Sedation Research Articles

Nonconvulsive status epilepticus in patients under intensive care: Should we view epilepsy as a sleep disorder?

Nonconvulsive status epilepticus (NCSE) was initially described in patients with typical and atypical absence status epilepticus (ASE) characterized by states of confusion varying in severity and in focal epilepsies with or without alteration of consciousness. Continuous EEG monitoring of critically ill patients has further refined the classification of NCSE into two main categories: with coma and without coma. Hypnotic, soporific or somniferous epileptic seizures do not exist. On the contrary, patients usually awaken when seizures occur during sleep, and their eyes remain open during ASE. Excessive sleepiness and coma alone are not ictal signs but are observed in the postictal phase of convulsive seizures. On the other hand, excessive sleepiness evolving into coma is a cardinal sign of metabolic/toxic encephalopathies with triphasic waves evolving to burst suppression patterns and ultimately to cerebral inactivity and death. NCSE alone does not directly cause coma. Comas are related to the underlying etiology, patient age and comorbidities, as well as the administration of intravenous sedative drugs to control epileptic seizures. In cases of severe brain injury, NCSE can explain the failure to awaken after the withdrawal of anesthetics and is only an aggravating factor of the neurological condition. In typical ASE, which is characterized by sustained, rhythmic, bilateral, synchronous and unreactive discharges with evolving spatiotemporal patterns (the best example of NCSE), there is no vigilance impairment. This contrasts with metabolic/toxic encephalopathies, which exhibit monomorphic generalized periodic discharges in which patients may become comatose and die. The extended concept of NCSE in comatose patients may lead to an inflated assessment of NCSE, implying a potentially worse prognosis compared to convulsive status epilepticus.

Physical Restraint in a Pediatric Intensive Care Unit: A Cross-Sectional, Observational Study in China.

Research data on the extent of and protocols related to physical restraint (PR) in pediatric intensive care units (PICUs) are scarce. Most previous studies in China on this topic have focused on the prevalence, reasons, and background of PR use among adult patients. This study was designed to delineate the application of PR and the factors associated with PR use in PICUs in China. A cross-sectional study was conducted in one PICU at West China Hospital, Sichuan University, from January 2020 to December 2020. A total of 1,086 pediatric patients in the PICU were included in this study. Data collection was performed over 11 months, utilizing PR observation forms and patient records. Descriptive statistical analysis was used to obtain the data, and logistic regression models were used to analyze the independent risk factors for PR. Of the 1,086 participants, 750 (69.1%) experienced being restrained, and 83.5% of the restrained participants who were pediatric patients were restrained for more than 50% of their time during their PICU stay. The results of logistic regression analysis identified age (1-6 years: OR = 2.090, 95% CI [1.508, 2.897], p < .001; 7-17 years: OR = 0.523, 95% CI [0.358, 0.765], p = .001), use of mechanical ventilation (OR = 2.126, 95% CI [1.480, 3.055], p < .001), use of drainage tubes (OR = 1.916, 95% CI [1.445, 2.541], p < .001), and sedation (OR = 1.494, 95% CI [1.101, 2.026], p = .010) as significantly correlated with the use of PR in the PICU. For the 750 patients who experienced being restrained, PR initiation was documented with a written medical order, and in 604 cases (80.5%), the restraints were removed without similar documentation. The use of PR is common in PICUs in China, with more than half of pediatric patients being restrained during their stay. Age, mechanical ventilation, use of drainage tubes, and use of sedative drugs were identified as significantly associated with PR use. Developing standardized procedures/guidelines for PR use in Chinese PICUs and enhancing medical staff education on PR practices are imperative.

Perioperative changes in anxiety and comfort in third molar extraction patients sedated with midazolam.

