Sedation Group Research Articles

Sedation During Endoscopy in Patients with Cirrhosis: Safety and Predictors of Adverse Events.

Sedation during endoscopy in cirrhotic patients is typically via moderate sedation, most commonly using a combination of a benzodiazepine (i.e., midazolam) and narcotic (i.e., fentanyl) or with propofol using monitored anesthesia care (MAC). Here, we examined the safety of moderate sedation and MAC in patients with cirrhosis. This retrospective cohort study of cirrhotic patients undergoing endoscopy from a large academic medical center between 2010 and 2014 examined extensive clinical data including the following: past history, physical findings, laboratory results, and procedural adverse events. Adverse events were defined a priori and included hypoxia, hypotension, bleeding, and death. We identified 2618 patients with cirrhosis who underwent endoscopic procedures; the mean age was 56years, 36% were female, the mean Child-Pugh score was 9.3 (IQR: 8, 11), and Charlson Comorbidity Index score was 3.2 (IQR: 1, 4); 1157 had MAC; and 1461 had moderate sedation. There was no difference in the frequency of adverse events in MAC and moderate sedation groups, with a total of 15 adverse events (7/1157 MAC and 8/1461 moderate sedation). The most common procedure performed was esophagogastroduodenoscopy (EGD, n = 1667) and was associated with 10 adverse events. Overall, adverse events included bradycardia (1), hypoxia (7), bleeding (5), laryngospasm (1), and perforation (1). The frequency was similar for EGD, ERCP, and colonoscopy-each at a rate of 0.6%. Adverse events in cirrhotic patients undergoing endoscopy appeared to be similar with moderate sedation or MAC, and the frequency was the same for different types of procedures.

Propofol Anesthesia Alters Spatial and Topologic Organization of Rat Brain Metabolism.

Loss of consciousness during anesthesia reduces local and global rate of cerebral glucose metabolism. Despite this, the influence of gradual anesthetic-induced changes on consciousness across the entire brain metabolic network has barely been studied. The purpose of the present study was to identify specific cerebral metabolic patterns characteristic of different consciousness/anesthesia states induced by intravenous anesthetic propofol. At various times, 20 Sprague-Dawley adult rats were intravenously administered three different dosages of propofol to induce different anesthetic states: mild sedation (20 mg · kg · h), deep sedation (40 mg · kg · h), and deep anesthesia (80 mg · kg · h). Using [F]fluorodeoxyglucose positron emission tomography brain imaging, alterations in the spatial pattern of metabolic distribution and metabolic topography were investigated by applying voxel-based spatial covariance analysis and graph-theory analysis. Evident reductions were found in baseline metabolism along with altered metabolic spatial distribution during propofol-induced anesthesia. Moreover, graph-theory analysis revealed a disruption in global and local efficiency of the metabolic brain network characterized by decreases in metabolic connectivity and energy efficiency during propofol-induced deep anesthesia (mild sedation global efficiency/local efficiency = 0.6985/0.7190, deep sedation global efficiency/local efficiency = 0.7444/0.7875, deep anesthesia global efficiency/local efficiency = 0.4498/0.6481; mild sedation vs. deep sedation, global efficiency: P = 0.356, local efficiency: P = 0.079; mild sedation vs. deep anesthesia, global efficiency: P < 0.0001, local efficiency: P < 0.0001; deep sedation vs. deep anesthesia, global efficiency: P < 0.0001, local efficiency: P < 0.0001). A strong spatial correlation was also found between cerebral metabolism and metabolic connectivity strength, which decreased significantly with deepening anesthesia level (correlation coefficients: mild sedation, r = 0.55, deep sedation, r = 0.47; deep anesthesia, r = 0.23; P < 0.0001 between the sedation and deep anesthesia groups). The data revealed anesthesia-related alterations in spatial and topologic organization of metabolic brain network, as well as a close relationship between metabolic connectivity and cerebral metabolism during propofol anesthesia. These findings may provide novel insights into the metabolic mechanism of anesthetic-induced loss of consciousness.

Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy

General anesthesia during thrombectomy for acute ischemic stroke has been associated with poor neurological outcome in nonrandomized studies. Three single-center randomized trials reported no significantly different or improved outcomes for patients who received general anesthesia compared with procedural sedation. To detect differences in functional outcome at 3 months between patients who received general anesthesia vs procedural sedation during thrombectomy for anterior circulation acute ischemic stroke. MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019. Randomized clinical trials of adults with a National Institutes of Health Stroke Scale score of at least 10 and anterior circulation acute ischemic stroke assigned to receive general anesthesia or procedural sedation during thrombectomy. Individual patient data were obtained from 3 single-center, randomized, parallel-group, open-label treatment trials with blinded end point evaluation that met inclusion criteria and were analyzed using fixed-effects meta-analysis. Degree of disability, measured via the modified Rankin Scale (mRS) score (range 0-6; lower scores indicate less disability), analyzed with the common odds ratio (cOR) to detect the ordinal shift in the distribution of disability over the range of mRS scores. A total of 368 patients (mean [SD] age, 71.5 [12.9] years; 163 [44.3%] women; median [interquartile range] National Institutes of Health Stroke Scale score, 17 [14-21]) were included in the analysis, including 183 (49.7%) who received general anesthesia and 185 (50.3%) who received procedural sedation. The mean 3-month mRS score was 2.8 (95% CI, 2.5-3.1) in the general anesthesia group vs 3.2 (95% CI, 3.0-3.5) in the procedural sedation group (difference, 0.43 [95% CI, 0.03-0.83]; cOR, 1.58 [95% CI, 1.09-2.29]; P = .02). Among prespecified adverse events, only hypotension (decline in systolic blood pressure of more than 20% from baseline) (80.8% vs 53.1%; OR, 4.26 [95% CI, 2.55-7.09]; P < .001) and blood pressure variability (systolic blood pressure >180 mm Hg or <120 mm Hg) (79.7 vs 62.3%; OR, 2.42 [95% CI, 1.49-3.93]; P < .001) were significantly more common in the general anesthesia group. Among patients with acute ischemic stroke involving the anterior circulation undergoing thrombectomy, the use of protocol-based general anesthesia, compared with procedural sedation, was significantly associated with less disability at 3 months. These findings should be interpreted tentatively, given that the individual trials examined were single-center trials and disability was the primary outcome in only 1 trial.

Awake Sedation With Propofol Attenuates Intraoperative Stress of Carotid Endarterectomy in Regional Anesthesia

Carotid endarterectomy in regional anesthesia is often associated with increased perioperative stress. We assumed that carotid endarterectomy performed under awake sedation with propofol is more beneficial to prevent such stress than alprazolam premedication only. A total of 47 consecutive patients with significant carotid artery stenosis were enrolled into this investigation and followed up for 5years to explore vascular complications. All operations were performed under regional anesthesia. As premedication, all patients took 0.5mg of alprazolam 30minutes before the procedure. After randomization, 22 patients had awake sedation with target controlled propofol infusion, and the other 25 had only premedication. Cortisol plasma levels were serially analyzed: before surgery (T1), before (T2) and after release of carotid clamp (T3), and at 2 (T4) and 24 postoperative hours (T5). Alprazolam levels were also measured before and after the surgery. The plasma concentration of cortisol was significantly lower in the propofol sedation group at T2 (P<0.001), T3 (P=0.001), and T4 (P<0.001) than in the alprazolam-only group. Alprazolam levels did not correlate with cortisol levels at any time point. A significant positive correlation was found between the clamp time and plasma cortisol level at T3 (P=0.018), similarly between the degree of contralateral carotid stenosis and plasma cortisol level at T3 (P=0.03). Plasma cortisol concentration 2hours after the operation (T4) proved to be an independent predictor of carotid restenosis during the 5-year follow-up (odds ratio: 1.67, 95% confidence interval: 1.02-2.73, P=0.04). An additional intraoperative propofol sedation provides better stress relief than alprazolam-only premedication during awake carotid endarterectomy.

The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients.

To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. Multicenter, prospective cohort study. The emergency department and ICUs of 15 medical centers. Mechanically ventilated adult emergency department patients. None. All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73). Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.

