Sedation Assessment Research Articles

The 95% effective dose of intranasal dexmedetomidine sedation for pulmonary function testing in children aged 1–3 years: A biased coin design up-and-down sequential method

Study objectiveIntranasal dexmedetomidine (DEX) can provide adequate sedation during short examinations in children. However, we found no data regarding the 95% effective dose (ED95) of intranasal DEX for children's pulmonary function testing (PFT). DesignProspective study and a biased coin design up-and-down sequential method. SettingSedation center of Children's Hospital of Chongqing Medical University. PatientsChildren aged 1–3 years undergoing pulmonary function testing. InterventionThe dose of DEX for each subsequent patient was determined by the response of the previous patient with the biased coin design up-and-down sequential method with an interval of 0.25 μg∙kg−1. MeasurementsChildren aged 1–3 years who received pulmonary function testing were involved in this dose-finding trial. Intranasal DEX started at a dose of 2 μg∙kg−1 on the first patient. The dose of DEX for each subsequent patient was determined by the response of the previous patient with the biased coin design up-and-down sequential method with an interval of 0.25 μg∙kg−1. The sedation was assessed by the Modified Observer Assessment of Alertness and Sedation (MOAA/S) scale, and recovery was assessed by the modified Aldrete recovery score. The ED95 was calculated using isotonic regression. Other variables, including the sedation onset time, examination time, wake-up time, blood pressure (BP), heart rate (HR), respiratory rate (RR), and oxyhaemoglobin desaturation (SpO2), were recorded. Adverse events such as hypotension, bradycardia, respiration depression, oxyhaemoglobin desaturation, regurgitation and vomiting were recorded. Main resultsA total of 68 children were enrolled for the study; 62 children had successful sedation, and 6 had failed sedation. The ED95 of intranasal DEX was estimated to be 2.64 μg∙kg−1 [95% confidence interval (CI), 2.49–2.87 μg∙kg−1]. The sedation onset time for all patients was 15.0 (12.3–19.0) min. The sedation onset time of successful sedation patients was 15.0 (12.0–19.0) min, the sedation onset time of failed sedation patients was 16.0 (15.0–27.8) min, the examination time was 8 (7–10) min, and the wake-up time was 40 (35–43) min. There were no adverse events during the whole procedure. ConclusionThe ED95 of intranasal DEX sedation in children aged 1–3 years undergoing PFT was 2.64 μg∙kg−1.

Practised sedation in mechanically ventilated patients: A survey of nurses’ perceptions

Recent clinical practice guidelines recommend analgosedation in intensive care unit patients, where the patients' pain first is relieved, followed by sedatives only on indication. The aims of the present study was to examine sedation practice today, to evaluate the degree to which there is a difference in sedation practice between units, and to investigate the associations between nurses' demographic characteristics and their perception of sedation practice. A cross sectional survey was conducted to the nurses in three intensive care units in Norway. The results indicated that light sedation was implemented in the three intensive care unit studied. Continuous infusion of propofol and dexmedetomidine were used most frequently, and continuous infusion of midazolam was used occasionally. However, the sedation practices varied significantly between the units. Subjective scoring systems, physician's prescriptions, and prescription follow-up were reported to be most frequently used as guidelines and directives, and Richmond Agitation–Sedation Scale was reported to be the most frequently used sedation assessment tool.

Intranasal dexmedetomidine in elderly subjects with or without beta blockade: a randomised double-blind single-ascending-dose cohort study