This study aimed to analyze changes in anxiety and comfort levels at each perioperative stage during third molar extraction under single-agent intravenous midazolam sedation, and to clarify how these conditions at each perioperative stage affect postoperative satisfaction. 115 who requested extraction of 1 ~ 4 third molars under single-agent intravenous midazolam sedation were targeted. These patients were administered a questionnaire survey one week after surgery. The questionnaire's five items (Anxiety before surgery, Comfort during surgery, Comfort after surgery, Amnesia, and Satisfaction) were evaluated using a visual analog scale (VAS). We investigated the correlation between each of the eight parameters which added age, operation time, and total amount of midazolam, to the VAS score. Furthermore, we compared each eight parameters according to the number of extracted wisdom teeth and sex differences. Regarding the correlation among each parameter, low preoperative anxiety were weak and positively correlated with reduced operation time reduced midazolam dosage, and an increase in postoperative comfort. All parameters influenced the patient's satisfaction level. Those levels were significantly affected by preoperative reassurance (r = 0.4402, p < 0.01), postoperative comfort (r = 0.5522, p < 0.01) amnesia (r = 0.5741, p < 0.01), and intraoperative comfort (r = 0.7578, p < 0.01). Each parameter had no significant difference depending on the number of teeth extracted. In comparison between men and women, only preoperative reassurance was significantly lower in women than in men (p<0.05). This sedation effectively managed preoperative anxiety and improved postoperative satisfaction. To obtain good sedative condition, Preoperative anxiolytics are recommended. This sedation is considered particularly effective in women.

Effect of one dose of ceftriaxone during endotracheal intubation on the incidence of aspiration pneumonia in cerebral hemorrhage patients: A randomized, controlled, double-blind clinical study protocol.

Patients with cerebral hemorrhage often require a tracheal intubation to protect the airway and maintain oxygenation. Due to the use of analgesic and sedative drugs during endotracheal intubation and the opening of the glottis may easily cause aspiration pneumonia. Ceftriaxone is a semi-synthetic third-generation cephalosporin with strong antimicrobial activity against most gram-positive and gram-negative bacteria. It can effectively prevent and treat aspiration pneumonia. This is a prospective, randomized, controlled, double-blind clinical study. Patients with intracerebral hemorrhage (ICH) undergoing endotracheal intubation in Dong E Hospital of Shandong Province from April 2023 to April 2025 will be enrolled and randomly assigned to the intervention group or control group. The intervention group will be treated using 100mL 0.9% sodium chloride with 2g ceftriaxone intravenously over the course of one hour beginning within two hours after endotracheal intubation. The control group will be given 100mL 0.9% sodium chloride injection intravenously of the course of one hour beginning within two hours after endotracheal intubation. The primary outcome is the incidence of aspiration pneumonia within 48 hours after endotracheal intubation. Secondary outcomes include: intensity of antimicrobial use, length of hospital stay, duration without mechanical ventilation, and 28-day mortality. The primary objective of this study is to explore whether a single dose of ceftriaxone administered during endotracheal intubation in patients with ICH reduced the incidence of pneumonia within 48 hours and provide evidence for the prevention of aspiration pneumonia in patients with ICH with endotracheal intubation. The trial is registered at the Chinese Clinical Trial Registry: ChiCTR2200066837. Registered on December 19, 2022.

Assessment of factors influencing suicidal thoughts and attempts among population in Mosul.

Suicide is one of the leading causes of death worldwide especially in low- middle-income areas as Mosul City. It exposed to wars and various stressors for decades that directly affecting populations' stability, psych and daily life. we aim to explore suicidal thoughts and attempts rates and their influencing risk factors. A cross-sectional study was performed among 652 individuals in Mosul along ten months period since March 2023. The questionnaire was distributed among them by using convenient sampling technique. According to PHQ-9 and ASQ, the sample was divided into three groups: normal people (396), suicidal thoughts (166), and suicidal attempts (90). Chi-square, Fishers' exact, and independent t-tests were used for significant association between variables. One quarter (25.46%) of population had suicidal thoughts and 13.8% attempted suicide. Among the risk factors were female sex, low education, low social class, big family size, sedative drug use, introverted personality, poor family and personal relationships, bullying, severe depression, and chronic diseases (p-values 0.031 - <0.001). Suicidal thoughts and attempts were present in high levels in Mosul City compared with other regions in the world. This should be addressed carefully while implanting national preventive and social welfare services.