The Associations Between Cognitive Dysfunction, Stress Biomarkers, and Administered Anesthesia Type in Total Knee Arthroplasties: Prospective, Randomized Trial

Background: Postoperative cognitive dysfunction (POCD) is a serious complication associated with total knee arthroplasty (TKA) and has been shown to increase the length of hospital stay, cause functional impairment, and morbidity. Objectives: We aimed to determine whether POCD is associated with the use of general or regional anesthesia in patients undergoing TKA. Our hypothesis was that POCD would be reduced in the group that received regional analgesia without any sedations. Our secondary hypothesis was POCD would be associated with biomarkers of surgical stress. Study Design: Randomized controlled study between general and spinal anesthesia. Setting: Single-centered, university hospital, from January to October 2017. Methods: A total of 112 patients were assessed for eligibility, and a total of 57 patients completed the study. We divided the patients into general and regional anesthesia groups. Blood samples were obtained preoperatively at the first intraoperative, the third and the 24th postoperative hour. C-reactive protein (CRP), cortisol, insulin, and blood glucose levels were tested. We used 4 neurocognitive tests that were administered 1 day before operation, 7 days and 30 days after operation. Main outcome measures were neurocognitive tests scores for regional anesthesia without sedation and general anesthesia groups. Cortisol, glucose, insulin, and CRP levels. Results: Patients who received regional anesthesia showed significantly higher Mini-Mental State Examination (MMSE) scored compared with the general anesthesia at the seventh day (P = 0.037). In the general anesthesia group, patients showed significantly higher variations for the Stroop number difference. There were negative correlations between MMSE scores measured at postoperative day 7 and the 1-hour intraoperative cortisol measurements (r = –0.302; P = 0.022) and 3-hour postoperative cortisol measurements (r = –0.295; P = 0.026). Limitations: A limitation was the small number of patients. Conclusions: We demonstrate that regional anesthesia results in better neurocognitive test scores than general anesthesia in patients undergoing TKA. Patients who received regional anesthesia showed lower cortisol, higher insulin, and lower glucose levels. We recommend that patients who undergo arthroplasty surgeries should receive regional anesthesia to avoid POCD at the early stages of the postoperative period. Key words: Cognitive dysfunction, stress biomarkers, acute pain, regional anesthesia, spinal anesthesia

Does Coadministration of Transforaminal Epidural Steroid Injection with Sedation Improve Patient Satisfaction? A Prospective Randomized Clinical Study

Background: Transforaminal epidural steroid injection (TFESI) can be administered with or without sedation in clinical practice. Objectives: The aim of this study was to compare both procedures in terms of patient and physician satisfaction, preoperative anxiety level, procedural pain level, and complications. Study Design: A prospective randomized trial. Setting: A university hospital interventional pain management center. Methods: The study included patients scheduled for single-level unilateral TFESI. The patients were randomized into 2 groups. The first group underwent TFESI without sedation, whereas the second group underwent TFESI with sedation. The Likert scale was used to determine the patient and physician satisfaction, and the Numeric Rating Scale (NRS-11) was used to determine the procedural pain level. Cases in which the procedure was to be repeated, the patient was questioned if they desired to undergo the procedure with the same technique. Results: A total of 64 patients, (31 [48.4%] in the sedation group) were included. In the sedation group, the patient and physician satisfaction were significantly higher (P = 0.0001), the periprocedural NRS-11 scores were significantly lower (P = 0.0001), and the rate of desire to have the intervention with the same technique was higher (P = 0.001). After the regression analysis, we reported that there was a significant correlation between being in the sedation group and NRS-11 procedure scores, the desire to have the same technique, and patient and physician satisfaction (odds ratio [OR], 0.341; OR, 0.648; OR, 0.329; OR, 0.514; P = 0.0001). Limitations: Both patients and physicians were unblinded. Conclusions: Coadministration of TFESI with sedation improves patient and physician satisfaction. Additionally, the low periprocedural pain level results in patients’ demand for the intervention to be performed with sedation in the event of repetition of the procedure. Key words: Patient satisfaction, transforaminal epidural steroid injection, sedation, physician satisfaction

Postinterventional Sedation Worsens Functional Outcomes in Patients with Acute Ischemic Stroke Treated with Endovascular Therapy