BackgroundThe aim of this double-blind, placebo-controlled, single-ascending-dose study was to determine the safety and tolerability of intranasal dexmedetomidine in the elderly. MethodsWe randomly assigned 48 surgical patients ≥65 yr of age to receive single intranasal doses of dexmedetomidine or placebo (5:1 ratio) in four sequential dose cohorts: 0.5, 1.0, 1.5, and 2.0 μg kg−1. Each dose cohort comprised two groups of six subjects: a group of subjects using β-blockers and a group not taking β-blockers. Vital signs and sedation depth (Modified Observer's Assessment of Alertness and Sedation [MOAA/S] and bispectral index) were measured for 2 h after administration. Blood samples were taken to determine dexmedetomidine plasma concentrations. ResultsOne subject (1.0 μg kg−1) had acute hypotension requiring ephedrine. Systolic arterial BP decreased >30% in 15 of 40 subjects (37.5%) receiving dexmedetomidine, lasting longer than 5 min in 11 subjects (27.5%). The MAP decreased >30% (>5 min) in 10%, 20%, 50%, and 30% of subjects receiving dexmedetomidine 0.5, 1.0, 1.5, and 2.0 μg kg−1, respectively, irrespective of β-blocker use. HR decreased 10–26%. MOAA/S score ≤3 occurred in 18 (45%) subjects; eight (20%) subjects receiving dexmedetomidine showed no signs of sedation. Tmax was 70 min. Cmax was between 0.15 ng ml−1 (0.5 μg kg−1) and 0.46 ng ml−1 (2.0 μg kg−1). ConclusionsIntranasal dexmedetomidine in elderly subjects had a sedative effect, but caused a high incidence of profound and sustained hypotension irrespective of β-blocker use. The technique is unsuitable for routine clinical use. Clinical trial registrationNTR5513 (The Netherlands Trial Registry 5513).

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil.

ABSTRACTObjective To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units.Methods A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units.Results Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process.Conclusion This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Oversedation, delirium and immobilisation in the intensive care unit are associated with increased length of stay in the unit. Routines of systematic pain and sedation assessment and the use of valid tools are highly stressed in international guidelines. For improving the quality of pain treatment and sedation in a Norwegian intensive care unit, in 2009-2015, we compared supplementation with an analgosedation approach and the existing systematic approach, measured by the adherence to current international pain, sedation and delirium guidelines. In a longitudinal study following the Standards for Reporting Implementation Studies, pain, sedation, delirium and mobilisation data from patients' complete intensive care unit stays, encompassing three separate periods of 4-6months, were compared. The primary outcome was adherence to current protocol including assessment and documentation of patients' level of pain, sedation and prevalence of delirium at least every 8hr, early mobilisation and titration towards a light level of sedation. We included 205 patients, corresponding to 1,607 patient intensive care unit days. The patient sedation levels, measured by the Richmond Agitation and Sedation Scale, decreased significantly, from -2.2 in 2009--1.7 in 2015, so did the amount of administrated propofol. Mean pain scores measured by the numeric rating scale during activity were maximum 3.1 in 2014, decreasing to 2.2 in 2015. In patients not able to self-report, pain mean scores were 1.7 in 2014 and 1.6 in 2015, measured by the Critical Care Pain Observational Tool. The number of patients unable to assess for delirium decreased significantly. By discounting the group of patients unable to assess, the prevalence of delirium varied from 32%, 25% and 33%. The goal of having an awake patient able to cooperate, with acceptable levels of pain, was gradually achieved during a 6-year period. The results showed that pain treatment and sedation in the intensive care unit primarily succeeded in the setting of an established routine of systematic assessment and documentation. The results of the study draw attention to pain treatment, sedation and delirium in intensive care patients, as well as implementation strategies aimed at achieving healthcare personnel's adherence to international guidelines in clinical practice.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

AimsMain aim: to discover the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. MethodAn observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit’s characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. ResultsOne hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. ConclusionsThe assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC

Prospective Observational Cohort Study on Dexmedetomidine and Midazolam in Mechanically Ventilated Children

