Sedation Failure Research Articles

Effectiveness of Chloral Hydrate on Brain MRI in Children with Developmental Delay/Intellectual Disability Comparing with Normal Intelligence: Single Tertiary Center Experience.

Neurodiagnostic investigation requirements are expanding for diagnostic and therapeutic purposes in children, especially in those with developmental delay/intellectual disability (DD/ID). Thus, determination of optimal sedatives to achieve successful sedation and immobility without further neurological compromise is important in children with DD/ID. The purpose of this study is to assess the effectiveness and adverse reactions of chloral hydrate (CH) for brain magnetic resonance imaging (B-MRI) in children with DD/ID compared to those with normal intelligence (NI). We performed a retrospective chart review of children aged from 1 day to 12 years who required elective sedation using CH for B-MRI. About 730 cases (415 with DD/ID and 315 with NI) of CH sedation were conducted for B-MRI. Children with DD/ID showed a higher failure rate (22%) than did those with NI (6%); additional CH and prolonged sedation time were required. There was no difference in incidence of adverse reactions between DD/ID and NI groups (p = 0.338). Older or heavier children with DD/ID (p = 0.036 and p = 0.013, respectively), as well as those diagnosed with epilepsy or neuropsychiatric disorders showed higher risk of sedation failure (p < 0.001 for each). In conclusion, CH was a suboptimal sedative drug for children with DD/ID compared with those with NI. Other alternative or supplementary sedatives should be taken into consideration especially for those vulnerable groups.

Patient-Controlled Sedation Versus Clinician-Administered Sedation for Endoscopic Retrograde Cholangiopancreatography: A Systematic Review.

Patient-controlled sedation (PCS) has been explored as a sedation method in endoscopic retrograde cholangiopancreatography (ERCP), yet a comprehensive review article on this topic is lacking. We performed a systematic review to compare PCS against clinician-administered sedation. The primary objectives are to compare the sedative dosage used and the sedation depth, while secondary objectives are to compare sedation failure rates, clinician intervention rates, and patient satisfaction. A systematic literature search was conducted on MEDLINE, EMBASE, and the Cochrane Library Database using the terms "ERCP," "Sedation," "Patient-controlled," and related terms. Randomized controlled trials comparing PCS against clinician-administered sedation in adults undergoing ERCP were included. Articles without English full texts were excluded. Studies were reviewed by 2 independent reviewers. The Cochrane Risk of Bias tool was used for quality assessment of individual included trials. This systematic review is registered in the International Prospective Register of Systematic Reviews (CRD42020198647). A total of 2619 articles were identified from the literature search. A total of 2615 articles were excluded based on the exclusion criteria. Four articles (comprised of 4 independent trials involving 425 patients) were included in analysis. When compared with clinician-administered sedation, PCS in ERCP may lead to lower propofol dosage used and lower sedation depth. The sedation failure rates appear to be higher in PCS, whereas lower rates of airway maneuvers are required. No significant difference was observable for patient satisfaction rates between PCS and clinician-administered sedation. The included studies demonstrated unclear to high risk of bias, particularly in randomization, incomplete outcome data, and outcome measurement. PCS appears to be a feasible option for sedation in ERCP. Nonetheless, large-scale, high-quality trials will be required before PCS can be regularly implemented in ERCP.

Outcomes of dexmedetomidine sedation for drug-induced sleep ciné magnetic resonance imaging studies in pediatric obstructive sleep apnea patients.