Postinterventional sedation is commonly used in clinical practice to ensure patient safety and comfort. Although sedation or anesthesia during thrombectomy has been well studied, the association between postinterventional sedation and functional outcomes in endovascularly treated patients with acute ischemic stroke (AIS) has yet to be investigated. We describe the association between postinterventional sedation and functional outcomes in patients with AIS treated with endovascular therapy (EVT). This observational study was based on a prospective registry. Patients with AIS treated with EVT from January 2013 to August 2017 at Xuanwu Hospital, Capital Medical University were included. Patients receiving postinterventional sedation were compared with patients not receiving sedation. The primary outcome was the 3 months modified Rankin Scale score. A total of 268 patients were eligible for study: 112 patients (41.8%) receiving postinterventional sedation and 156 patients (58.2%) without sedation. At 3 months follow-up, the median modified Rankin Scale score was 4 (interquartile range, 3-6) in the sedation group and 2 (interquartile range, 1-4) in the nonsedation group (P<0.001). Multivariable regression analysis suggested that the need for postinterventional sedation was associated with unfavorable outcomes, with an odds ratio of 0.20 for functional independence (95% confidence interval [CI], 0.078-0.487; P < 0.001), 0.06 for freedom from disability (95% CI, 0.017-0.228; P < 0.001), and 8.37 for death (95% CI, 2.196-31.889; P= 0.002). Postinterventional sedation worsens functional outcomes in patients with AIS with large-vessel occlusions treated with EVT. Whether the sedation is a causative factor or a surrogate for poor functional outcomes remains to be determined.

Patient Satisfaction with Oral versus Intravenous Sedation for Cataract Surgery: A Randomized Clinical Trial

To determine whether patient satisfaction with oral sedation is noninferior to intravenous sedation for cataract surgery. Prospective, randomized, double-masked clinical trial. A volunteer sample of patients 18 years or older from diverse backgrounds scheduled for cataract surgery. Patients who were allergic to benzodiazepines, older than 70 years with a failed delirium screening questionnaire, pregnant or nursing, using a medication inhibiting cytochrome 450 3A, or intoxicated on the day of surgery were excluded. Patients were randomized to receive either oral triazolam with intravenous placebo or intravenous midazolam with oral placebo before surgery. The primary outcome was patient satisfaction, measured by a survey administered on postoperative day 1. Secondary outcomes included surgeon and anesthesia provider satisfaction, need for supplemental anesthesia, and surgical complications. Among the 85 patients (42 men [49.4%]; mean age, 65.8 years; standard deviation, 9.5 years) completing the study, the mean satisfaction score was 5.34±0.63 (range, 3.75-6) in the oral sedation group and 5.40±0.52 (range, 4-6) in the intravenous group. With an a priori noninferiority margin of 0.5 and a difference in mean scores between the 2 groups of 0.06 (1-tailed 95% confidence interval [CI], -infinity to 0.27), our results demonstrate noninferiority of oral sedation with a P value of 0.0004. Surgeon and anesthesia provider satisfaction was similar between the 2 groups. Intraoperative complications occurred in 16.7% in the oral group and 9.3% in the intravenous group (difference, 7.4%; 95% CI, -6.9% to 21.6%; P= 0.31). The only major intraoperative complication-a posterior capsular tear-occurred in the intravenous group. Eight patients in the oral group (19.0%) and 3 in the intravenous group (7.0%) received supplemental intravenous sedation (difference, 12.1%; 95% CI, -2.0% to 26.2%; P= 0.097). The use of oral sedation in cataract surgery has been suggested as a cost- and space-saving measure, potentially allowing the transition of some patients from an operating to procedure room or office-based setting. We report the noninferiority of oral compared with intravenous sedation for cataract surgery in a diverse patient population in terms of patient satisfaction.

Three Different Anesthesia Approaches in Blepharoptosis Surgery.