Comparison of midazolam and dexmedetomidine combined with thoracic paravertebral block in hemodynamics, inflammation and stress response, and cognitive function in elderly lung cancer patients.

This study aimed to compare the clinical outcomes of midazolam and dexmedetomidine combined with ropivacaine-induced thoracic paravertebral nerve block (TPVB) in radical lung cancer surgery. To retrospectively analyze the clinical data of elderly patients who underwent thoracoscopic radical lung cancer surgery from March 2020 to February 2023 in our hospital. All patients underwent a single two-site method of TPVB at the levels of T4 and T7 under ultrasound guidance. The patients were divided into midazolam group (0.25% ropivacaine+0.1mg/kg midazolam) and dexmedetomidine group (0.25% ropivacaine+0.8μg/kg dexmedetomidine) according to the application of sedative drugs, with 78 cases in each group. Ramsay sedation score, mean arterial pressure (MAP), heart rate (HR), electroencephalographic bispectral index (BIS), and blood oxygen saturation (SpO2), as well as the serum levels of C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), epinephrine (E), cortisol (Cor), and norepinephrine (NE) were recorded at 6, 12, 24, 36 and 48h postoperatively, respectively. The patients' cognitive function was assessed using the Brief Mental State Evaluation Scale (MMSE) at 1 d preoperatively, 1 d postoperatively, and 7 d postoperatively. The amount of intraoperative sufentanil in the dexmedetomidine group was lower than that in the midazolam group (P<0.05). The rate of atropine use was higher in the dexmedetomidine group than that in the midazolam group (P<0.05). There was no significant difference in the occurrence of overall intraoperative adverse reactions (P>0.05), but the incidence of respiratory depression in the dexmedetomidine group was significantly lower than that in the midazolam group, and the incidence of bradycardia in the dexmedetomidine group was significantly higher than that in the midazolam group (P<0.05). At T0∼T4, BIS and MAP showed a decreasing trend in both groups. 12, 24, 36 and 48h postoperatively, the Ramsay sedation score was higher in the dexmedetomidine group than in the midazolam group (P<0.05). At 36 and 48h postoperatively, the serum Cor, E, NE, CRP, TNF-α, and IL-6 levels were lower in the dexmedetomidine group than in the midazolam group (P < 0.05). Compared with the preoperative 1d, the MMSE scores were significantly lower in both groups on one day postoperative, while the MMSE scores were significantly higher at postoperative day 7 than on postoperative day 1 (P < 0.05). At postoperative day 1, the MMSE score was significantly higher in the dexmedetomidine group than in the midazolam group (P < 0.05). The difference in the incidence of adverse events within 72h postoperatively between the two groups was not statistically significant (3.95% vs. 1.28%, χ2=0.284, P = 0.594). Dexmedetomidine compounded with ropivacaine-induced ultrasound-guided thoracic paravertebral nerve block is superior to midazolam for sedation, anti-inflammation, and anti-stress in elderly lung cancer patients.

Safety and Satisfaction Analysis of Intravenous and Inhalational Conscious Sedation in a Geriatric Population Undergoing Oral Surgery

Safety and Satisfaction Analysis of Intravenous and Inhalational Conscious Sedation in a Geriatric Population Undergoing Oral Surgery

The Impact of Listening to Quran Recitation during Pain-Inducing Procedure among Patients Receiving Mechanical Ventilation Support: An Interventional Study

