Sedation Regimens Research Articles

Effect of Sedation Regimen on Weaning from Mechanical Ventilation in the Intensive Care Unit.

BackgroundIntensive care unit patients undergoing mechanical ventilation have traditionally been sedated to make them comfortable and to avoid pain and anxiety. However, this may lead to prolonged mechanical ventilation and a longer length of stay.ObjectiveThe aim of this retrospective study was to explore whether different sedation regimens influence the course and duration of the weaning process.Patients and methodsIntubated adult patients (n = 152) from 15 general intensive care units in Sweden were mechanically ventilated for ≥ 24 h. Patients were divided into three groups according to the sedative(s) received during the weaning period (i.e. from being assessed as ‘fit for weaning’ until extubation): dexmedetomidine alone (DEX group, n = 32); standard of care with midazolam and/or propofol (SOC group, n = 67); or SOC plus dexmedetomidine (SOCDEX group, n = 53).ResultsPatients receiving dexmedetomidine alone were weaned more rapidly than those in the other groups despite spending longer time on mechanical ventilation prior to weaning. Anxiety during weaning was present in 0, 9 and 24% patients in the DEX, SOC and SOCDEX groups, respectively. Anxiety after extubation was present in 41, 20 and 34% in the DEX, SOC and SOCDEX groups, respectively. Delirium during weaning was present in 1, 2 and 1 patient in the DEX, SOC and SOCDEX groups, respectively. Delirium at ICU discharge was present in 1, 0 and 3 patients in the DEX, SOC and SOCDEX groups, respectively. Few patients fulfilled criteria for post-traumatic stress disorder.ConclusionDexmedetomidine, used as a single sedative, may have contributed to a shorter weaning period than SOC or SOCDEX. Patients who received dexmedetomidine-only sedation tended to report better health-related quality of life than those receiving other forms of sedation.Electronic supplementary materialThe online version of this article (10.1007/s40261-018-0636-2) contains supplementary material, which is available to authorized users.

Feasibility of continuous sedation monitoring in critically ill intensive care unit patients using the NeuroSENSE WAVCNS index.

Sedation in the intensive care unit (ICU) is challenging, as both over- and under-sedation are detrimental. Current methods of assessment, such as the Richmond Agitation Sedation Scale (RASS), are measured intermittently and rely on patients' behavioral response to stimulation, which may interrupt sleep/rest. A non-stimulating method for continuous sedation monitoring may be beneficial and allow more frequent assessment. Processed electroencephalography (EEG) monitors have not been routinely adopted in the ICU. The aim of this observational study was to assess the feasibility of using the NeuroSENSE™ monitor for EEG-based continuous sedation assessment. With ethical approval, ICU patients on continuous propofol sedation were recruited. Depth-of-hypnosis index (WAVCNS) values were obtained from the NeuroSENSE. Bedside nurses, blinded to the NeuroSENSE, performed regular RASS assessments and maintained the sedation regimen as per standard of care. Participants were monitored throughout the duration of their propofol infusion, up to 24h. Fifteen patients, with median [interquartile range] age of 57 [52-62.5] years were eachmonitored for a duration of 9.0 [5.7-20.1] h. Valid WAVCNS values were obtained for 89% [66-99] of monitoring time and were widely distributed within and between individuals, with 6% [1-31] spent < 40 (very deep), and 3% [1-15] spent > 90 (awake). Significant EEG suppression was detected in 3/15 (20%) participants. Observed RASS matched RASS goals in 36/89 (40%) assessments. The WAVCNS variability, and incidence of EEG suppression, highlight the limitations of using RASS as a standalone sedation measure, and suggests potential benefit of adjunct continuous brain monitoring.

The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation.