Despite the many methods of anesthesia for blepharoptosis, there is little documentation in the literature. When using the Müller aponeurosis composite flap advancement approach, one of the 3 anesthesia methods is chosen: general, local, and sedative anesthesia. On the other hand, the choice of anesthesia method is controversial. A total of 101 patients (48 female and 53 male) admitted to hospital for treatment were selected: 38 (37.6%) patients (49 eyes) with local anesthesia, 34 (33.7%) patients (60 eyes) with general anesthesia, and 29 (28.7%) patients (42 eyes) with sedative anesthesia. The preoperative average marginal reflex distance (MRD1) in the local, general, and sedative anesthesia groups was 0.90, 0.35, and 0.47 mm, respectively. The corneal exposure area (CEA) in the local, general, and sedative approach groups was 63.2%, 57.8%, and 55.9%, respectively. The postoperative average distance for the MRD1 was significantly different among the 3 anesthesia approaches. The postoperative MRD1 in the local approach group was 3.28 mm and the CEA improved to 75.4%. In the general anesthesia approach group, the MRD1 was 3.01 mm and the CEA was 73.4%. In the sedative anesthesia approach group, the MRD1 and CEA were 3.62 mm and 74.0%, respectively. The MRD1 in the general, local, and sedative groups was 2.65 ± 1.48, 2.39 ± 1.65, and 3.17 ± 1.77, respectively; the difference was not significant (P > 0.05). The general, local, and sedative anesthesia approaches are all effective in the correction of blepharoptosis; the results were similar regardless of the anesthesia approach. On the other hand, the patients felt more comfortable and surgeons could control the process more easily using the sedative approach.

Propofol sedation in colonoscopy: from satisfied patients to improved quality indicators.

BackgroundPropofol-mediated sedation is safe and clearly associated with increased patient satisfaction. However, whether it results in a favorable effect on colonoscopy outcomes and performance compared to standard sedation with benzodiazepines/opiates remains unclear.ObjectivesTo determine the effect of propofol-mediated sedation on colonoscopy-quality measures compared to traditional sedation.MethodsA large cohort of 44,794 patients who had undergone sedated colonoscopies were included. Colonoscopy-quality indicators were examined in benzodiazepine/opiate-sedated patients and compared with a propofol-mediated sedation group. Adjustment for potential confounders, such as age, sex, quality of bowel preparation, procedural setting, and indication was performed.ResultsPatients who received propofol-mediated sedation were more likely, and in a dose-dependent manner, to have an enhanced polyp-detection rate (22.8% vs 20.9%, P<0.001), cecal intubation rate (90.4% vs 87.3%, P<0.001), and terminal ileum-intubation rate (6.4% vs 1.6%, P<0.001). On multivariate analysis, these findings were maintained, as propofol-mediated sedation use was significantly associated with improved colonoscopy indicators.ConclusionPropofol-mediated sedation during colonoscopy is associated with better examination performance and improved outcomes. Further prospective or randomized trials to support these findings are warranted.

Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients

Background:Postoperative cognitive dysfunction (POCD) is a serious complication after surgery, especially in elderly patients. The anesthesia technique is a potentially modifiable risk factor for POCD. This study assessed the effects of dexmedetomidine, propofol or midazolam sedation on POCD in elderly patients who underwent hip or knee replacement under spinal anesthesia.Methods:The present study was a prospective randomized controlled preliminary trial. From July 2013 and December 2014, a total of 164 patients aged 65 years or older who underwent hip or knee arthroplasty at China-Japan Friendship Hospital and 41 non-surgical controls were included in this study. Patients were randomized in a 1:1:1 ratio to 3 sedative groups. All the patients received combined spinal-epidural anesthesia (CSEA) with midazolam, dexmedetomidine or propofol sedation. The sedative dose was adjusted to achieve light sedation (bispectral index[BIS] score between 70 and 85). All study participants and controls completed a battery of 5 neuropsychological tests before and 7 days after surgery. One year postoperatively, the patients and controls were interviewed over the telephone using the Montreal cognitive assessment 5-minute protocol.Results:In all, 60 of 164 patients (36.6%) were diagnosed with POCD 7 days postoperatively, POCD incidence in propofol group was significantly lower than that in dexmedetomidine and midazolam groups (18.2% vs. 40.0%, 51.9%, χ2 = 6.342 and 13.603, P = 0.012 and < 0.001). When the patients were re-tested 1 year postoperatively, the incidence of POCD was not significantly different among the 3 groups (14.0%, 10.6% vs. 14.9%, χ2 = 0.016 and 0.382, P = 0.899 and 0.536).Conclusion:Among dexmedetomidine, propofol and midazolam sedation in elderly patients, propofol sedation shows a significant advantage in term of short-term POCD incidence.