Dexmedetomidine is utilized as a sedative agent for drug-induced sleep cine magnetic resonance imaging studies due to its ability to mimic natural sleep and lack of respiratory depressant effects. The outcomes of dexmedetomidine sedation such as respiratory complications and unplanned admissions in obstructive sleep apnea patients undergoing these studies are currently unknown. To describe the outcomes of dexmedetomidine sedation for outpatient drug-induced sleep magnetic resonance imaging in pediatric patients with obstructive sleep apnea. This is a retrospective chart review conducted in pediatric patients with obstructive sleep apnea undergoing outpatient drug-induced sleep ciné magnetic resonance imaging studies with dexmedetomidine sedation. Demographics, comorbidities, polysomnography study results, vital signs, respiratory complications, airway interventions, successful completion of the scan, and unplanned hospital admissions were measured. We analyzed 337 patients aged 2-18years (median age of 11years). The imaging was completed with dexmedetomidine as the sole sedative agent in 61% (N=207) patients. Ketamine was administered as additional sedative agent in 36% (N=122) of the patients. There was no difference in sedation-related adverse events and respiratory complications with regard to the severity of sleep apnea with the exception of mild desaturation episodes (SpO2 85%-90%). Patients who received additional sedative agents had significantly longer recovery room stay (71.5 [44] vs 55 [39] minutes; 95% CI of difference [9 to 23min], p<0.001) and total periprocedural stay (164.5 [52] vs 138 [64] minutes; 95% CI of difference [17 to 35min], p<.001). Dexmedetomidine alone or along with ketamine provided acceptable sedation in majority of the patients with obstructive sleep apnea undergoing outpatient diagnostic sleep magnetic resonance imaging studies without significant respiratory adverse events regardless of the severity of sleep apnea. Sedation failure and unplanned admissions are rare, and routine planned admission may not be required for this patient population.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

The Role of Clinical Characteristics in Stratifying Sedation Risk: A Cohort Study.

BackgroundDetermination of sedation type during gastrointestinal procedures is generally based on risk assessment via the American Society of Anesthesiologists (ASA) classification system, but the reliance of anesthesia risk on clinical factors remains largely uninvestigated. We aim to determine the association between various clinical factors and choice of sedation type during gastrointestinal procedures.MethodsThis single-center, retrospective cohort study used electronic medical records to identify patients receiving colonoscopy or endoscopy at Rhode Island Hospital. The electronic medical record was queried for history of alcohol abuse, opioid abuse, polysubstance abuse, prescriptions for psychotropic or opioid medications and ASA classification. Logistic regression was used to measure how patient characteristics correlated with sedation type.ResultsTotally, 2,033 patients were included in the study; 1,080 patients received moderate sedation and 853 received monitored anesthesia care (MAC). Three hundred fifty-four (60.2%) MAC patients had a history of alcohol abuse compared to 234 (39.8%) moderate sedation patients (P < 0.2334); 178 (62.9%) MAC and 105 (37.1%) moderate sedation patients had a history of opioid abuse (P < 0.001); 203 (73.6%) MAC and 73 (26.4%) moderate sedation patients had a history of polysubstance abuse (P < 0.001); and 815 (75.1%) MAC patients had psychiatric comorbidities versus 270 (24.9%) in the moderate sedation group (P < 0.001). In the MAC cohort, alcohol, opioid, polysubstance abuse and psychiatric history were associated with previous failure of moderate sedation (P < 0.0001).ConclusionsFor a subset of patients, clinical factors including alcohol, opioid, polysubstance abuse and psychiatric history, in addition to ASA classification, play an important role in sedation management.

Intranasal dexmedetomidine: the ideal drug for sedation in the pediatric echo lab?

Intranasal dexmedetomidine is an attractive option for procedural sedation in pediatrics due to ease of administration and its relatively short half-life. This study sought to compare the safety and efficacy of intranasal dexmedetomidine to a historical cohort of pediatric patients sedated using chloral hydrate in a pediatric echo lab. Chart review was performed to compare patients sedated between September, 2017 and October, 2019 using chloral hydrate and intranasal dexmedetomidine. Vital signs, time to sedation, duration of sedation, need for second dose of medication, rate of failed sedation, and impact on vital signs were compared between groups. Subgroup analysis was performed for those with complex and cyanotic heart disease. Chloral hydrate was used in 356 patients and intranasal dexmedetomidine in 376. Patient age, complexity of heart disease, and duration of sedation were similar. Rates of failed sedation were very low and similar. Average heart rate and minimum heart rate were lower for those receiving intranasal dexmedetomidine than chloral hydrate. Impact on vital signs was similar for those with complex and cyanotic heart disease. No adverse events occurred in either group. Sedation with intranasal dexmedetomidine is comparable to chloral hydrate in regards to safety and efficacy for children requiring echocardiography. Consistent with the mechanism of action, patients receiving intranasal dexmedetomidine have a lower heart rate without morbidity.