For decades, chloral hydrate (CH) was the standard agent used to provide sedation for noninvasive pediatric procedures.1 The drug had a long history of safe administration by nonanesthesia providers, which in many institutions included registered nurses.2,3 Despite reasonably high reported rates of success, CH had a number of disadvantages: a variable half-life in young children, clinical resedation, and a potential role as a neuroapoptotic agent in the developing brain.4,5 Perhaps the greatest disadvantage was the loss of the oral formulation in the US market, limiting its availability. After the loss of oral CH, many institutions evolved to an intravenous (IV) sedation regimen with propofol.6 Propofol was an attractive agent because of its high success rate, rapid onset, and short recovery. However, this change in practice presented new challenges because propofol is typically administered only by pediatric providers with advanced training in deep sedation or anesthesiologists. These deep sedation systems often require more intensive resource utilization (IV catheter placement, advanced monitoring systems, postanesthesia care, etc), which may have economic consequences for both the patient and the health care system. For many years, IV dexmedetomidine has been used for sedation in the critical care setting.7 In 2008, Mason et al8 took …

Respiratory Failure: Innovations in Diagnostics and Therapy

Acute and chronic respiratory failures require immediate diagnosis and preferably individualized ventilation therapy. If possible, non-invasive ventilation should be considered to avoid complications of invasive mechanical ventilation. Especially in patients with ARDS and moderate to severe cases, non-invasive ventilation may not be suitable and should not be used uncritically.Invasive mechanical ventilation parameters should be adjusted individually. In the future, additional parameters such as transpulmonary pressure, monitoring of regional ventilation using electrical impedance tomography could help to individualize ventilator settings. Problems include the lack of wide distribution of these techniques and automatic tools for data analyses are missing.So for today the best thing is to implement the current evidence consequently. This includes lung-protective ventilation with an adequate PEEP and a tidal volume between 6 and 8 ml/kg IBW and a limitation of peak pressure or driving pressure. According to this early mobilization and positioning including prone-position is important, same as a score-based sedation regime and an individualized volume therapy.

Subcutaneous dexmedetomidine infusions to treat or prevent drug withdrawal in infants and children

This retrospective study reports a cohort of pediatric patients in whom subcutaneous dexmedetomidine was used to treat or prevent drug withdrawal following prolonged sedation in the Pediatric Intensive Care Unit setting. There were seven patients ranging in age from 6 months to 3.75 years and in weight from 4.8 to 17.7 kg. The dexmedetomidine infusion before switching to subcutaneous administration varied from 0.8 to 1.4 microg/kg/h. Four of the patients had received dexmedetomidine in conjunction with an opioid as part of a sedation regimen during mechanical ventilation. In these four patients, the duration of the intravenous dexmedetomidine infusion varied from 4 to 10 days. In the three other patients, an intravenous dexmedetomidine infusion was used to treat withdrawal following the prolonged use of an opioid and/or a benzodiazepine. In these three patients, the duration of the intravenous dexmedetomidine varied from 3 to 5 days. Following the switch to subcutaneous dexmedetomidine, the infusion was gradually decreased by 0.1 microg/kg/h every 12 h. Subcutaneous access was maintained, and subcutaneous dexmedetomidine was administered for 4 to 7 days. No problems with the subcutaneous access were noted during treatment. No patient exhibited behavior suggestive of withdrawal during the use of subcutaneous dexmedetomidine. The maximum modified Finnegan score in the seven patients varied from 3 to 7. Our preliminary experience suggests that dexmedetomidine can be administered by subcutaneous infusion without difficulty or alteration of its efficacy. This approach allows the administration of dexmedetomidine when peripheral venous access becomes problematic and may facilitate the removal of central venous catheters in patients recovering from critical illnesses. It also offers the possibility of using dexmedetomidine in settings where peripheral venous access is not available such as home palliative care.

Association between Bispectral Index System and airway obstruction: an observational prospective cohort analysis during third molar extractions.