Introduction: Though target sedation was achieved with Midazolam and Dexmedetomidine, Dexmedetomidine has demonstrated the lesser complications and shorter duration of stay in Intensive Care Unit (ICU). Most of the studies are reported from high income countries. The studies on Midazolam and Dexmedetomidine use in mechanically ventilated children are scanty in low-middle income regions. Aim: To compare the efficacy of Midazolam and Dexmedetomidine for sedation in mechanically ventilated children. Materials and Methods: This prospective observational cohort study was conducted in academic hospital Paediatric Intensive Care Unit (PICU) from March 2015 to June 2016. Children aged less than 13 years mechanically ventilated for more than 24-hour and received sedative with either infusion of Midazolam or Dexmedetomidine without loading dose were involved. Patients with unstable haemodynamic throughout PICU stay and expired within 24-hour and incomplete medical data were excluded. Intermittent Fentanyl/Morphine was used as when needed as per treating team decisions. Sedation assessment was performed with Ramsey sedation scale (RSS, target=3-4 out of 6), Tracheal suctioning score and PICU sedation score. The primary outcome was “percentage of time with target sedation” till extubation. The secondary outcome was the cumulative dose of sedation used, the need for rescue sedation and the rate of complications, organ dysfunction {by Sequential Organ Failure Assessment (SOFA) score and Paediatric Logistic Organ Dysfunction (PELOD) score} and the length of stay in ventilation, PICU and mortality. Results: A total of 115 patients (Midazolam-group, n=63 and Dexmedetomidine-group, n=52) were enrolled. The median age was 12 months (IQR 8-30). Mean (±SD) PRISM-III score was 11.3±7.2. About 54.8% were ventilated for respiratory pathology, followed by CNS pathology (25.2%) and sepsis (10.4%). Mean (±SD) percentage of the duration of proper sedation was not significantly different in Midazolam-group (83.4±15.6) and Dexmedetomidine-group (81.4±17) (p=0.510). The cumulative dose (microgram per kg) requirement was higher in Midazolam-group {median (IQR) 12.2 (9.8-17.1) vs. 9.6 (5-15.3); p=0.019)}.No difference was note in need for “rescue dose of sedation” per patient {median (IQR) 1 (0-2) vs. 1 (0-2)}, rate of complications (bradycardia 9.5% vs. 1.9%; hypotension 9.5% vs. 5.8%). No difference was noted in organ dysfunction score {mean difference, 95% CI; SOFA score: -0.2 (-1.6 to 1.33); p=0.808 and PeLOD score: 1.3 (-1.5 to 4.1); p=0.364}, duration of ventilation (median, IQR 2.7 (2-3.3) vs. 2.0 (1.5-3.1) days and mortality (20.6% vs. 21.2%). PICU stay was significantly lower in Midazolam-group (median, IQR 3 days, 1-5 vs. 5 days, 4-6; p=<0.001). Conclusion:Midazolam and Dexmedetomidine were associated with similar target sedation with a comparable rate of complications in mechanically ventilated children. However, Midazolam required a higher cumulative dose to achieve target sedation.

Literature Review for Office-Based Anesthesia.

Literature Review for Office-Based Anesthesia.

Out of the dark – improving the assessment of pain sedation and delirium

Out of the dark – improving the assessment of pain sedation and delirium

Inter-rater Reliability of the Ramsay Sedation Scale for Critically-ill Intubated Patients.

Introduction: Titratable palliative sedation (TPS) is frequently applied in sedative therapeutics to ameliorate unendurable and refractory distress via reduction in patient consciousness. TPS may be adjusted based on objective and subjective data: vitals, labs, Ramsay Sedation Scale (RSS), and Richmond Agitation-Sedation Scale (RASS). Inappropriate dosing, including over-sedation from variability in clinician assessment of sedation scales, can contribute to significant negative clinical outcomes. We evaluated inter-rater reliability (IRR) and its relationship to variations in dosing to determine whether additional training in sedation scale assessment is necessary at our community institution.Methods: This was a prospective study assessing sedation in intensive care unit (ICU) mechanically ventilated patients without neurogenic abnormalities. Non-nursing healthcare personnel conducted independent sedation assessments using the RSS and compared their evaluations to those documented by the nursing staff. Data obtained from the patients' chart included: demographics, Ramsay Score, past medical history, diagnosis, and body mass index (BMI). Post-analysis, non-nursing healthcare personnel scores were classified into three categories: equal to, higher than, or lower than those charted by nursing staff.Results: There were 83 random RSS assessments conducted in 44 patients with a mean age of 63.6 +/10.09 years (range: 38-82) and a mean BMI of 31.2 +/12.4 (range: 15-77). 19/42 (45%) patients had a diagnosis of respiratory failure or pneumonia. Other diagnoses included congestive heart failure (3), seizures (5), aortic valve replacement (1), small bowel obstruction (1), drug overdose (2), cardiac arrest (2), and urinary tract infection (1), ST-elevated myocardial infarction (2), pulmonary embolism (2), coronary artery bypass graft (1), sepsis (1), hemoptysis (1), altered mental status (1). Non-nursing healthcare professionals' assessments were compared to nurses' and observed to be equal in 29%, higher in 59%, and lower in 12% of the cases. Of the 83 assessments, the average RSS score non-nursing healthcare professionals assigned was 4.8 +/1.6 while the nurses' charted average was3.39 +/- 0.97; a mean difference of 1.45, 95% CI (1.04 - 1.85)p< 0.0001.Conclusions: Our data demonstrated equal RSS ratings in only 29% of cases for non-nursing healthcare personnel and nurses’ evaluations. Without proper education, the RSS may not be a reliable tool for sedation assessments and may result in over-sedation of critically ill patients. Recurrent nursing education is warranted to ensure proper use and optimization of the RSS.