The Effect of Preoperative Anxiety and Pain Sensitivity on Preoperative Hemodynamics, Propofol Consumption, and Postoperative Recovery and Pain in Endoscopic Ultrasonography.

IntroductionThe present study investigates how preoperative anxiety and pain sensitivity affect the consumption of anesthetics, time elapsed until the desired sedation level is achieved, preoperative hemodynamics, postoperative recovery time, and postoperative pain.MethodsThe present study includes 80 ASA 1–2 patients aged between 20 and 65 who were scheduled for endoscopic ultrasonography (EUS) under sedation. Patients were instructed to fill out the Spielberger State-Trait Anxiety Inventory (STAI) and Pain Sensitivity Questionnaire (PSQ) before the procedure. For sedation, 0.03 mg kg−1 intravenous midazolam, 1 mg kg−1 lidocaine, 1 µ kg−1 fentanyl, and then a bolus dose of 1 mg kg−1 propofol were infused over a period of 60 s. The time elapsed until the bispectral index (BIS) value reached 75 was recorded. For anesthesia maintenance, 2 mg kg−1 h−1 propofol infusion was administered. In the case of sedation failure, an additional dose of 0.1 mg kg−1 propofol (IV) was administered to ensure sedation depth with a BIS level of 65–75, and the propofol infusion was halted once the BIS value dropped below 65.ResultsSTAI-S and STAI-T scores were significantly positively correlated with PSQ minor pain and PSQ total scores. The time elapsed until reaching a BIS level of 75, propofol infusion dose used during sedation, and the need for additional doses of propofol, heart rate (HR), and duration of post-anesthesia care unit stay were significantly positively correlated with both preoperative anxiety and preoperative pain sensitivity. In terms of postoperative pain, the visual analog scale (VAS) at 1 h was more highly correlated with STAI-S and STAI-T than with PSQ. The VAS 2 h was only correlated with STAI-S and STAI-T.ConclusionThe significant linear correlation between preoperative anxiety and pain sensitivity and anesthesia need can facilitate better preoperative management by predicting individual anesthetic consumption.Trial RegistrationThe study was registered with the number NCT03114735 on ClinicalTrials.gov.

Iliac vein stenting is safe when performed in an office based laboratory setting

BackgroundVenous stenting for iliac vein outflow obstruction is associated with excellent long-term stent patency and symptom resolution. However, the safety of iliac vein stenting performed in an office-based laboratory (OBL) setting is not well-defined. The purpose of our investigation was to determine the safety profile of iliac vein stenting in an OBL setting. MethodsData were prospectively collected in the Center for Vascular Medicine electronic medical record system (NextGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Standardized patient safety and sedation protocols were used in accordance with the accreditation standards of the Joint Commission for Accreditation of Hospital Organizations for office-based surgery centers. Patient consultations, interventions, and follow-up at 1 to 6 weeks were included in the present analysis. All the patients had received moderate sedation during their procedure. Complications requiring hospitalization were classified as major complications. Minor complications consisted of bleeding, hematoma, vasovagal response, in-stent thrombosis resulting in complete occlusion of the iliac vein stent, an allergic reaction, hematemesis, hypotension, pelvic discomfort, and pseudoaneurysm. ResultsBetween January 2015 and January 2019, 1223 iliac vein stents were placed in 1104 patients (23.7% male; 76.3% female). A total of 90 minor complications (7.36%) and 5 major complications (0.41%) were observed. The major complications included the following: one allergic reaction, one episode of atrial fibrillation, one episode of supraventricular tachycardia, one episode of chest pain, and one case of acute stent occlusion. The minor complications were primarily insertion site hematomas. No complications were related to sedation or acute renal failure. No patient died. ConclusionsMajor complications were rare after iliac vein stenting in an OBL setting. Minor complications were primarily insertion site hematomas, which did not require inpatient hospitalization. Our analysis has shown that iliac vein stenting in an OBL setting is a safe and well-tolerated procedure.