Background: Pain experienced by intubated patients is caused by several extrinsic sources, including nursing care procedures such as endotracheal suctioning. Several nonpharmacological therapies, including listening to Quran recitation, have never been tested for their pain relief effects among intubated patients, despite these therapies being cost-effective, easy to implement, and free of adverse effects. This study aimed to examine the pain-relieving effect of listening to Quran recitation during pain-inducing procedures in patients receiving mechanical ventilation support. Materials and Methods: This pilot study used an experimental design with 32 intubated patients at King Abdullah University Hospital in Irbid, Jordan. The Behavioral Pain Scale and Ramsay Sedation Scale were used to assess pain levels and sedation, and physiologic parameters were monitored before and during endotracheal suctioning. Results: The findings showed significant differences in Behavioral Pain Scale (BPS) scores and heart rate measures between the intervention and control groups after controlling for the level of sedation. The patients in the intervention group scored lower pain and HR measures than those in the control group (F5,26 = 11.47, p &lt; 0.001). Conclusions: The findings showed significant improvement in the levels of pain and heart rate measures among intubated patients who are exposed to Quran recitation. Complementary medicine is essential to the healthcare plans of critically ill patients and their families. Holy Quran recitation has been reported to be a useful nonpharmacological intervention for critically ill Muslim patients.

Comparative risks and clinical outcomes of midazolam versus other intravenous sedatives in critically ill mechanically ventilated patients: A systematic review and meta-analysis of randomized trials

Comparative risks and clinical outcomes of midazolam versus other intravenous sedatives in critically ill mechanically ventilated patients: A systematic review and meta-analysis of randomized trials

Depression of cortical neuronal activity after a low-dose fentanyl in preterm infants.

Opioids might be harmful to the developing brain and dosing accuracy is important. We aimed at investigating fentanyl effects on cortical activity in infants using computational re-analysis of bedside recorded EEG signals. Fifteen infants born at median 26.4 gestational weeks (range 23.3-34.1), with a birth weight 740 grams (530-1420) and postnatal age 7 days (5-11) received fentanyl 0.5 or 2 μg/kg intravenously before a skin-breaking procedure or tracheal intubation, respectively. Cortical activity was continuously recorded using amplitude-integrated electroencephalography (aEEG). Analyses using three computational EEG features representing cortical synchrony and signal power, were conducted five minutes pre- and 10 minutes post the drug administration. Visual assessment of trends displayed from the EEG metrics did not indicate systematic changes. However, the magnitude of the changes in the parietal and right hemisphere signals after the dose was significantly correlated (ρ < -0.5, p < 0.05) to the EEG amplitude and frequency power level before drug administration. This effect started after 3-4 min. Fentanyl, even in small doses, may affect cortical activity in the preterm brain. The effect is robustly related to the state of cortical activity prior to drug treatment, which must be taken into account when analysing the effects of sedative drugs.

Intravenous sedation for adults with profound acquired brain injury undergoing dental treatment - a seven-year service evaluation

Abstract Background Dental treatment may not be possible for patients with a profound acquired brain injury without pharmacological support. Intravenous (IV) sedation with midazolam is a widely accepted, safe, and effective mode of treatment for people with a disability, but there is limited evidence in this patient cohort. Aims This evaluation aimed to review the IV sedation service for patients with profound acquired brain injury within the dental department at the Royal Hospital for Neuro-disability. Method This study was a retrospective service evaluation of IV sedation for dental treatment over seven years. Descriptive statistics are presented. Results In total, 303 episodes of sedation were undertaken at the Royal Hospital of Neurodisability over seven years. Ninety-two percent were graded with an American Society of Anaesthesiologists (ASA) grade 3, and one-third had a history of stroke. 91% had treatment completed successfully. Complications occurred in 7.9% of cases, but all were minor, with no resulting patient harm (e.g. a transient drop in oxygen saturation). Conclusion Dentist-led IV sedation with midazolam is safe and effective for dental treatment for patients with a profound acquired brain injury in a specialised setting with experienced clinicians.

Intravenous Sedation in a Patient With Sotos Syndrome and Intellectual Disability: A Case Report

Intravenous Sedation in a Patient With Sotos Syndrome and Intellectual Disability: A Case Report

Effects of a Very Low Dose Naloxone Addition to Intraoperative Remifentanil Infusion on Postoperative Pain in Patients Undergoing Total Hip Replacement Surgery: A Randomized Clinical Trial

