Sedative Doses Research Articles

Feasibility of pulsed field ablation for atrial fibrillation under mild conscious sedation

Abstract Background Pulsed field ablation (PFA) is a new modality for pulmonary vein isolation (PVI) for atrial fibrillation (AF). PFA is performed under general anaesthetic (GA) or deep sedation with propofol, but this requires anaesthetic support in many countries, restricting use. No study has tested the feasibility of PFA under mild conscious sedation (MCS). Methods We prospectively recruited patients undergoing PFA PVI, offered the option of MCS delivered by electrophysiologists, and compared these with patients who opted for GA. MCS comprised intravenous midazolam and fentanyl. All procedures were performed under anaesthetic supervision in case of requirement to convert to GA, which formed the primary outcome. Results Twenty-three patients were recruited (8 MCS, 15 GA). One patient (1/8 [12.5%]) required conversion from MCS to GA. Total procedural times were similar between groups (MCS 92 ± 12.4 min vs. GA 101 ± 17.3 min; p = 0.199). High mean sedative doses were required in the MCS group (5.12 ± 0.83 mg midazolam and 209 ± 40 mcg fentanyl). Median intraprocedural pain perception by the patient, rated from 0 to 100 was 45 (IQR 22.5–72.5) in the MCS group. Post-procedural groin pain (0 [0–0] vs. 5 [0–35]; p = 0.027) and throat pain (0 [0–0] vs. 10 [5–40]; p = 0.001) were lower in the MCS group. Conclusion PFA under MCS is feasible in selected patients but pain and tolerance may be suboptimal, and high sedative doses are required. Graphical abstract

Effect of remimazolam besylate versus propofol on haemodynamic profiles in patients undergoing thyroid surgery with recurrent laryngeal nerve monitoring: a protocol for a randomised controlled trial

IntroductionThyroid surgery with intraoperative nerve monitoring under total intravenous anaesthesia often requires deeper sedation due to limitations or lack of neuromuscular blocking agents, usually resulting in haemodynamic instability. Remimazolam, a...

Efficacy and safety of supraglottic jet oxygenation and ventilation to minimize sedation-related hypoxemia: a meta-analysis with GRADE approach

IntroductionHypoxemia is a common complication of sedation. This meta-analysis aimed to evaluate the efficacy and safety of supraglottic jet oxygenation and ventilation (SJOV) in preventing hypoxemia during sedative procedures.MethodsRandomized controlled trials (RCTs) that compared SJOV with conventional oxygen therapy in sedated patients were searched in five databases (MEDLINE, EMBASE, Cochrane Library, China National Knowledge Infrastructure [CNKI], and Google Scholar) from their inception to March 2024. The primary outcome was the proportion of patients who developed hypoxia (SpO2 < 90%). The secondary outcomes included subclinical respiratory depression (90% ≤ SpO2 < 95%), severe hypoxemia (SpO2 < 75%), airway interventions, adverse events, hemodynamics, propofol dosage, and procedure time. The certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.ResultsTwelve trials (n = 3058) were included in the analysis. The evidence suggests that SJOV results in a large reduction in the risk of hypoxemia (risk ratio [RR], 0.26; 95% confidence interval, 0.19–0.36; low certainty) and subclinical respiratory depression (RR, 0.40; low certainty) compared with the control. SJOV likely resulted in a large reduction in the risk of severe hypoxemia (RR, 0.22; moderate certainty). In addition, it may result in a large reduction in the need for jaw lift (RR, 0.22; low certainty) and mask ventilation (RR, 0.13; low certainty). The risk of sore throat probably increases with SJOV (RR, 1.71; moderate certainty), whereas SJOV may result in little to no difference in nasal bleeding (RR, 1.75; low certainty). Evidence is very uncertain regarding the effect of SJOV on hemodynamics (very low certainty) and procedure time (very low certainty). SJOV probably resulted in little to no difference in sedative doses between the groups (moderate certainty).ConclusionAccording to the GRADE approach, SJOV likely results in a large reduction in the risk of severe hypoxemia but probably increases the risk of sore throat. Compared with the control, evidence suggests that SJOV results in a large reduction in the risk of hypoxemia, subclinical respiratory depression, and the need for airway manipulation, with little to no difference in nasal bleeding. The integration of SJOV into clinical practice may help minimize hypoxemic events in at-risk patients.