Automated tracking of level of consciousness and delirium in critical illness using deep learning

Over- and under-sedation are common in the ICU, and contribute to poor ICU outcomes including delirium. Behavioral assessments, such as Richmond Agitation-Sedation Scale (RASS) for monitoring levels of sedation and Confusion Assessment Method for the ICU (CAM-ICU) for detecting signs of delirium, are often used. As an alternative, brain monitoring with electroencephalography (EEG) has been proposed in the operating room, but is challenging to implement in ICU due to the differences between critical illness and elective surgery, as well as the duration of sedation. Here we present a deep learning model based on a combination of convolutional and recurrent neural networks that automatically tracks both the level of consciousness and delirium using frontal EEG signals in the ICU. For level of consciousness, the system achieves a median accuracy of 70% when allowing prediction to be within one RASS level difference across all patients, which is comparable or higher than the median technician–nurse agreement at 59%. For delirium, the system achieves an AUC of 0.80 with 69% sensitivity and 83% specificity at the optimal operating point. The results show it is feasible to continuously track level of consciousness and delirium in the ICU.

Validity of bispectral index monitoring during deep sedation in children with spastic cerebral palsy undergoing injection of botulinum toxin.

BackgroundThis prospective study aimed to determine whether the bispectral index (BIS) is a valid objective tool for differentiating adequate from inadequate deep sedation in spontaneously breathing children with cerebral palsy (CP).MethodsPropofol was titrated to increase the level of sedation with a continuous infusion of remifentanil at a rate of 0.05 μg/kg/min while maintaining spontaneous ventilation in 22 children with spastic CP, aged 3–18 years. The depth of sedation was assessed using the University of Michigan Sedation Scale (UMSS) and the Modified Observer’s Assessment of Alertness and Sedation (MOAAS) scale. Receiver operating characteristic curve analysis was performed to determine the cutoff BIS values for deep sedation, defined as a UMSS score of 3–4 and a MOAAS score of 0–1.ResultsThe BIS values significantly changed with the increase in the level of sedation across both the UMSS and MOAAS scores (P < 0.001). The BIS values correlated with the UMSS (r = −0.795, P < 0.001) and MOAAS (r = 0.815, P < 0.001) scores. The cutoff BIS value to detect adequate deep sedation in children with CP was 61.5 (UMSS score: sensitivity 0.860, specificity 0.814; MOAAS score: sensitivity 0.794, specificity 0.811).ConclusionsThe BIS value strongly correlates with the clinical sedation scales, such as the UMSS and MOAAS, during deep sedation in children with CP. Therefore, BIS monitoring can be used as a valid tool for assessing the level of propofol sedation in spontaneously breathing children with CP undergoing a botulinum toxin injection.

Implementing the Richmond Agitation-Sedation Scale in a respiratory critical care unit: a best practice implementation project.