An Easy and Reliable Way to Prevent Electrocardiographic Deteriorations of Patients Undergoing Off-Pump Coronary Artery Bypass Surgery: Preoperative Anxiolytic Treatment.

ObjectiveTo investigate the effects of preoperative anxiety relieving on electrophysiological changes in patients undergoing off-pump coronary artery bypass surgery.MethodsA total of 61 patients at ASA III risk group in the age range of 18-65 years were enrolled in the present study. Patients were randomly divided into two groups. Group S (Sedation group) was administered 0.04 mg/kg lorazepam per os (PO) twice before the operation. Group C (control group) was not administered with any anxiolytic premedication. State Trait Anxiety Inventory (STAI-I) and Beck Anxiety Inventory (BAI) were used to evaluate the level of anxiety. Electrocardiography (ECG), pulse oximeter and standard monitoring were performed for each patient. QT and P dispersions in each derivation of all ECGs were calculated.ResultsPreoperative STAI-I scores were significantly lower in sedation group compared to the controls. Mean values of QT dispersion measured before induction, at the 1st minute of induction, 30th second of intubation and 4th minute of intubation in sedation group were significantly reduced compared to controls (P=0.024; P=0.027; P=0.001; P=0.033, respectively). The mean values of P dispersion measured before induction, at the 3rd minute of induction, 30th second of intubation and 4th minute of intubation in sedation group were significantly reduced compared to controls (P=0.001; P=0.020; P=0.023; P=0.005, respectively).ConclusionElevated anxiety levels in patients undergoing coronary bypass surgery have a negative effect through prolonged QT and P-wave dispersion times. Anxiolytic treatment before surgery may be useful to prevent ventricular and atrial arrhythmias and associated complications through decreasing the QT and P-wave dispersion duration.

Efficacy of Clonidine as an Additive on the Duration of Action of Brachial Plexus Block Performed Under Ultrasound and Nerve Locator Guidance: A Prospective Randomized Study.

Background:Clonidine, an alpha2 agonist, when added to local anesthetics in different regional and neuraxial blocks reduces the onset time, improves the efficacy, and increases the duration of postoperative analgesia.Aims:This study evaluated the effect of bupivacaine clonidine combination in ultrasound and nerve locator-guided supraclavicular brachial plexus block for upper limb surgeries.Settings and Design:This was a prospective, randomized, controlled, double-blind study carried out in a tertiary care center in South India on 50 patients with American Society of Anesthesiologists (ASA) physical status classes I and II undergoing elective upper limb surgery under supraclavicular brachial plexus block.Materials and Methods:Eligible participants were randomized equally to either Group B who received 20 ml of bupivacaine and 7 mL of 2% lignocaine or Group C who received 20 ml of bupivacaine, 7 ml of 2% lignocaine, and 100 μg of clonidine.Statistical Analysis:Continuous outcome variables were tested for statistical significance using Student's t-test, and Mann–Whitney U-test was used for outcomes that were nonnormally distributed. Categorical variables were compared using Fisher's exact test. P <0.05 was considered as statistically significant.Results:The onset of sensory and motor blockade was significantly faster (P < 0.05) in Group C compared to Group B. The duration of sensory and motor block and the duration of analgesia were significantly longer in Group C (P < 0.001). The sedation in Group C patients was significantly more (P < 0.05) when compared to Group B, but none of the sedation scores exceeded 3 on the Ramsay sedation score. Hemodynamic parameters did not differ between groups (P > 0.05).Conclusion:The inclusion of 100 μg of clonidine with bupivacaine in ultrasound-guided supraclavicular brachial plexus blocks prolongs both sensory and motor blockade. It also provides significant postoperative analgesia and mild sedation which is beneficial in the immediate stressful postoperative period.

Deep Sedation or Paracervical Block for Daycare Gynecological Procedures: A Prospective, Comparative Study.