Effects of dexmedetomidine sedation for magnetic resonance imaging in children: a systematic review and meta-analysis.

Pediatric sedation is commonly required to obtain high-quality images in magnetic resonance imaging (MRI). We performed a systematic review and meta-analysis to assess the effects of dexmedetomidine sedation for MRI in children. A systematic review was conducted to find all randomized controlled trials concerning dexmedetomidine sedation for MRI in children. We searched databases using the Ovid platform in the Cochrane Controlled Trials Register, MEDLINE, and EMBASE. This study was registered in the PROSPERO database: CRD42020198368. Seven studies and 753 participants were included. Dexmedetomidine sedation showed a significantly delayed onset time [weighted mean differences (WMD) = 8.13min, 95% confidence interval (CI) 4.64 to 11.63, I2 = 98%] and recovery time (WMD = 5.22min, 95% CI 0.35 to 10.09, I2 = 92%) compared to propofol, ketamine, and midazolam sedation. There was no difference in quality of sedation [risk ratio (RR) = 1.25, 95% CI 0.92 to 1.69, I2 = 89%], or incidence of sedation failure (RR = 1.39, 95% CI 0.53 to 3.66, I2 = 83%) between groups. Although a significantly decreased heart rate (WMD = - 17.34 beats/minute, 95% CI - 22.42 to - 12.26, I2 = 96%) was observed, bradycardia that required treatment was not increased (RR = 8.00, 95% CI 1.02 to 62.64, I2 = 0%). Dexmedetomidine sedation had a lower incidence of desaturation events (RR = 0.42, 95% CI 0.20 to 0.86, I2 = 4%). However, there was no difference in incidence of postoperative vomiting (RR = 0.42, 95% CI 0.15 to 1.17, I2 = 17%) between groups. Dexmedetomidine sedation provided a similar sedation quality with a reduced incidence of desaturation events. However, the delayed onset and recovery times were drawbacks. The clinical significance of bradycardia is considered to be low. GRADE assessment revealed the quality of the evidence in this meta-analysis ranged from very low to moderate.

Use of volatile agents for sedation in the intensive care unit: A national survey in France

Current intensive care unit (ICU) sedation guidelines recommend strategies using non-benzodiazepine sedatives. This survey was undertaken to explore inhaled ICU sedation practice in France. In this national survey, medical directors of French adult ICUs were contacted by phone or email between July and August 2019. ICU medical directors were questioned about the characteristics of their department, their knowledge on inhaled sedation, and practical aspects of inhaled sedation use in their department. Among the 374 ICUs contacted, 187 provided responses (50%). Most ICU directors (73%) knew about the use of inhaled ICU sedation and 21% used inhaled sedation in their unit, mostly with the Anaesthetic Conserving Device (AnaConDa, Sedana Medical). Most respondents had used volatile agents for sedation for <5 years (63%) and in <20 patients per year (75%), with their main indications being: failure of intravenous sedation, severe asthma or bronchial obstruction, and acute respiratory distress syndrome. Sevoflurane and isoflurane were mainly used (88% and 20%, respectively). The main reasons for not using inhaled ICU sedation were: "device not available" (40%), "lack of medical interest" (37%), "lack of familiarity or knowledge about the technique" (35%) and "elevated cost" (21%). Most respondents (80%) were overall satisfied with the use of inhaled sedation. Almost 75% stated that inhaled sedation was a seducing alternative to intravenous sedation. This survey highlights the widespread knowledge about inhaled ICU sedation in France but shows its limited use to date. Differences in education and knowledge, as well as the recent and relatively scarce literature on the use of volatile agents in the ICU, might explain the diverse practices that were observed. The low rate of mild adverse effects, as perceived by respondents, and the users' satisfaction, are promising for this potentially important tool for ICU sedation.