Effect of remimazolam on oxygen reserve compared with propofol during upper gastrointestinal endoscopy: Randomized controlled study.

Propofol is commonly used for endoscopic sedation. However, it can induce adverse hemodynamic effects. Remimazolam is known to have a fast onset and short duration comparable to that of propofol, but with fewer effects on hemodynamics. We assessed the Oxygen Reserve Index to verify whether a sedative dose of remimazolam would better preserve oxygenation in the mild hyperoxic range than propofol in sedated patients undergoing diagnostic upper gastrointestinal endoscopy. Patients scheduled for diagnostic upper gastrointestinal endoscopy were enrolled. Patients were randomly assigned to either the remimazolam or propofol groups and received 0.1 mg/kg remimazolam or 0.5 mg/kg propofol, respectively. Bolus injections of either 0.05 mg/kg remimazolam or 0.25 mg/kg propofol were added if required. The primary outcome was the prevalence of oxygen reserve depletion, defined as the Oxygen Reserve Index decreasing to 0.00, and hypoxia defined as peripheral oxygen saturation falling to <94%. Among 69 patients, the incidence of oxygen reserve depletion was significantly higher in the propofol group (65.7% vs. 38.2%, P = 0.022). Hypoxia was frequently observed in the propofol group, whereas none was observed in the remimazolam group (11.4% vs. 0%, P = 0.042). Additional sedative injections were frequently required to complete endoscopy in the propofol group. None of the patients in the remimazolam group required airway interventions. Nausea was frequent in the propofol group in the recovery room. Our results indicate that remimazolam is a safe and useful sedative for upper gastrointestinal endoscopy.

The effect of a subsequent dose of dexmedetomidine or other sedatives following an initial dose of dexmedetomidine on electrolytes, acid-base, creatinine, and troponin in dogs. Part II

The effect of a subsequent dose of dexmedetomidine or other sedatives following an initial dose of dexmedetomidine on electrolytes, acid-base, creatinine, and troponin in dogs. Part II

The effect of a subsequent dose of dexmedetomidine or other sedatives following an initial dose of dexmedetomidine on sedation and quality of recovery in dogs. Part I

The effect of a subsequent dose of dexmedetomidine or other sedatives following an initial dose of dexmedetomidine on sedation and quality of recovery in dogs. Part I

Association Between Sex and Race and Ethnicity and IV Sedation Use in Patients Receiving Invasive Ventilation

BackgroundIntravenous sedation is an important tool for managing invasively ventilated patients, yet excess sedation is harmful, and dosing could be influenced by implicit bias. Research questionWhat is the association between sex, race and ethnicity, and sedation practices? MethodsWe performed a retrospective single-center cohort study of adults receiving invasive ventilation for 24 hours or more using the MIMIC-IV (2008-2019) database from Boston, USA. We used a repeated-measures design (4-hour intervals) to study the association between sex (female, male) or race and ethnicity (Asian, Black, Hispanic, White) and sedation outcomes. Sedation outcomes included sedative use (propofol, benzodiazepine, dexmedetomidine) and minimum sedation score. We categorized sedative use as follows: no sedative, then lowest, second, third, and highest quartiles of sedative dose. We adjusted for covariates with multilevel Bayesian proportional odds modeling and reported odds ratios (OR) with 95% credible intervals (CrI). ResultsWe studied 6,764 patients: 43% female; 3.5% Asian, 12% Black, 4.5% Hispanic and 80% White. Benzodiazepines were administered to 2,334 (36%) patients. Black patients received benzodiazepines less often and at lower doses than White patients (OR for more benzodiazepine 0.66, CrI 0.49-0.92). Propofol was administered to 3,865 (57%) patients. Female patients received propofol less often and at lower doses than male patients (OR for more propofol 0.72, CrI 0.61-0.86). Dexmedetomidine was administered to 1,439 (21%) patients, and use was similar across sex or race and ethnicity. Female patients were less sedated than male patients (OR for deeper sedation 0.71, CrI 0.62 to 0.81), and Black patients were more sedated than White patients (OR for more sedated 1.28, CrI 1.05 to 1.55). InterpretationAmong patients invasively ventilated for at least 24 hours, intravenous sedation and attained sedation levels varied by sex and race and ethnicity. Adherence to sedation guidelines may improve equity in sedation management for critically ill patients.