Adequate sedation can lead to patient-ventilator synchrony, facilitation of treatment, and decreased physical and psychological discomfort for patients with respiratory failure in the intensive care unit (ICU). The Richmond Agitation-Sedation Scale (RASS) is considered to be the most appropriate tool in sedation assessment. This aim of this project was to implement evidence-based recommendations for sedation assessment using the RASS in mechanically ventilated patients in the ICU. This implementation project was conducted in an ICU at a tertiary medical center in Taiwan. Using the JBI Practical Application of Clinical Evidence System software, a baseline audit was conducted in the ICU, followed by an identification of barriers of RASS assessment and an implementation of management of strategies to improve the consistency of sedation assessment. Results of the baseline audit showed that four of the six selected criteria had 0% compliance. Following the implementation of the strategies, which included education, visual management and development of a "RASS Reminder Card", there was an improvement in all the criteria audited, with each criterion achieving 83-100% of compliance. The project successfully improved the implementation of RASS assessment in the respiratory ICU. Following the development and implementation of evidence-based resources, a high level of compliance was achieved for nurses using the RASS in the ICU to assess sedation in patients with a ventilator.

Application of Narcotrend index and Richmond agitation-sedation score in sedation assessment of patients with short-term mechanical ventilation after pancreatoduodenectomy: a randomized controlled trial

To explore the feasibility of Narcotrend index (NTI) for digital monitoring of light sedation depth in patients undergoing short-term mechanical ventilation after pancreaticoduodenectomy. A prospective randomized controlled trial was conducted. Patients with mechanical ventilation for 12-48 hours after pancreaticoduodenectomy admitted to department of critical care medicine of the First Affiliated Hospital of Wannan Medical College from January 2016 to December 2018 were enrolled. They were randomly divided into two groups, and NTI and Richmond agitation-sedation score (RASS) were used to guide light sedation treatment respectively. The implementation effect of light sedation, duration of mechanical ventilation, dosage of sedative drugs, occurrence of adverse events (accidental extubation, delirium, cardiovascular events) and stress response [cortisol, epinephrine, norepinephrine, C-reactive protein (CRP)] were compared between the two groups. A total of 87 patients were enrolled in this study, of whom 45 received NTI-guided sedation assessment and 42 received RASS-guided sedation assessment. There were no significant differences in gender, age, body mass index (BMI), liver function classification, operation time, blood loss, conversion to laparotomy and acute physiology and chronic health evaluation II (APACHE II) score between the two groups. During sedation treatment, the light sedation compliance rate after light sedation, 2, 4, 6 hours and cumulative compliance period number (Dt) in NTI group were higher than those in RASS group [71.1% (32/45) vs. 50.0% (21/42), 80.0% (36/45) vs. 54.8% (23/42), 88.9% (40/45) vs. 59.5% (25/42), 83.9% (642/765) vs. 62.8% (475/756), all P < 0.05]. The dosage of dexmedetomidine in NTI group was higher than that in RASS group (μg×kg-1×h-1: 0.60±0.10 vs. 0.54±0.12, P < 0.01), but more patients in RASS group receiveda larger dose of propofol to maintain sedation [ratio of use of propofol: 64.3% (27/42) vs. 37.8% (17/45), dose of propofol (mg/h): 47.82±7.31 vs. 30.83±10.35, both P < 0.05]. The sedation duration and duration of mechanical ventilation in NTI group were lower than those in RASS group (hours: 15.68±2.43 vs. 17.29±2.43, 16.27±2.42 vs. 18.25±2.04, both P < 0.01). There were no significant differences in hypertension, bradycardia, accidental extubation and delirium between the two groups during sedation treatment, but the incidence of hypotension in RASS group was higher than that in NTI group [35.7% (15/42) vs. 13.3% (6/45), P < 0.05]. Compared with RASS group, epinephrine, norepinephrine and the levels of CRP at treatment of 6 hours with light sedation and 2 hours after tracheal catheter removal in NTI group were decreased [epinephrine (pg/L): 138.35±18.60 vs. 157.50±19.91, 136.24±40.40 vs. 150.46±20.22; norepinephrine (pg/L): 347.34±45.46 vs. 393.75±49.77, 340.59±50.95 vs. 376.37±49.70; CRP (μg/L): 62.26±18.78 vs. 71.31±10.32, 53.30±14.47 vs. 64.26±14.69, all P < 0.05], and cortisol level 6 hours after treatment with light sedation was lower than that of RASS group (nmol/L: 327.03±41.04 vs. 358.12±70.01, P < 0.05). The application of NTI monitoring to guide light sedation therapy for patients with short-term mechanical ventilation after pancreaticoduodenectomy can better achieve the goal of light sedation.