Sedation regimes during oral procedures frequently associated with airway obstruction. The aim of this study was to define the association of Bispectral Index (BIS) to the depth of sedation and airway obstruction events. Forty-seven patients between 14-21 years old, who were candidates for 3rd molar teeth extraction, were enrolled in this study. Patients received a total of 4 mg midazolam, 100 microgram fentanyl followed by titrated incremental propofol in 10 mg. The Richmond Agitation Sedation Score (RASS) was used to assess the depth of sedation. Each patient was attached to BIS monitor, while clinicians were not involved in the data collection process. Apnea, airway obstruction, O2 saturation, timing and interventions for controlling the situation were recorded. All data was synchronized with BIS data monitoring. The results show that 97.5% of cases were ASA 1 and 2, with average age of 17.3 years (±1.4) and a median BMI of 26.1. By using linear regression, for every unit decrease of median RASS (less than zero), there was 1.78 decrease in mean BIS Score (P=0.045, 95% CI: 0.08-3.47). The mean BIS Index (over 1 minute) with airway obstruction was 64 (±10.2), which was significantly lower than the BIS during non-airway obstruction (77±11.6), (P<0.001). By using logistic regression analysis, for every on unit increase in BIS Index, there is 24% decrease in odds in having airway obstruction (P=0.0009, 95% CI: 0.65-8.94). This study demonstrates that the BIS could potentially be a valid continuous monitoring method to avoid airway obstruction during sedation for patients undergoing dental surgery.

Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications

ObjectivesSedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different...

OP87 Nitrous Oxide As Sedation Regimen In Children—How To Assess Safety?

Introduction:Children who undergo short, painful procedures at hospitals are given different kinds of pain relief (analgesics), often in combination with drugs for relaxation (sedatives). Nitrous oxide (NO) is a drug administered for pain relief and relaxation, it is applied by inhalation and its effects are analgesic, anxiolytic and sedative. It is used in several countries, but is not normally used as a sedation method for children in Norwegian hospitals, although widely used in maternity wards during labor. Our aim was to evaluate the effectiveness and safety of this sedation regimen in children. However, we also wanted to assess safety for health personnel after repetitive or long-term exposure.Methods:We performed a systematic review on effectiveness and safety of nitrous oxide for sedation in children. For evidence on efficacy and safety in children, only randomized controlled trials (RCT) were included. For safety of health personnel we also accepted other study designs. For all endpoints, we presented the evidence in summary of finding tables.Results:We retrieved twenty-two randomized controlled trials on the effectiveness or safety in children undergoing sedation with nitrous oxide. Outcomes were hospital procedure satisfaction or characteristics, and pain relief. Safety was reported as acute adverse events. None of the RCTs reported evidence on safety for health personnel. We are currently exploring different ways to systematically assess safety for health personnel within the form of an HTA otherwise designed for a different population.Conclusions:Assessing safety of new technologies, methods or procedures through HTAs is a crucial point. However, assessing the long-term safety of the health personnel should also be included, but evidence will often not be retrieved through literature search designed for the patient group, and long-term safety data is in general difficult to retrieve for exposure to a novel technology. We will discuss our approach to this challenge.

Sedation Protocol During Bevacizumab Intravitreal Injection in Preterm Infants With Retinopathy of Prematurity.

This study describes outcomes of intravenous (IV) analgesics and sedatives for bedside intravitreal bevacizumab injections for retinopathy of prematurity. This retrospective study included infants receiving intravitreal bevacizumab injections between January 2012 and May 2016. Infants were excluded if bevacizumab was administered under general anesthesia or for incomplete records. Data collection included demographics, sedation and analgesia regimen, and cardiopulmonary adverse events (AEs). The primary objective was to identify the median doses of the IV analgesics and sedatives. The secondary objectives included the number of patients with cardiopulmonary AEs and those with procedure success, defined as procedure completion without interruption and absence of interventions. Fifteen infants were included. Fourteen (93.3%) were initiated on a fentanyl infusion at a median of 2 mcg/kg/hr (IQR, 2-3.6), and 12 (80%) received midazolam infusions at a median of 0.06 mg/kg/hr. All patients received at least 1 IV neuromuscular blocker dose just prior to the procedure. Only 2 patients (13.3%) required an increase in their fentanyl or midazolam infusions. Procedure success was achieved in 13 patients (86.7%). Five patients (33.3%) experienced 1 cardiopulmonary AE. One patient (6.7%) had a delay in the procedure, and 1 patient (6.7%) required naloxone. Despite this, the procedure was completed in all patients. Most received fentanyl and midazolam infusions with a dose of vecuronium just prior to the procedure. Thirteen (86.7%) met the criteria for procedure success. One-third experienced a cardiopulmonary AE. Future studies are needed to identify the optimal agents and route of administration for this procedure.