Context:Many minor gynecological procedures are done for diagnostic and therapeutic reasons. A balance has to be struck between ability to discharge a patient at the earliest with minimum procedure-related discomfort to ensure patient safety as well as satisfaction.Aim:This prospective randomized study was designed to compare deep sedation versus paracervical block for minor gynecological surgeries comparing the time to discharge readiness, pain after the procedure, and overall patient satisfaction.Setting and Design:This prospective randomized comparative study was conducted at a tertiary level hospital after institutional ethics committee approval and registry of trial at CTRI (India).Methods:Seventy young women underwent minor gynecological procedures under these two modes of anesthesia. Time to discharge readiness from hospital to home was assessed using modified postanesthesia discharge score system (PADSS). Pain after procedure as well as patient satisfaction was evaluated. Patients were also asked whether they would recommend the same anesthetic technique for the procedure in the future. Answers were noted on a Likert scale.Results:Patients were ready to be discharged faster in deep sedation group compared to paracervical block group based upon modified PADSS score (1 h 9.6 min vs. 1 h 18 min) (P = 0.005). Pain in the perioperative period was analyzed using repeated-measures ANOVA and found to be significantly lesser in deep sedation group when considered till 80 min after surgery. The mean satisfaction score in patients who underwent deep sedation was 91.24 (standard deviation [SD] 2.8) compared to patients given paracervical block which was low at 64.67 (SD 15.8). All patients given deep sedation were ready to recommend the anesthesia technique as compared to only 53.3% of patients who were given paracervical block.Conclusions:Deep sedation may be preferred over paracervical block for daycare minor gynecological procedures.

Effects of propofol sedation on psychological stress in surgical patients under epidural

To explore the effects of propofol sedation on psychological stress in patients undergoing surgery under epidural anesthesia. Sixty patients scheduled to undergo elective ileostomy closure under epidural anesthesia were randomized into propofol sedation group and control group (n=30). The patients in the sedation group received a loading dose of propofol of 0.6 mg·kg- 1· h- 1 followed by a maintenance dose with continuous infusion of 3 mg·kg- 1· h- 1 given after the Observer's Assessment of Alertness/Sedation (OAA/S) score reached 2-3. An equivalent volume of normal saline was administered in patients in the control group. The patients' preoperative and intraoperative anxiety scores were assessed with the State Anxiety Inventory (SAI) on the day before and on the first day after the surgery, respectively. The mean blood pressure (MBP), heart rate (HR), SpO2, OAA/S, and the indicators of psychological stress of brain functional state of the patients (including the wavelet index [WLi], anxiety index [ANXi], comfortable index [CFi] and pain index [Pi]) were recorded at 5 min after entering the operating room (T0), at the time of lumbar puncture (T1) and change to supine position after the puncture (T2), at 20 s (T3), 40 s (T4), and 60 s (T5) after intravenous administration, and at 2 min (T6), 4 min (T5), 6 min (T8), 8 min (T9), 10 min (T10) and 40 min (T11) after skin incision. The patient's satisfaction with anesthesia was assessed with the Visual Analog Scale (VAS) score on the first day after the operation. Serum cortisol level was measured before anesthesia and at the end of operation to calculate the changes in cortisol level. The two groups of patients were comparable for preoperative SAI scores (P&gt;0.05); The patients in the sedation group appeared to have lower intraoprative SAI scores, but this difference was not statistically significant (P=0.05). MBP, HR, and SpO2 at the time points from T6 to T10 and OAA/S, WLi, ANXi, CFi, and Pi at the time points from T6 to T11 were significantly lower in the sedation group (all P &lt; 0.05), and these parameters were not significantly different between the two groups at the other time points (all P&gt;0.05). The patient satisfaction scores were significantly higher in the sedation group (Z=2.07, P &lt; 0.05). Compared with the preoperative levels, serum cortisol level at the end of the operation was increased in the sedation group but lowered in the control group, and the variations of serum cortisol level differed significantly between the two groups (t=4.75, P &lt; 0.01). Intraoperative propofol sedation can alleviate the patients' anxiety, improve the comfort level, and lessen physiological stress during surgeries under epidural anesthesia.

Sedation and neurodevelopmental outcomes in PICU: Identification of study groups.