Using Valid and Reliable Tools for Pain and Sedation Assessment in Pediatric Patients

Pain management and sedation strategies have become more complex in recent years, with accompanying documented increases in morbidity and mortality. Consequently, various government agencies and professional associations have issued requirements or recommendations designed to ensure optimal and safe pain management in different populations. The pediatric nurse must understand the rationale behind these guidelines, which pain and sedation assessment tools are valid and reliable, how and when to use these tools, and the purpose and limitations of each tool. This article summarizes the recent recommendations, identifies valid and reliable pediatric pain and sedation assessment tools, and describes the appropriate use of these tools to provide safe and high-quality patient care.

The sedation practices of paediatric intensive care unit nurses and the influencing factors in China.

Nurses play a key role in administering sedation to mechanically ventilated children, which impacts children's psychological, physiological and cognitive changes in the paediatric intensive care unit. This study aimed to survey the sedation practices of paediatric intensive care unit nurses on mechanically ventilated children in China and explored the influencing factors. A cross-sectional survey was conducted based on electronic questionnaires comprised of the Nurse Sedation Practices Scale (Chinese version) in 14 different types of paediatric intensive care units of 11 academic hospitals in China from 15 February to 15 April 2017. A convenience sample of 495 nurses [73·4% response rate, (674)] completed the survey. Seven units applied Ramsay Sedation Scale as a sedative assessment tool. The majority of the nurses used observed behaviours and physiological changes of the ventilated children as indicators to assess the sedation level, and they had a positive attitude and intention, which may influence practice positively, whereas high clinical workload and the lack of communication between the nurses and families might hinder practice. The practice of sedation varied greatly in different regions, and the respondents of the northwest region scored lower. Paediatric nurses in China rarely used a validated paediatric instrument to assess sedation, and most nurses relied on physiological and behavioural cues. The quality of sedation training, nursing workload and regional economic disparity affected the sedation practice. The restricted visiting policy and lack of clearly defined nursing responsibilities around sedation may hinder effective sedation assessment and management. This study found that there was no paediatric-validated tool popularized in paediatric intensive care units in China and explored influencing factors. We suggest that a validated tool, high-quality training and hospital's policy, such as visiting regulation, should be promoted to improve the sedation practice.

Sedation and analgesia for critically ill children

Effective analgesia and sedation in the paediatric intensive care unit (PICU) encompasses the provision of physical comfort and caring for the psychological well-being of critically ill children. In the UK the most commonly used sedative and analgesic agents for critically ill children are midazolam and either morphine or fentanyl. Consensus clinical practice guidelines for the provision of sedation and analgesia in critically ill children were published in 2006 by the UK Paediatric Intensive Care Society, and an ESPNIC position statement on clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children was published in 2016: Despite this, considerable variation in practice persists. Pain experienced early in life may result in long-term changes in neurosensory function and there are also concerns that sedative and analgesic agents may themselves be associated with developmental neurotoxicity, particularly amongst neonates, and adverse psychological outcomes in survivors of critical care. Validated tools for assessment of withdrawal syndrome and delirium are available and this article will briefly discuss these and how to use them in clinical practice. The most important single factor in reducing avoidable psychological morbidity in survivors of PICU is to minimize the administered doses of sedative and analgesic agents.