The Use of Propofol versus Dexmedetomidine for Patients Receiving Drug-Induced Sleep Endoscopy: A Meta-Analysis of Randomized Controlled Trials.

The sedation outcomes associated with dexmedetomidine compared with those of propofol during drug-induced sleep endoscopy (DISE) remains unclear. Electronic databases (i.e., the Cochrane controlled trials register, Embase, Medline, and Scopus) were searched from inception to 25 December 2020 for randomized controlled trials (RCTs) that evaluated the sedation outcomes with dexmedetomidine or propofol in adult patients diagnosed with obstructive sleep apnea (OSA) receiving DISE. The primary outcome was the difference in minimum oxygen saturation (mSaO2). Five RCTs (270 participants) published between 2015 and 2020 were included for analysis. Compared with dexmedetomidine, propofol was associated with lower levels of mSaO2 (mean difference (MD) = −7.24, 95% confidence interval (CI) −12.04 to −2.44; 230 participants) and satisfaction among endoscopic performers (standardized MD = −2.43, 95% CI −3.61 to −1.26; 128 participants) as well as a higher risk of hypoxemia (relative ratios = 1.82, 95% CI 1.2 to 2.76; 82 participants). However, propofol provided a shorter time to fall asleep and a lower risk of failed sedation compared with dexmedetomidine. No significant difference was found in other outcomes. Compared with propofol, dexmedetomidine exhibited fewer adverse effects on respiratory function and provided a higher level of satisfaction among endoscopic performers but was associated with an elevated risk of failed sedation.

Melatonin for non-operating room sedation in paediatric population: a systematic review and meta-analysis

ContextThe literature on melatonin as a sedative agent in children is limited.ObjectiveTo conduct a systematic review of studies assessing the efficacy and safety of melatonin for non-operating room sedation in...

P0425 / #1735: RETROSPECTIVE REVIEW OF THE FAILURE RATES OF NON-INVASIVE VENTILATION ON A PAEDIATRIC HIGH DEPENDENCY UNIT

Aims & Objectives: Both continuous- and bi-level positive airway pressure are forms on non-invasive ventilation (NIV) being increasingly used in paediatric critical care (PCC). We aim to evaluate the practice in out Level 2 PCC unit by comparing NIV failure rates to those published elsewhere. Methods: We conducted a retrospective review of patients aged 0 – 17 years old admitted to our HDU for NIV between December 2014 and March 2019. In those who subsequently required intubation or died while receiving NIV, we recorded the time to failure from NIV first being commenced, and classified these as ‘early’ (< 6 hours), ‘intermediate’ (6 – 24 hours), or ‘late’ (> 24 hours). Results: 212 patients met the inclusion criteria, of which 44 (20.8%) failed treatment (44 intubations and 1 death). Of these, 16 (7.5%) were early, 17 (8.0%) were intermediate, and 6 (2.8%) were late. Data on timing of failures was missing for 5 (2.4%) patients. Conclusions: Our results are comparable to similarly designed studies in the literature (table 1). To our knowledge, these are the first data published on a group this large outside of a paediatric intensive care unit (PICU) setting. We believe our results were achieved by implementing practice which may be contentious outside of a PICU, such as nasogastric feeding, sedation, and clear NIV failure criterion. By implementing annual education on NIV skills and troubleshooting care, and devising clear, accessible NIV guidelines, we have achieved failure rates similar to those in PICUs – practice which may prevent children being admitted to PICUs.