Dexmedetomidine ameliorates diabetic intestinal injury by promoting the polarization of M2 macrophages through the MMP23B pathway.

Diabetes is often associated with gastrointestinal dysfunctions, which can lead to hypoglycemia. Dexmedetomidine (DEX) is a commonly used sedative in perioperative diabetic patients and may affect gastrointestinal function. To investigate whether sedative doses of DEX alleviate diabetes-caused intestinal dysfunction. Sedation/anesthesia scores and vital signs of streptozotocin (STZ)-induced diabetic mice under DEX sedation were observed. Diabetic mice were divided into saline and DEX groups. After injecting sedatives intraperitoneally, tight junctions (TJs) and apoptotic levels were evaluated 24 hours later to assess the intestinal barrier function. The role of DEX was validated using Villin-MMP23B flox/flox mice with intestinal epithelial deletion. In vitro, high glucose and hyperosmolarity were used to culture Caco-2 monolayer cells with STZ inter-vention. Immunofluorescence techniques were used to monitor the barrier and mitochondrial functions. MMP23B protein levels in the intestinal tissue of STZ-induced diabetic mice were significantly higher than those in the intestinal tissue of control mice, with the DEX group displaying decreased MMP23B levels. Diabetes-mediated TJ dis-ruption, increased intestinal mucosal permeability, and systemic inflammation in wild-type mice might be reversed by DEX. In Caco-2 cells, MMP23B was associated with increased reactive oxygen species accumulation, mitochondrial membrane potential depolarization, and TJ disruption. DEX reduces MMP23B, which may potentially contribute to STZ-induced intestinal barrier dysfunction, affecting TJ modification through mitochondrial dysfunction.

Quadratus lumborum block for procedural and postprocedural analgesia in renal cell carcinoma percutaneous cryoablation.

This study assesses the efficacy of the quadratus lumborum block (QLB) in the management of procedural and periprocedural pain associated with small renal mass cryoablation. To the best of our knowledge, this is the first study that examines the use of QLB for pain management during percutaneous cryoablation of renal cell carcinoma (RCC). A single-center retrospective review was conducted for patients who underwent cryoablation for RCC with QLB between October 2020 and October 2021. The primary study endpoint included a total dose of procedural conscious sedation and administered, postprocedural analgesia. Technical success in cryoablation was achieved in every case. No patients required additional analgesic during or after the procedure, and no complications resulted from the use of the QLB. The QLB procedure appears to be an effective locoregional block for the management of procedural and periprocedural pain associated with renal mass cryoablation.

Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine.

This Rapid Practice Guideline (RPG) aimed to provide evidence‑based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. Data from 17 randomized clinical trials (n=898) and 9 observational studies (n=1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital – the effect of anti-retroviral therapy: A retrospective chart analysis

PurposeAdequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug–drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs.MethodsThis retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status.ResultsA total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72 h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs.ConclusionThe data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Ketamine analgo-sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine.

This Rapid Practice Guideline (RPG) aimed to provide evidence-based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. Data from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.