Benzodiazepine premedication in general anaesthesia: a clinical comparative study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The main aims of pre-anaesthetic medication are anxiolysis, analgesia, anti-emesis and reducing perioperative patient risk. Producing a state of amnesia for pre and post-operative events is desired by all. This study has been undertaken to evaluate the role of three of the benzodiazepines i.e. diazepam, lorazepam and midazolam during general anaesthesia, in providing anxiolysis, sedation and amnesia.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study included patients with ASA grade I and ASA grade II physical status of both sexes, age ranging between 18-60 years. Patients were divided into three groups of thirty patients each, every group receiving intramuscular injections of diazepam 0.1 mg/kg body weight, lorazepam 0.07 mg/kg body weight and midazolam 0.08 mg/kg body weight respectively; 45 minutes prior to induction of general anaesthesia. Anxiety assessment before premedication along with assessment of sedation after premedication was done.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Before premedication the mean values of pulse rate, blood pressure and respiratory rate were not significantly different among the three groups (p&amp;gt;0.05). Maximum changes in these parameters were observed with Midazolam followed by lorazepam and diazepam. The dose of thiopentone used as inducing agent was also lowered significantly in case of midazolam (p&amp;lt;0.05). One patient in midazolam group showed respiratory depression whereas four patients receiving lorazepam and diazepam showed delayed recovery and prolonged sedation, but the effects were self-limiting.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Midazolam offers the maximum advantage in allaying anxiety and providing excellent sedation and amnesia during general anaesthesia and proves to be the most suitable premedicant before general anaesthesia.&lt;/p&gt;

Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD

AimsMain aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients’ levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. MethodAn observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. ResultsOne hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. ConclusionsThe assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874)

Intraoperative local infiltration with ropivacaine 0.5% in women undergoing vaginal hysterectomy and pelvic floor repair: Randomized double-blind placebo-controlled trial

ObjectiveTo evaluate the effectiveness of infiltration with ropivacaine 0.5% on controlling postoperative pain in women undergoing vaginal hysterectomy (VH) and pelvic floor repair for prolapse stage > II. Study designThis double-blind randomized 1:1 placebo-controlled trial included 59 women. Thirty millilitres of ropivacaine 0.5% or placebo was infiltrated in the round and uterosacral ligaments and in the perineal body. Primary outcomes included postoperative pain intensity at rest and during cough (measured using 10-cm visual analogue scale), and proportion of patients reporting moderate/severe pain. Secondary outcomes included morphine consumption and assessment of nausea, vomiting and sedation. Outcomes were compared between groups at 2, 4, 8 and 24 h postoperatively. Statistical (p-values) and clinical significance {effect size [Cliff’s delta] [95% confidence interval (CI)] and odds ratio (95% CI)} of results were assessed. Outcomes are presented as median (min–max) and n (%). ResultsPain intensity was lower after ropivacaine infiltration compared with placebo at 2 and 4 h postoperatively at rest [0.5 (0.1–7.2) vs 1.1 (0.2–9.3) (p = 0.007) and 1.3 (0.1–5.1) vs 3.1 (0.1–9.8) (p = 0.02), respectively] and during cough [0.9 (0.1–8.9) vs 1.9 (0.1–10) (p = 0.03) and 1.6 (0.1–4.7) vs 3.2 (0.3–9.6) (p = 0.009), respectively]. The proportion of patients with moderate/severe pain was significantly less after ropivacaine infiltration compared with placebo at 2, 4 and 8 h postoperatively at rest [4% vs 32% (p = 0.03), 16% vs 44% (p = 0.03) and 12% vs 40% (p = 0.02), respectively] and during cough [8% vs 40% (p = 0.008), 16% vs 52% (p = 0.007) and 20% vs 52% (p = 0.02), respectively]. Patients in the ropivacaine group consumed significantly less morphine compared with those in the placebo group up to 24 h postoperatively [4 (0–17) mg vs 7 (0–19) mg (p = 0.02)]. The incidence of nausea and vomiting was 3 (12%) and 0–2 (0–8%) in the ropivacaine group, compared with 1–7 (4–28%) and 1–4 (4–16%) in the placebo group. No significant difference was found in the proportion of patients using morphine, proportion of patients reporting the presence of nausea/vomiting, and the intensity of sedation between the groups (all p > 0.05). ConclusionLocal infiltration with ropivacaine 0.5% significantly reduces postoperative pain and morphine consumption in patients undergoing VH and pelvic floor repair for advanced pelvic organ prolapse.