As little as 30minutes of exposure to anesthetic and sedative agents may adversely affect the developing brain. Safe, humane management of critically ill infants requires the use of sedative agents, often for prolonged periods. We sought to identify two comparable groups of critical care patients who did or did not receive sedatives, with the aim of designing a long-term neurodevelopment follow-up study. This feasibility study aimed to determine if two comparable groups could be found. Infants with respiratory diagnoses having noninvasive ventilation without sedation (Group C) or intubation and ventilation with sedation (Group S) were identified by chart review. Charts of patients fulfilling the above inclusion criteria were searched for exclusion criteria including neurological disease, extreme prematurity, congenital cardiac disease, and genetic anomalies. Data were extracted to score pediatric severity of illness scores (PRISM and PELOD) for each patient. These scores were then compared using the absolute scores and by risk strata. Group S included 33 patients and Group C had 39. The absolute PRISM and PELOD scores were different between groups. Comparing the groups in three risk strata (PRISM greater or less than 5 or 10), there were no significant differences between groups. It is not possible to randomize infants to sedation or no sedation to investigate neurodevelopmental outcomes. This phase of the project aimed to determine the comparability of two groups of PICU patients. These findings indicate that these groups could be enrolled as exposed and control subjects in an outcomes study.

Virtual Reality Distraction during Endoscopic Urologic Surgery under Spinal Anesthesia: A Randomized Controlled Trial.

Sedation protocols during spinal anesthesia often involve sedative drugs associated with complications. We investigated whether virtual reality (VR) distraction could be applied during endoscopic urologic surgery under spinal anesthesia and yield better satisfaction than pharmacologic sedation. VR distraction without sedative was compared with pharmacologic sedation using repeat doses of midazolam 1–2 mg every 30 min during urologic surgery under spinal anesthesia. We compared the satisfaction of patients, surgeons, and anesthesiologists, as rated on a 5-point prespecified verbal rating scale. Two surgeons and two anesthesiologists rated the scale and an overall score was reported after discussion. Thirty-seven patients were randomized to a VR group (n = 18) or a sedation group (n = 19). The anesthesiologist’s satisfaction score was significantly higher in the VR group than in the sedation group (median (interquartile range) 5 (5–5) vs. 4 (4–5), p = 0.005). The likelihood of both patients and anesthesiologists being extremely satisfied was significantly higher in the VR group than in the sedation group. Agreement between the scores for surgeons and those for anesthesiologists was very good (kappa = 0.874 and 0.944, respectively). The incidence of apnea was significantly lower in the VR group than in the sedation group (n = 1, 5.6% vs. n = 7, 36.8%, p = 0.042). The present findings suggest that VR distraction is better than drug sedation with midazolam in terms of patient’s and anesthesiologist’s satisfaction and avoiding the respiratory side effects of midazolam during endoscopic urologic surgery under spinal anesthesia.

Brain magnetic resonance imaging using a customized vacuum shape-keeping immobilizer without sedation in preterm infants

ObjectiveTo validate that a customized vacuum shape-keeping immobilizer (VaSKI) can be used in preterm infants without sedation. MethodsPreterm infants who underwent brain MRI from February 2008 to March 2017 at Osaka Medical College Hospital were retrospectively assigned to the sedation group (February 2008 to September 2013, n = 64) or VaSKI group (October 2013 to November 2016, n = 64). The examination success rates and diagnosable case classification were determined by pediatricians and radiologists. We compared the time from preparation to examination completion between the groups. Furthermore, we measured the time from immobilization to sleep in the preterm infants in the VaSKI group. ResultsThe examination success rate was 90.6% in both of the groups. The median (interquartile range) times of preparation were 24.0 (15.3) and 18.0 (13.0) min in the sedation and VaSKI groups, respectively. In the VaSKI group, the time from immobilization to sleep was within 3 min in 87.1% of the preterm infants. ConclusionsThe brain MRI examination success rates and motion artifact suppression effects were equivalent between the groups, whereas the time from preparation to examination completion was much shorter in the VaSKI group. Therefore, the VaSKI was validated as an immobilizer for MRI in preterm infants without using sedation.

Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

Objective: The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only. Methods: We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury. Results: Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10–69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49–5.80, and OR =2.15, 95% CI, 1.07–4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate. Conclusions: This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.