Background: The objective of this study was to assess the effect of adding a very low dose of naloxone to a remifentanil infusion on postoperative pain in patients undergoing hip replacement surgery in the lateral position. Methods: This randomized clinical trial involved 80 patients who underwent hip replacement surgery under general anesthesia and were randomly assigned into two groups through block randomization: group 1 received remifentanil at a dose of 0.3 μg/kg/minute, while group 2 received remifentanil at a dose of 0.3 μg/kg/minute with a very low dose of naloxone administered at 0.05 μg/kg/hour following injection. Postoperative pain [measured using the visual analog scale (VAS)], drowsiness caused by narcotics and analgesics in recovery, and the duration of getting out of bed were all monitored and recorded in the ward. Results: The median [interquartile range (IQR)] of time to administration of the first sedative drug was 0 (0, 4) hours in the control group and 4 (0, 4) hours in the intervention group. The difference between the groups was statistically significant (P &lt; 0.0001). The frequency of pain after surgery at 0, 4, and 8 hours was significantly different between the control and intervention groups (P = 0.003, P &lt; 0.0001, and P = 0.021, respectively). Conclusion: Based on the results, we recommend using a very low dose of naloxone along with remifentanil infusion in patients undergoing complete hip replacement surgery to reduce their pain and the need for painkillers

Efficacy of oral modafinil on accelerating consciousness recovery in adult patients with moderate to severe acute traumatic brain injury admitted to intensive care unit: a randomized double-blind clinical trial.

Traumatic Brain Injury (TBI) is a leading cause of hospitalization and disability in young and middle-aged adults. This study aims to survey the efficacy of oral modafinil, a low-side-effect central nervous system stimulant, in the enhancement of consciousness recovery in moderate to severe TBI patients in the ICUs of a referral trauma center. All ICU patients meeting inclusion criteria between April 2021 and April 2023 were screened. Eligible patients had a motor Glasgow Coma Score(GCS) of 4 or 5 and did not receive continuous intravenous sedatives within 24 h before screening. They were randomly assigned to receive 200mg of enteral modafinil or placebo daily for 7 days. Motor GCS and total GCS scores, ICU/hospital stay duration, mechanical ventilation requirement, tracheal tube removal time, and tracheostomy needs were recorded. Among the included 85 eligible patients, there was no significant difference between the modafinil and placebo groups in the median days between the intervention and the time of a 2-unit increase in total GCS (P = 0.25) or a 1-unit increase in motor GCS (P-value = 0.31). The group assignment also had no impact on the mean GCS (P-value = 0.533) and mean motor GCS (P-value = 0.167) over time. The only significant difference was in the proportion of patients with an increase in total GCS by 2 units, which was 54% for the modafinil vs. 32% for the placebo group (P-value = 0.04), and an increase in motor GCS by 1 unit, with 56% in the modafinil vs. 34% in the placebo group (P-value = 0.04). The administration of modafinil appears to be safe and beneficial for patients with severe TBI during their stay in the ICU.

Effects of Sedation Medications on Postoperative Delirium and Cognitive Dysfunction in Cardiac Surgery Patients with Cardiopulmonary Bypass: A Network Meta-Analysis

Background: Neuropsychological deficits, such as delirium and cognitive dysfunction, are common consequences of cardiac surgery. The effectiveness of sedative drugs remains controversial. The purpose of this study was to collect and summarize the current evidence on the application of sedatives in randomized trials to prevent delirium and cognitive dysfunction in adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods: We searched for relevant studies in the databases from inception to September 1, 2024. Randomized controlled trials (RCTs) investigating the effects of sedatives and comparators on postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) in adults undergoing cardiac surgery with CPB were included in this research. Frequentist network meta-analysis (NMA) was utilized for comparing various interventions. Results: Forty-five RCTs were included in the analysis. For POD, there were statistically significant differences between the dexmedetomidine group and the control group (odds ratio [OR]: 0.70; 95% CI: 0.50, 0.98; p = 0.038), which was mainly dependent on the effect of the postoperative application. Ketamine (92%) and esketamine (91%) also showed higher surface under the cumulative ranking curve (SUCRA) ranks, and trial sequential analysis also indicated their potential effectiveness. For the Mini-Mental State Examination (MMSE) outcome, the results indicated that dexmedetomidine (standardized mean difference [SMD]: 3.14; 95% CI: 1.12, 5.16; p = 0.002) and remifentanil (SMD: 4.24; 95% CI: 0.28, 8.20; p = 0.036) resulted in significantly higher MMSE scores than the control group. Conclusions: Postoperative dexmedetomidine significantly outperformed the control in terms of POD risk and MMSE score. Esketamine/ketamine also demonstrated potential efficacy in preventing POD. Further research is required to validate these findings.