Sleep deprivation did not enhance the success rate of chloral hydrate sedation for non-invasive procedural sedation in pediatric patients.

In Asian countries, oral chloral hydrate is the most commonly used sedative for non-invasive procedures. Theoretically, mild sleep deprivation could be considered as one of assisted techniques. However, there is no consensus on sleep deprivation facilitating the sedation during non-painful procedures in children. The aim of our study is to analyze the clinical data of children undergoing non-invasive procedural sedation retrospectively and to evaluate the association between mild sleep deprivation and sedative effects in non-invasive procedures. Consecutive patients undergoing chloral hydrate sedation for non-invasive procedures between December 1, 2019 to June 30, 2020 were included in this study. The propensity score analysis with 1: 1 ratio was used to match the baseline variables between patients with sleep deprivation and non-sleep deprivation. The primary outcome was the failure rate of sedation with the initial dose. The secondary outcomes included the failure rate of sedation after supplementation of chloral hydrate, the incidence of major and minor adverse events, initial and supplemental dose of chloral hydrate, and the length of sedation time. Of the 7789 patients undergoing chloral hydrate sedation, 6352 were treated with sleep deprivation and 1437 with non-sleep deprivation. After propensity score matching, 1437 pairs were produced. The failure rate of sedation with initial chlorate hydrate was not significantly different in two groups (8.6% [123/1437] vs. 10.6% [152/1437], p = 0.08), nor were the failure rates with supplemental chlorate hydrate (0.8% [12/1437] vs. 0.9% [13/1437], p = 1) and the length of sedation time (58 [45, 75] vs. 58 [45, 75] min; p = 0.93). The current results do not support sleep deprivation have a beneficial effect in reducing the pediatric chloral hydrate sedation failure rate. The routine use of sleep deprivation for pediatric sedation is unnecessary.

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.

Fahr Sendromu Olan Bir Hastada Yoğun Bakımdaki Sedasyon Problemi

Fahr Sendromu Olan Bir Hastada Yoğun Bakımdaki Sedasyon Problemi

Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy

The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure. Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n= 488) were matched to controls (n= 976) without a sedation failure by endoscopist and endoscopy date. Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score≥3.5 (odds ratio, 17.31; P= 2× 10-14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls. The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.

Adverse events of conscious sedation using midazolam for gastrointestinal endoscopy.

BackgroundThis study was conducted to identify the types and incidence of adverse events associated with midazolam, which is the most widely used drug to induce conscious sedation during gastrointestinal endoscopy, and to analyze the factors associated with hypoxemia and sedation failure.MethodsOf 87,740 patients who underwent gastrointestinal endoscopy between February 2015 and May 2017, the electronic medical records of 335 who reportedly developed adverse events were retrospectively reviewed, and analysis was performed to determine the risk factors for hypoxemia and sedation failure, the two most frequent adverse events among those manifested during gastrointestinal endoscopy.ResultsThe overall adverse event rate was 0.38% (n = 335); hypoxemia was most frequent, accounting for 40.7% (n = 90), followed by sedation failure (34.8%, n = 77), delayed discharge from the recovery room (22.1%, n = 49), and hypotension (2.2%, n = 5). Compared with the control group, the hypoxemia group did not show any significant differences in sex and body weight, but mean age was significantly older (P < 0.001) and a significantly lower dose of midazolam was administered (P < 0.001). In the group with sedation failure, the mean rate was higher in men (P < 0.001) and a significantly higher dose of midazolam was administered (P < 0.001), but no age difference was found.ConclusionsMidazolam-based conscious sedation during gastrointestinal endoscopy can lead to various adverse events. In particular, as elderly patients are at higher risk of developing hypoxemia, midazolam dose adjustment and careful monitoring are required in this group.