A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk

propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.

Comparative Analysis of Dexmedetomidine and Propofol Based Sedation Regimens on Anaesthetic Requirements in Cardiac Surgery with On-pump Cardiopulmonary Bypass

Comparative Analysis of Dexmedetomidine and Propofol Based Sedation Regimens on Anaesthetic Requirements in Cardiac Surgery with On-pump Cardiopulmonary Bypass

Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy.

AIMTo evaluate the safety and efficacy of sedating pediatric patients for outpatient flexible bronchoscopy.METHODSA retrospective chart review was conducted for all children, age 17 years or under who underwent flexible bronchoscopy under deep sedation in an outpatient hospital-based setting. Two sedation regimens were used; propofol only or ketamine prior to propofol. Patients were divided into three age groups; infants (less than 12 mo), toddlers (1-3 years) and children (4-17 years). Demographics, indication for bronchoscopy, sedative dosing, sedation and recovery time and adverse events were reviewed.RESULTSOf the total 458 bronchoscopies performed, propofol only regimen was used in 337 (74%) while propofol and ketamine was used in 121 (26%). About 99% of the procedures were successfully completed. Children in the propofol + ketamine group tend to be younger and have lower weight compared to the propofol only group. Adverse events including transient hypoxemia and hypotension occurred in 8% and 24% respectively. Median procedure time was 10 min while the median discharge time was 35 min. There were no differences in the indication of the procedure, propofol dose, procedure or recovery time in either sedative regimen. When compared to other age groups, infants had a higher incidence of hypoxemia.CONCLUSIONChildren can be effectively sedated for outpatient flexible bronchoscopy with high rate of success. This procedure should be performed under vigilance of highly trained providers.

Delirium and Catatonia in Critically Ill Patients: The Delirium and Catatonia Prospective Cohort Investigation.

Catatonia, a condition characterized by motor, behavioral, and emotional changes, can occur during critical illness and appear as clinically similar to delirium, yet its management differs from delirium. Traditional criteria for medical catatonia preclude its diagnosis in delirium. Our objective in this investigation was to understand the overlap and relationship between delirium and catatonia in ICU patients and determine diagnostic thresholds for catatonia. Convenience cohort, nested within two ongoing randomized trials. Single academic medical center in Nashville, TN. We enrolled 136 critically ill patients on mechanical ventilation and/or vasopressors, randomized to two usual care sedation regimens. Patients were assessed for delirium and catatonia by independent and masked personnel using Confusion Assessment Method for the ICU and the Bush Francis Catatonia Rating Scale mapped to Diagnostic Statistical Manual 5 criterion A for catatonia. Of 136 patients, 58 patients (43%) had only delirium, four (3%) had only catatonia, 42 (31%) had both, and 32 (24%) had neither. In a logistic regression model, more catatonia signs were associated with greater odds of having delirium. For example, patient assessments with greater than or equal to three Diagnostic Statistical Manual 5 symptoms (75th percentile) had, on average, 27.8 times the odds (interquartile range, 12.7-60.6) of having delirium compared with patient assessments with zero Diagnostic Statistical Manual 5 criteria (25th percentile) present (p < 0.001). A cut-off of greater than or equal to 4 Bush Francis Catatonia Screening Instrument items was both sensitive (91%; 95% CI, 82.9-95.3) and specific (91%; 95% CI, 87.6-92.9) for Diagnostic Statistical Manual 5 catatonia. Given that about one in three patients had both catatonia and delirium, these data prompt reconsideration of Diagnostic Statistical Manual 5 criteria for "Catatonic Disorder Due to Another Medical Condition" that preclude diagnosing catatonia in the presence of delirium.

Conscious Sedation During Bronchoscopy: How Far We’ve Come

Flexible bronchoscopy (FB) is a cornerstone of modern pulmonary medicine. However, considerable heterogeneity persists with respect to education, training, and the performance of sedation during FB. Sedation administered by a non-anesthesiologist during FB has been demonstrated to be safe and effective, although comorbidities and respiratory disease severity must be taken into account regarding choice of sedation and monitoring. There is undoubtedly room for improvement concerning basic education and training in this field. In addition, current study heterogeneity complicates comparisons between various sedation regimens which in turn limit state of the art recommendations. To reach a broad acceptance of non-anesthesiologist administered sedation, future studies and guidelines must increasingly focus on education and training. Research should be performed to establish a concept of harmonized patient selection for different sedation practices.