An Instance of Green-tinted Urine Related to the use of Propofol

Urine typically has an amber-yellow color due to the amorphous pigment urochrome, a distinct scent, and an average pH of 6.0, which is somewhat acidic. Green urine can result from drug intake, dyes, infections, adverse drug reactions, and other causes. Less than 1% of propofol users experience green urine, a rare and benign side effect. The green tint in urine is caused by the phenolic metabolites of propofol. In this case, a 33-year-old man diagnosed with organophosphorus poisoning and aspiration pneumonia had been given a modest dose of propofol sedation for six hours and began to exhibit green urine. After five hours of halting the propofol infusion, the urine returned to its usual color. Healthcare practitioners should be aware of this unusual but safe side effect of propofol.

Increased risk of respiratory events during endobronchial ultrasound examination in patients with reduced forced expiratory volume: a prospective observational study.

The incidence of adverse events during endobronchial ultrasound is low. Nevertheless, it is unclear, whether patients with impaired pulmonary function have an increased risk of respiratory events during the intervention. A monocentric prospective observational study was performed at the Department of Respiratory Medicine, University Hospital Frankfurt/Main, Germany. Adult patients undergoing an endobronchial ultrasound examination with propofol-sedation were included. Pre-interventional screening included pulmonary function testing, laboratory tests and electrocardiogram. The occurrence of hypercapnia >55 mmHg or reduced oxygen saturation <85% was defined as a respiratory event was recorded and compared between patients with normal and impaired pulmonary function tests. In total, 126 patients were included. Pulmonary function testing revealed a median FEV1 of 2.2 l (range 0.4-6.04l) and a predicted FEV1 of 79.5% (range 20-127.8%) respectively. The median FVC was 3.0 l (range 0.87-7.28l), the median predicted FVC was 82% (range 31.4-128.4%). In 72 examinations (60%) pCO2 levels >55 mmHg were measured. Transient oxygen desaturation <85% occurred in 31 cases (25.8%). The Mann Whitney U-test showed a significantly lower FEV1 (% predicted value) in patients with respiratory events (p = 0.007). ROC analysis identified a predicted FEV1 of 78.5% as the optimal cut-off with a sensitivity of 58% and a specificity of 71%. Using Z-score instead of predicted values, there was no significant association between a lower Z- score of FEV or FVC and hypercapnic or hypoxic events. However, both a lower absolute value of FEV1/FVC and a lower Z-score of the FEV1/FVC index were associated with the occurrence of respiratory events. In binary logistic regression analysis, we could not demonstrate any association with other relevant parameters (age, BMI, sedation dosage, sedation duration, or ASA-score). An impaired forced expiratory volume is associated with the frequency of respiratory events during endobronchial ultrasound examination under propofol-sedation.

Daily Sedation Interruption vs Continuous Sedation in Pediatric Patients Receiving Mechanical Ventilation

The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients. To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU). A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023. Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU. Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis. The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality. A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65). This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.

Music therapy during weaning from mechanical ventilation in the intensive care unit: Study protocol for a randomised control trial

ABSTRACT Introduction People admitted to the intensive care unit (ICU) who require mechanical ventilation (MV) must complete the weaning process as soon as possible to reduce associated risk factors. Previous research suggests that music therapy may be beneficial for improving breathing capacity and relaxation, but studies related to weaning are limited. This article presents a music therapy protocol for a randomised controlled trial (RCT). Method ICU patients aged 18–80 who meet the clinical criteria for initiating weaning are eligible for this RCT with two parallel groups. Participants (n = 100) are randomly assigned to a control group (receiving standard treatment during weaning) and an intervention group (receiving daily music therapy intervention combined with standard treatment). The outcome measures are (1) duration of weaning in hours, (2) dosage of sedatives and analgesia, (3) agitation, (4) delirium, (5) perception of pain, and (6) perceived stress at 90 days follow-up. During music therapy, (7) blood pressure, heart rate, respiratory rate and oxygenation level are only measured in the intervention group. The flexible music therapy protocol addresses patient needs from a humanistic biopsychosocial perspective. It includes an assessment of individual music preferences (adapted from the Musical Life Story Questionnaire) and methods such as entrainment, clinical instrumental improvisation, songwriting, and receptive music therapy to reinforce breathing capacity and promote relaxation, stimulation, communication, and emotional regulation. Discussion The findings of this study may offer relevant implications for healthcare delivery and the application of music therapy during weaning in the ICU.