521 Developing and Validating a Prediction Model to Identify Patients at High Risk for Failing Standard Sedation for Routine GI Endoscopy

INTRODUCTION: In recent years, use of anesthesia-assisted (AA) sedation for routine GI endoscopy has increased markedly. One factor contributing to this increased use is clinical uncertainty about which patients are most likely to benefit from AA. We aimed to develop a prediction model to help providers identify patients who require AA due to high-risk of failing standard sedation (SS). METHODS: This was an IRB-approved retrospective longitudinal study of national Veterans Affairs (VA) data of all patients who underwent an EGD and/or colonoscopy in 2009-13 (during which AA was used for 4.1% of routine GI endoscopy in VA). Using step-wise logistic regression, we developed a model to predict the primary outcome of failed sedation using potentially predictive patient and procedure-level variables (Table 1). Failed sedation cases were identified electronically as patients who had a routine procedure (without polypectomy, dilation, or injection) with AA within 3-months of a prior similar SS procedure. All cases were manually validated by chart review (index endoscopy report or other records) documenting patient discomfort/agitation and/or medical instability resulting in either an incomplete procedure or specific mention of need for AA for future procedures. 10-fold cross validation was used to validate the final model. RESULTS: Of 710,252 SS procedures, there were 398 cases of failed sedation (173 EGD, 225 colonoscopy; prevalence = 0.06%). None of the factors found to be significant predictors of failed sedation (e.g., high-dose opioid use, younger age) had an odds ratio &gt; 3; factors NOT associated with failed sedation included body mass index, obstructive sleep apnea, functional GI disorders, and others (Table 1). 10-fold cross-validation yielded a mean area under the curve (AUC) of 0.67 (range 0.63-0.71). The model was well-calibrated, but patients in the top decile of risk had a failed sedation prevalence of only 0.16% (Table 2). CONCLUSION: Failed sedation among patients undergoing routine outpatient GI endoscopy with SS is very rare, even among patients in the highest decile of risk. This suggests that concerns regarding failed sedation due to commonly cited factors such as chronic opioid use, obesity, or increased comorbidity do not justify forgoing SS in favor of AA in most patients. It also suggests that use of AA is generally unnecessary, since failed sedation is very uncommon even in VA where overall use of AA is much lower than in the private sector.

Comparison of dexmedetomidine with propofol as sedatives for pediatric patients undergoing magnetic resonance imaging: A meta-analysis of randomized controlled trials with trial sequential analysis.

Dexmedetomidine and propofol are commonly used sedative agents in pediatric patients undergoing magnetic resonance imaging (MRI). The present meta-analysis aimed to compare dexmedetomidine with propofol in pediatric patients undergoing MRI using trial sequential analysis (TSA). The PubMed, Cochrane Library and Web of Knowledge databases were systematically searched for entries up to August 2018 for potential randomized controlled trials comparing dexmedetomidine with propofol in pediatric patients undergoing MRI. Data were extracted by two independent authors and analyzed using Revman version 5.2 software. Six trials involving 415 pediatric patients were included in the final analysis. A shorter recovery time (P<0.01) and onset time of sedation were identified for propofol compared with dexmedetomidine (P<0.01); however, there were no significant differences in the duration of sedation (P=0.37). Furthermore, pediatric patients receiving propofol were discharged sooner than those receiving dexmedetomidine (P=0.02). The incidence of failed sedation did not significantly differ between the two groups (P=0.81). Propofol induced a lower incidence of 5-min (P=0.03) and 10-min Pediatric Anesthesia Emergence Delirium (P<0.01), but a higher incidence of desaturation (P<0.01). The duration of MRI was similar between the two groups (P=0.15). TSA indicated that the monitoring boundary was crossed by the cumulative z curve, providing supportive evidence for the shorter recovery time in the propofol group. Propofol is recommended for pediatric sedation during MRI, owing to shorter recovery time and onset of sedation time, as well as a faster discharge from hospital, and a lower incidence of PAED score >10, compared with dexmedetomidine. However, considering the possibility of desaturation, propofol should be used with caution.