Pharmacokinetics of S-ketamine during prolonged sedation at the pediatric intensive care unit.

S-ketamine is the S(+)-enantiomer of the racemic mixture ketamine, an anesthetic drug providing both sedation and analgesia. In clinical practice, significant interpatient variability in drug effect of S-ketamine is observed during long-term sedation. The aim of this study was to evaluate the pharmacokinetic variability of S-ketamine in children aged 0-18years during long-term sedation. Twenty-five children (median age: 0.42years, range: 0.02-12.5) received continuous intravenous administrations of 0.3-3.6mg/kg/h S-ketamine for sedation during mechanical ventilation. Infusion rates were adjusted to the desired level of sedation and analgesia based on the COMFORT-B score and Visual Analog Scale. Blood samples were drawn once daily at random time-points, and at 1 and 4hours after discontinuation of S-ketamine infusion. Time profiles of plasma concentrations of S-ketamine and active metabolite S-norketamine were analyzed using nonlinear mixed-effects modeling software. Clearance and volume of distribution were allometrically scaled using the ¾ power model. A total of 86 blood samples were collected. A 2-compartment and 1-compartment model adequately described the PK of S-ketamine and S-norketamine, respectively. The typical parameter estimates for clearance and central and peripheral volumes of distribution were: CLS-KETAMINE =112L/h/70kg, V1S-KETAMINE =7.7L/70kg, V2S-KETAMINE =545L/70kg, QS-kETAMINE =196L/h/70kg, and CLS-NORKETAMINE =53L/h/70kg. Interpatient variability of CLS-KETAMINE and CLS-NORKETAMINE was considerable with values of 40% and 104%, respectively, leading to marked variability in steady-state plasma concentrations. Substantial interpatient variability in pharmacokinetics in children complicates the development of adequate dosage regimen for continuous sedation.

A Cost Comparison Between Propofol and Midazolam Use for Targeting Moderate Sedation During Curvilinear Endobronchial Ultrasound Bronchoscopy

SESSION TITLE: Rapid Session: Interventional Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 03:15 PM - 04:15 PM PURPOSE: Propofol is an effective option for providing moderate sedation during bronchoscopy. However, a cost assessment of its use with endobronchial ultrasound (EBUS)-guided bronchoscopy has not been performed. Our objective was to analyze differences in cost of performing curvilinear-array EBUS-guided sampling under moderate sedation, based on type of sedative delivery. METHODS: This was a retrospective analysis of prospectively collected data. We assessed three sedative delivery methods for all curvilinear EBUS bronchoscopies performed at our institution under moderate sedation over a two year period. Procedures involving radial probe (peripheral) EBUS were excluded. Procedural sedation was administered by a qualified nurse, under the direction of the bronchoscopist. The sedation regimens were propofol by continuous infusion only (PC, n=54), propofol by bolus induction followed by maintenance continuous infusion (PBC, n=44), and midazolam by bolus dosing (M, n=31). Supplemental fentanyl was given per the same protocol for all subjects. Procedure-related and sedation characteristics were assessed. A cost comparison was performed based on differences in labor, drug, and resource utilization between the groups. RESULTS: Patient and procedural characteristics were similar in all three groups, including the breadth of sampling achieved, the specific diagnostic yield, and complications observed. However, total sedation time (sum of induction, maintenance, and recovery) was significantly longer in the midazolam group than in either propofol group (M=80.4 minutes ±26.7 vs PC=67.5 ±22.6 and PBC=66.7 ±19.7; p=0.01). This was primarily driven by the recovery phase. The midazolam group exhibited more agitation-related procedure interruptions, and required more fentanyl (M=125.9 mcg ±54.4 vs PC=90.3 ±35.0 and PBC=99.7 ±39.0; p=0.002). Calculating relevant labor and drug utilization expenditures at our institution revealed that midazolam use resulted in an additional per-procedure cost of $7.42 compared to propofol given by continuous infusion (PC), and $8.02 more than propofol delivery using bolus induction followed by continuous maintenance infusion (PBC). Assessment of the most conservative estimate of mean sedation time differences between the midazolam and propofol groups still resulted in essentially equivalent costs. CONCLUSIONS: Using propofol rather than midazolam for targeting moderate sedation during EBUS bronchoscopy may lead to labor cost savings resulting from shorter sedation time. Our analysis did not demonstrate any differences in procedural characteristics, specific diagnostic yield, or adverse events between the sedative delivery methods. Therefore, we assume that any ‘downstream’ costs of required interventions, follow-up testing, and disease management would also be similar. CLINICAL IMPLICATIONS: Bronchoscopist-directed moderate sedation using propofol infusion for EBUS bronchoscopy may be a cost-efficient alternative to midazolam. DISCLOSURE: The following authors have nothing to disclose: Ara Chrissian, Destry Washburn, Avi Cohen No Product/Research Disclosure Information

