscopy for UGIB is acceptable for safe endoscopic procedures.

Using a combination of midazolam and butorphanol is a safe and effective reversible field sedation protocol for Weddell seal (Leptonychotes weddellii) pups.

Weddell seals (Leptonychotes weddellii) are a well-studied species of phocid with an apparent sensitivity to immobilising agents. Mortality as high as 31% has been reported during field immobilisation. This study investigated the use of a benzodiazepine in combination with an opioid agonist/antagonist for sedation in Weddell seal pups as part of a physiological study. During the 2017 and 2019 Antarctic pupping seasons, 18 Weddell seal pups were sedated by intramuscular administration of a combination of midazolam and butorphanol or intravenous midazolam alone. Individuals were sedated at 1, 3, 5 and 7 weeks of age. Naltrexone and flumazenil were used to reverse sedation. The combination was 100% effective in providing appropriate sedation for the intended procedures. Analyses were performed to investigate relationships between dose administered, age, individual reactions, adverse effects and changes in dive physiology. Transient apnoea (10-60 seconds) was the most frequently observed adverse effect. No sedation-associated morbidity or mortality occurred. The sample size is small and there is no pharmacokinetic information for either sedative or reversal in phocid species. The combination of midazolam (0.2-0.3mg/kg) and butorphanol (0.1-0.2mg/kg) provided safe and effective sedation, with reversible effects, in Weddell seal pups.

Analysis of variation in pre-procedural fasting duration for common inpatient gastrointestinal procedures.

BackgroundGastrointestinal procedures generally require pre-procedural fasting to optimize sedation safety. While the American Society of Anesthesiologists (ASA) recommends no intake of clear liquids and solid food 2–4 and 6–8 hours respectively prior to endoscopic procedures, the actual nil per os (NPO) duration for these procedures in practice is unknown. Our objective was to analyze NPO duration for patients undergoing these procedures and to determine its association with clinical and administrative variables.MethodsInpatient data from 2016–2018 for the three procedures was extracted from electronic medical records and administrative data at a single-center tertiary academic medical center. Various statistical tests (Kruskal-Wallis, Wilcoxon, Pearson) were employed depending on the outcome type and data distribution.ResultsOne thousand three hundred and twenty-five esophagogastroduodenoscopies (EGDs), 753 colonoscopies, and 550 endoscopic retrograde cholangiopancreatographies (ERCPs) were included. The median NPO time for all procedures was 12.6 hours (IQR, 9.6–16.1 hours). The median NPO times were 12.6, 11.9, and 13.1 hours for EGD, colonoscopy, and ERCP respectively. NPO duration was greater for Hispanic than non-Hispanic patients (median 13.9 vs. 12.4, P=0.018). NPO duration was also associated with increased age (r=0.041, P=0.027) and inversely related to hospital occupancy (r=–0.08, P<0.0001). There were no statistically significant associations with provider type, hospital location or service, length of stay, and total number of comorbidities.ConclusionsNPO times for common inpatient gastroenterology (GI) procedures generally exceeded 12 hours, suggesting there is an opportunity to adopt changes to decrease NPO duration for low-risk patients while maintaining adherence to guidelines and best practice.

Moderate sedation by total intravenous remimazolam-alfentanil vs. propofol-alfentanil for third molar extraction: A prospective randomized controlled trial.

BackgroundOral dental treatment cause anxiety, fear, and physical stress. This study aimed to investigate the efficacy and safety of moderate sedation by remimazolam with alfentanil vs. propofol with alfentanil in third molar extraction.MethodsThis single-center, randomized, single-blind clinical trial included 100 adults who underwent third molar ambulatory extraction. All patients had continuous infusion of Alfentanil 0.2 μg/kg/min. Group remimazolam with alfentanil (group RA) had an induction dose of 80 μg/kg and maintenance dosage of 5 μg/kg/min. In group propofol with alfentanil (PA group), propofol was infused at an initial concentration of 1.8 μg/mL under target controlled infusion (TCI) mode and a maintenance concentration of 1.5 μg/mL. The incidence rates of adverse effects were recorded and compared. Depth of sedation was assessed using the modified observer alertness/sedation assessment (MOAA/S) and entropy index. Recovery characteristics were recorded and complications observed for next 24 h.ResultsThe incident of adverse events 6 (12%) in the group RA was lower than the group PA 25 (50%) [Mean difference 0.136 (95%CI, 0.049–0.377); P < 0.05], with no serious adverse events during the sedation procedure. The incidence of injection pain in group RA was significantly lower than that in group PA [4 vs. 26%, mean difference 0.119 (95%CI, 0.025–0.558); P = 0.004]. Before starting local anesthesia, the mean arterial pressure, heart rate, and respiratory rate of the PA group were lower than those of the RA group. None of the patients required further treatments for a decreased heart rate, blood pressure, or low SpO2. The rate of moderate sedation success was 100% in both groups. The MOAA/S score was similar between the groups indicating that the depth of sedation was effective. Group RA had significantly shorter recovery and discharge times than those of group PA.ConclusionsRemimazolam with alfentanil is a safer and more effective alternative for ambulatory sedation and can reduce recovery and discharge time and the incidence of perioperative adverse events compare with propofol.Clinical trial registrationhttp://www.chictr.org.cn/index.aspx, identifier: ChiCTR2200058106.

Safe intravenous sedation for oral surgery in a primary care setting.