In vivo changes in zebrafish anesthetic sensitivity in response to the loss of kif5Aa are associated with the alteration of mitochondrial motility.

Anesthetic and sedative drugs are small compounds known to bind to hundreds of proteins. One intriguing binding partner of propofol is the kinesin motor domain, kif5A, a neuronal mitochondrial transport protein. Here, we used zebrafish WT and kif5Aa KO larval behavioral assays to assess anesthetic sensitivity and combined that with zebrafish primary neuronal cell culture to probe for alteration in mitochondrial motility. We found that the loss of kif5Aa increases behavioral sensitivity to propofol and etomidate, with etomidate hypersensitivity greater than propofol. In contrast, kif5Aa KO animals were resistant to the behavioral effects of dexmedetomidine. Finally, WT and kif5Aa KO larvae responded similarly to the behavioral effects of ketamine. Propofol inhibited the anterograde motility of mitochondria in WT zebrafish neurons, while etomidate inhibited mitochondrial motility in both anterograde and retrograde directions; neither drug altered mitochondrial motility in the kif5Aa knockout (KO) neurons. In contrast, dexmedetomidine enhanced retrograde mitochondrial motility in both WT and kif5Aa KO animals. Finally, ketamine had little significant effect on mitochondrial motility in either mutant or WT animals. These data demonstrate that each anesthetic/sedative drug affects the motor protein machinery uniquely and is associated with unique changes in behavior. Understanding how different anesthetic compounds alter neuron motor proteins will be important in defining how anesthetics alter neuronal signaling and energetic dynamics.

Investigation of Abdominoplasty Without General Anesthesia: A Scoping Review

Introduction: Abdominoplasty is a common aesthetic surgical procedure primarily performed under general anesthesia (GA). However, GA is aerosol-generating and involves extended immobilization associated with systemic complications like venous thromboembolisms (VTEs). There is increasing interest in performing abdominoplasties without GA because of potential lower complication rates and shorter postoperative recovery time. This review sought to summarize all available literature on the safety and outcomes of abdominoplasty performed without GA. Methods: A scoping review was conducted with no date limits in October 2023 encompassing Medline, Embase, Web of Science, and CINAHL. The type of anesthesia was separated into 3 categories: conscious or intravenous (IV) sedation, regional anesthetic blocks (RAB: spinal and epidural), and local anesthesia (direct local infiltration and field blocks). Results: A total of 28 studies were included. Safety data was reported for abdominoplasty alone ( n = 6), with liposuction ( n = 14), or both ( n = 1). The employed anesthesia methods were IV and local ( n = 13), RAB and local ( n = 3), IV and RAB ( n = 2), IV and RAB and local ( n = 2), and IV only ( n = 1). A total of 48 379 patients were identified, with 30 cases of VTEs reported. Two studies reported GA conversion rates between 4.8% and 6.0%. A total of 11 studies assessed abdominoplasty outcomes, highlighting high patient satisfaction and low postoperative pain. The majority of analyzed studies had a “high” or “critical” risk of bias. Conclusion: Our review provides preliminary evidence that performing abdominoplasty without GA is safe and feasible. Additional high-quality studies are necessary to further validate our findings and to develop a standardized approach.