Utility of Neonatal Pain, Agitation and Sedation Scale and Amplitude Integrated Electroencephalogram for Detection of Different Levels of Sedation in NICUs

Abstract Background Sedatives are essential drugs in every intensive care unit used to ensure the patient's optimal level of comfort. Avoiding conditions of over and under sedation is a challenge in a neonatal intensive care setting. To date, there are no definitions of optimal levels of sedation in neonates. Testing the hypothesis that if a combined use of Neonatal Pain, Agitation and Sedation Scale (N- PASS) and amplitude integrated electroencephalography (aEEG) score might be helpful to distinguish different levels of neonatal sedation and therefore useful in titration of the drugs used. Aim of the Work The primary aim of the present study is to assess Neonatal Pain, Agitation and Sedation Scale (N-PASS) and amplitude integrated electroencephalography (aEEG) in the detection of different levels of neonatal sedation. Patients and Methods This was prospective observational study conducted on 30 full term neonates on mechanical ventilation reciving sedation (midazolam,fentanyl). we divided our patients into two groups (lightly sedated and deeply sedated patients) according to dose of sedation which determined by the expert opinion according to the clinical condition of the patients. all patients were subjected to the following:(demographic data, clinical signs &amp; symptoms, laboratory investigations, N-PASS and aEEG before and after sedation from march 2021 to August 2022 to evaluate N-PASS and aEEG in the detection of different levels of neonatal sedation. Results In our study which was conducted on 30 patients admitted to NICU at Ain shams university hospitals, our patients were of mean gestational age 38.34, all patients presented with respiratory distress, were mechanically ventilated and received sedation (midazolam, fentanyl). we divided our patients into two groups (lightly sedated patients who were 11 patients (36.7%), deeply sedated patients who were 19 patients ( 63.3% ) according to dose of sedation. There was a significant decrease of co2 level in deeply sedated patients, mean co2 after deep sedation 43.36 mmHg while mean co2 after light sedation 51.52 mmHg (p 0.034),and regarding N-PASS significant decrease in N-PASS total score after sedation (p &amp;lt; 0.001 ),and regarding aEEG significant decrease of total burdjalov score after sedation (p &amp;lt; 0.001 ) Conclusion We recommend combining a clinical scoring system such as the N-PASS, with a continuous brain activity monitor such as the aEEG for assessing the level of sedation in neonates.

Unveiling significant risk factors for intensive care unit-acquired weakness: Advancing preventive care

In this editorial, we discuss an article titled, “Significant risk factors for intensive care unit-acquired weakness: A processing strategy based on repeated machine learning,” published in a recent issue of the World Journal of Clinical Cases . Intensive care unit-acquired weakness (ICU-AW) is a debilitating condition that affects critically ill patients, with significant implications for patient outcomes and their quality of life. This study explored the use of artificial intelligence and machine learning techniques to predict ICU-AW occurrence and identify key risk factors. Data from a cohort of 1063 adult intensive care unit (ICU) patients were analyzed, with a particular emphasis on variables such as duration of ICU stay, duration of mechanical ventilation, doses of sedatives and vasopressors, and underlying comorbidities. A multilayer perceptron neural network model was developed, which exhibited a remarkable impressive prediction accuracy of 86.2% on the training set and 85.5% on the test set. The study highlights the importance of early prediction and intervention in mitigating ICU-AW risk and improving patient outcomes.