Procedural Sedation With Ketamine Versus Propofol for Closed Reduction of Pediatric Both Bone Forearm Fractures.

Effective treatment of pediatric both bone forearm fractures consists of timely restoration of anatomic alignment with manipulation and immobilization, often accomplished with the aid of procedural sedation in the emergency department setting. The current lack of consensus regarding a safe and optimal regimen may result in inadequate sedation, compromised quality of reduction, or patient harm. The current study was conducted to answer the following questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation: (1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? (2) Is there a difference in the rates of major sedation-related complications? Medical records, data on procedural sedation, and radiographs of 74 skeletally immature patients with diaphyseal or distal metaphyseal both bone forearm fractures treated with manipulation were reviewed (ketamine sedation, 26; propofol sedation, 48). Rates of unacceptable alignment for the 2 cohorts were similar both immediately after reduction and at 4 weeks. Rates of complications of procedural sedation did not differ between cohorts. The duration of procedural sedation was longer and the padding index was greater with ketamine. Malalignment after reduction was more likely in older patients and those with a higher padding index. Although no difference was found in the rates of malalignment or sedation-related complications between fractures reduced with ketamine or propofol sedation, the sedation regimens differ in both procedural duration and padding index. Careful consideration of the risks and benefits of procedural sedation for closed reduction of pediatric forearm fractures is warranted. [Orthopedics. 2017; 40(5):288-294.].

A randomized double-blind controlled trial comparing three sedation regimens during flexible bronchoscopy: Dexmedetomidine, alfentanil and lidocaine.

No standardized sedation protocol is available for flexible bronchoscopy (FB). The aim of this study was to evaluate the efficacy and safety of three regimens used for sedation during FB. This randomized double-blind controlled trial assessed patients undergoing bronchoscopy and receiving lidocaine alone (C) or combined with dexmedetomidine (D) or alfentanil (A). Tolerance was assessed using the bronchoscopy score, and level of sedation was assessed using the Nursing Instrument for the Communication of Sedation. Safety was evaluated in terms of pulmonary function and vital signs. A total of 162 patients were enrolled. The bronchoscopy score was identical in all groups. Group D subjects were the most sedated (P=.013), whereas group A subjects were the least agitated. Linear regression showed a negative association between bronchoscopy score and age in A (β=-0.06; P=.001). Positive predictors of bronchoscopy score were female gender (β=1.96; P=.003) in D and obesity (β=2.41; P=.012), longer procedures (β=0.08; P=.009) and female gender (β=1.15; P=.038) in C. Longer procedures (β=-0.12; P=.010) was a negative predictor of bronchoscopy score in D. Desaturation, hypoxia and heart rate changes were most prevalent in group A. Hypotension was mostly observed in D. No consistent differences were present between the three regimens; however, each was more appropriate in certain patient profiles. We consequently proposed a protocol as a first step towards standardizing sedation practice in FB in a patient-tailored manner. A more comprehensive and detailed protocol including other sedative agents with their corresponding doses should be developed.

Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium.

Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. Children from birth to less than or equal to 21 years old. None. A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.

Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice. This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes. In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone. There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.