Comparison of caudal bupivacaine and dexmedetomidine with caudal bupivacaine and intravenous dexmedetomidine for postoperative analgesia in children: A randomized controlled trial

Abstract Background and Aims: Caudal block is a part of multimodal analgesic regimen to alleviate pain in pediatric patients undergoing variety of surgeries. This study compares the effectiveness of caudal versus intravenous dexmedetomidine as an additive to caudal bupivacaine for prolonging analgesia in children posted for elective lower abdominal surgeries. The level of sedation and hemodynamic effects through both routes were also compared. Material and Methods: Ninety-six children (aged 1–8 years) of either gender scheduled for elective lower abdominal and pelvic surgeries were prospectively enrolled and randomized into two groups of 48 each: Group A (caudal bupivacaine + caudal dexmedetomidine) and Group B (caudal bupivacaine + intravenous dexmedetomidine). The postoperative pain was monitored using the Face, Legs, Activity, Cry, Consolability (FLACC) scale, and sedation was assessed using the Ramsay sedation scale (RSS). Results: The degree of analgesia was comparable in both groups in the initial hours after surgery. Significantly higher FLACC scores were seen in Group B at 8 h (P- 0.016), 12 h (P &lt; 0.001), and 16 h (P &lt; 0.001), with 89.58% patients needing two rescue analgesic doses. RSS was higher in Gr=oup A till 12 h postsurgery. Conclusion: Caudal dexmedetomidine with bupivacaine provides improved analgesia after 8 h of surgery in comparison to caudal bupivacaine with intravenous dexmedetomidine in children undergoing lower abdominal surgeries.

Intranasal Analgesia in Preterm and Term Neonates.

The prevention, recognition, and treatment of pain is crucial in the management of neonates. Infants do not tolerate pain better than adults; indeed, the immaturity of the endogenous antalgic system means they exhibit an increased stress response. Pain has been associated with worse cognitive and motor scores, reduced growth trend, reduced brain maturation, and altered corticospinal tract structure. The use of the intranasal route for drug delivery is currently expanding because it has many advantages. In certain contexts, it is preferable over the oral route because of the faster entry of drugs into the circulation, the absence of structural changes by the gastrointestinal environment, and the absence of the hepatic first-pass effect. The pharmacokinetics and pharmacodynamics of drugs commonly used for pain management have peculiar characteristics in infants, especially premature infants. In this article, we summarise the evidence regarding pain management in infants using intranasally administered drugs. We then provide a practical guide to the use of intranasal drugs currently being studied in the neonatal population, focusing on appropriate dosages and indications. Intranasal fentanest appears to be an attractive therapeutic alternative for procedural and palliative neonatal pain management when intravenous access is unavailable in preterm infants. Intranasal midazolam is a valid alternative to consider in term or near-term neonates, especially when the aim is to obtain sedation (and not analgesia, i.e. during magnetic resonance imaging), ketamine has favourable cardiovascular effects and should be considered in specific patients and situations. Intranasal dexmedetomidine is well tolerated in premature neonates. Additionally, endonasal dexmedetomidine can be used in combination with other anaesthetic, sedative, hypnotic, and opioid drugs to allow for dose reduction in sedated neonates.

Clinical Experience and Video Description of Minimally Invasive Surgery for Benign Prostatic Obstruction using the Schelin Catheter®.

Although designed for in-office use, water vapor thermal therapy (RezumTM) remains a painful procedure, and oral ± intravenous sedation is often required. Schelin Catheter® (ProstaLund AB, Lund, Sweden) is an innovative bladder catheter that delivers local anesthesia to the prostate in a sterile transurethral way. We aimed to evaluate the safety and feasibility of RezumTM for male lower urinary tract symptoms due to benign prostatic obstruction (LUTS/BPO) with local anesthesia delivered with Schelin® catheter, and to report its first step-by-step video description. A total of 15 patients were enrolled, and 14 analyzed. Median pain numeric rating scale at catheter insertion, anesthetic injection, RezumTM insertion, RezumTM treatment, and at 2-h post-operatively were 3(2-5), 3(2-5), 1(0-3), 3.5(2-6), and 0(0), respectively. In 1 patient local anesthesia protocol failed and intravenous sedation was used. All RezumTM therapies were performed successfully. Local anesthesia with Schelin® catheter opens up new possibilities for ultra-minimally invasive surgery for LUTS/BPO.