Comparing Bispectral Index Monitoring vs Clinical Assessment for Deep Sedation in the ICU: Effects on Delirium Reduction and Sedative Drug Doses—A Randomized Trial

BackgroundSedative overdoses pose a delirium risk among Intensive Care Unit (ICU) patients, with potential mitigation through the use of a processed EEG monitor (BIS) to guide depth of sedation. Research QuestionCan BIS-guided deep sedation (RASS -4, -5) reduce sedative dosage and increase delirium-free and coma-free (DFCF) days? Study Design and MethodsA randomized controlled trial was conducted in a tertiary mixed ICU, enrolling patients requiring deep sedation for >8 hours. Patients were randomly assigned to either the Clinical Assessment (CA) or BIS groups (BIS range of 40-60). Both groups utilized a BIS sensor, while the CA group's screen remained covered. After deep sedation, BIS sensors were removed, and delirium was assessed twice daily by researchers blinded to the randomization. The primary outcome was the number of DFCF days within 14 days after deep sedation. Additionally, we compared doses of sedative drugs and BIS values during deep sedation. ResultsNinety-nine patients were included in the study. We found no significant difference in DFCF (p=0.1) between CA and BIS arms, but propofol doses were significantly lower in the BIS group (CA group 1.77 mg/kg/hr [95% CI 1.60, 1.93] vs. BIS group 1.44 mg/kg/hr [95% CI 1.04, 1.83]; p=0.03). During deep sedation, the CA group spent 46% of the total hours (95% CI 35, 57%) with BIS values below 40, whereas the BIS group spent 32% (95% CI 25, 40%), (p=0.03). Subgroup analysis focusing on patients sedated for more than 24 hours revealed an increase in DFCF in the BIS group (CA group median of 1 day [IQR 0, 9] vs. BIS group 8 days [IQR 0, 13]; p=0.04). InterpretationBIS-guided deep sedation did not improve DFCF days but reduced sedative drug use. In patients requiring sedation for more than 24 hours, it showed an improvement in DFCF days.

LC-MS-MS method for mitragynine and 7-hydroxymitragynine in hair and its application in authentic hair samples of suspected kratom abusers.

Kratom is a natural psychoactive product known primarily in Southeast Asia, including Thailand, Malaysia, etc. It is also known as krathom, kakuam, ithang, thom (Thailand), biak-biak, ketum (Malaysia) and mambog (Philippines) and is sometimes used as an opium substitute. It is stimulant at doses of 1-5 g, analgesic at doses of 5-15 g and euphoric and sedative at doses of >15 g. Mitragynine is the most abundant indole compound in kratom (Mitragyna speciosa) and is metabolized in humans to 7-hydroxymitragynine, the more active metabolite. Adverse effects include seizures, nausea, vomiting, diarrhea, tachycardia, restlessness, tremors, hallucinations and death. There are few studies on the analytical method for the detection of mitragynine and 7-hydroxymitragynine in hair. Therefore, this study proposes a liquid chromatography-tandem mass spectrometry (LC-MS-MS) method for the analysis of kratom in hair. Hair samples were first weighed to ∼10 mg and washed with methanol. Then the washed hair samples were cut into pieces and incubated in methanol with stirring and heating (16 h/38℃). Extracts were then analyzed by LC-MS-MS. This method was validated by determining the limit of detection (LOD), limit of quantification, linearity, intra- and inter-day accuracy and precision, recovery and matrix effects. The intra- and inter-day precision (CV%) and accuracy (bias%) were within ±20%, which was considered acceptable. Using this newly developed LC-MS-MS method, the simultaneous detection of mitragynine and 7-hydroxymitragynine in six authentic hair samples was achieved to provide the direct evidence of kratom use in the past. Mitragynine concentrations ranged from 16.0 to 2,067 pg/mg (mean 905.3 pg/mg), and 7-hydroxymitragynine concentrations ranged from 0.34 to 15 pg/mg (mean 7.4 pg/mg) in six authentic hair samples from kratom abusers. This may be due to the higher sensitivity of the LOD in this study, with values of 0.05 pg/mg for mitragynine and 0.2 pg/mg for 7-hydroxymitragynine in hair.