Conscious sedation is a useful adjunct in oral surgery due to the invasive nature of procedures and the prevalence of dental anxiety in the general population. The most common conscious sedation technique used in the UK is intravenous sedation with a single drug, midazolam, which has an excellent record of safety. This paper gives an overview of areas to consider when planning oral surgery procedures in primary care under intravenous sedation with midazolam, to enhance success and patient safety. The fundamentals of providing safe sedation include careful patient assessment, patient preparation, a good understanding of the complexity of treatment, and an appropriately trained team. This paper also reviews the current guidance on conscious sedation in the UK, the governance of sedation in dentistry, the medications used, and training of the sedation team.

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures.

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

Dexmedetomidine for sedation during epicardial ablation for ventricular tachycardia: a single-center experience.

Epicardial approach to ventricular tachycardia (VT) ablation is mainly performed under general anesthesia (GA). Although catheter manipulation and ablation in the epicardial space could be painful, GA lowers blood pressure and may interfere with arrhythmia induction and mapping, and the use of muscle relaxants precludes identification of the phrenic nerve (PN). Moreover, an anesthesiologist's presence is required during GA for the whole procedure, which may not always be possible. Therefore, we evaluated the feasibility and safety of epicardial VT ablations performed under conscious sedation using dexmedetomidine in our center. Between January 2018 and January 2022, all patients who underwent epicardial VT ablation under continuous dexmedetomidine infusion were prospectively included in the study. All patients received premedication 30min before the epicardial puncture with paracetamol (acetaminophen 10mg/ml) 1000mg and ketorolac 30mg. Sedation protocol included an intravenous bolus of midazolam hydrochloride (0.03-0.05mg/kg) followed by continuous infusion of dexmedetomidine (0.2-0.7 mcg/kg/h). In addition, an intravenous fentanyl citrate bolus (0.7-1.4 mcg/kg) was given for short-term analgesia, followed by a second dose repeated after 30 to 45min. Sedation-related complications were defined in case of respiratory failure, severe hypotension, and bradycardia requiring treatment. Sixty-nine patients underwent epicardial or endo-epi VT ablation under conscious sedation and were included in the analysis. The mean age was 65.4 ± 12.1years; forty-six patients were males (66.6%). All patients had drug-refractory recurrent VT. Forty-seven patients (68.1%) had non-ischemic cardiomyopathy (NICM), 13 patients (18.9%) had ischemic-cardiomyopathy (ICM), and 9 patients (13%) had myocarditis. Standard percutaneous sub-xiphoid access was attempted in all patients. Non-inducibility of any VT was achieved in 82.6% (9/9 myocarditis, 10/13 ICM, 38/47 NICM, n = 57/69 patients), inducibility of non-clinical VT in 13% (3/13 ICM, 6/38 NICM, n = 9/69 patients), and failure in 4.3% (3/38 NICM, n = 3/69 patients). Although we observed procedural-related complications in five patients (7.2%), one transient PN palsy, two pericarditis, and two vascular complications, those were not related to the conscious sedation protocol. No respiratory failure, severe hypotension, or bradycardia requiring treatment has been observed among the patients. Prompt availability of anesthesiology support remains crucial for complex procedures such as epicardial VT ablation. Continuous infusion of dexmedetomidine and administration of midazolam and fentanyl seem to be a safe and effective sedation protocol in patients undergoing epicardial VT ablation.

Efficacy and safety of the combination of propofol and S(+)-ketamine for procedural sedation in pediatric patients undergoing totally implantable venous access port implantation: A prospective randomized controlled study.

BackgroundTotally implantable venous access port (TIVAP) implantation is usually performed under general anesthesia with endotracheal intubation in children. Procedural sedation without endotracheal intubation has been applied to minor pediatric surgeries like central venous catheter insertion. To explore a more efficient and less invasive anesthesia mode to implant TIVAPs for children, we aimed to evaluate the efficacy and safety of procedural sedation using propofol and S(+)-ketamine compared with general anesthesia.MethodsSixty-six patients aged 6 months to 10 years undergoing TIVAP implantation were randomly allocated to two groups. Patients under procedural sedation [S(+)-ketamine-propofol (sketofol) group] were given target-controlled infusion of propofol 4 μg/ml using the Paedfusor model and S(+)-ketamine 0.5 mg/kg as induction, and had target-controlled infusion of propofol 3–4 μg/ml as maintenance. Patients in sketofol group received medium-flow oxygen inhalation through facemasks during surgery. Patients under general anesthesia (control group) were given propofol 2 mg/kg, cisatracurium 0.2 mg/kg, fentanyl 3 μg/kg as induction, and sevoflurane 0.8 minimum alveolar concentration as maintenance after endotracheal intubation. Primary outcome was the postoperative emergence agitation evaluated 5 min after awakening.ResultsPostoperative emergence agitation evaluated 5 min after awakening was lower in sketofol group versus control group [1.0 (0.5, 1.0) vs. 3.0 (2.0, 4.0); median difference (95% CI): 2.0 (1.0, 2.0); P < 0.001]. Time to awakening was significantly lower in sketofol group versus control group [15.0 (5.0, 23.0) vs. 26.0 (20.5, 37.5); median difference (95% CI): 11.0 (7.0, 19.0); P < 0.001], as well as time to discharge from post anesthesia care unit [35.0 (24.0, 45.0) vs. 45.0 (37.5, 59.5); median difference (95% CI): 10.0 (10.0, 23.0); P < 0.001]. Postoperative complications or adverse events were not reported in sketofol group.ConclusionsCompared to general anesthesia with endotracheal intubation, procedural sedation using propofol and S(+)-ketamine improves the postoperative emergence agitation right after the recovery of consciousness, and has advantage in shortening anesthetic recovery time for pediatric patients undergoing TIVAP implantation.