Sedative Agents Research Articles

Can intravenous lidocaine definitely attenuate propofol requirement and improve outcomes among colonoscopic patients under intravenous sedation?: A double-blinded, randomized controlled trial.

Background:Propofol-sparing effect of lidocaine has not been fully elucidated because propofol is usually mixed with many medications in anesthetic practice. Therefore, the study aimed to verify the additive effect of intravenous lidocaine to propofol without other sedative medications and control the depth of anesthesia using the bispectral index (BIS) during colonoscopy in a prospective, randomized, double-blinded controlled trial.Methods:Sixty-eight patients scheduled and undergoing colonoscopy were randomly allocated to receive intravenous lidocaine (1.5 mg/kg then 4 mg/kg/h) (Group L) or a similar volume of normal saline (Group C) with propofol administration guided by BIS monitoring. The primary outcome was total propofol requirements between group comparisons. The secondary outcomes included the number of hypoxemic periods, hemodynamic changes, duration in returning of BIS > 85, sedation scores, pain scores, postoperative opioid requirement, and patient satisfaction between group comparisons.Results:Intravenous lidocaine showed significantly reduced total propofol use (151.76 ± 50.78 mg vs 242.06 ± 50.86 mg, Group L vs Group C, respectively, P < .001). Duration in returning to BIS > 85, sedation scores, and patient satisfaction scores were significantly superior in Group L (P < .05). The number of hypoxemic episodes, changes of hemodynamic response, pain scores, and postoperative opioid requirement were similar in both groups. No adverse effects were detected in both groups.Conclusion:Intravenous lidocaine produced a definitely effective reduced propofol requirement without other sedative agents and improved outcomes including patient satisfaction, duration in returning to BIS > 85, and sedation score during colonoscopy without adverse effects.

Comparison of Bolus Dosing of Methohexital and Propofol in Elective DirectCurrent Cardioversion.

Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.

Postoperative cognitive dysfunction: time for enhanced recovery after surgery programmes.

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are frequent complications in elderly patients undergoing cardiac and noncardiac surgery.1 They have been associated with delayed recovery, decreased quality of life, persistent neurocognitive disorders and increased morbidity and mortality within the first year of surgery. The concern that anaesthetic and sedative agents may be implicated in the pathogenesis of POD has prompted multiple studies. Regional anaesthesia, avoiding the use of sedative–hypnotic anaesthetics, rather than general anaesthesia, has thus long been held up as one strategy to prevent postoperative cognitive dysfunction. However, two recent large, randomised studies (the REGAIN and RAGA trials) comparing regional and general anaesthesia in elderly patients undergoing hip fracture surgery reported no significant difference between groups in the percentage of patients with POCD.2,3 In their accompanying editorial, Avidan et al.4 concluded that surgery with general anaesthesia was not implicated in persistent neurocognitive disorders at a population level. Even so, there might still be individuals or patient subgroups with specific vulnerabilities to POD5 including some older surgical patients with mild cognitive impairment (MCI), characterised by subclinical or unnoticed cognitive decline often missed by most of the tests, and where POD and early POCD can reflect a cognitive trajectory towards a clinically apparent cognitive decline.5 Important risk factors for postoperative neurocognitive disorders include pre-operative general and cognitive health, and medical comorbidities.5 Prevention of POD and POCD should, therefore, focus on improvement of pre-operative fitness, optimisation of pre-operative comorbidities and mitigating physiological and biochemical disturbances secondary to surgical stress and inflammatory reactions to avert organ dysfunction and peri-operative stroke.5 Measures to reach these goals should be part of good clinical practice in all patients but they have only been scantily tested specifically to prevent POCD. Neuroinflammation secondary to surgery is also considered a major contributor to the development of POCD,6 and ageing, atherosclerosis and neurodegenerative diseases may lead to an increased systemic and cerebral inflammatory response to surgery. Also, postoperative complications, such as infection, pulmonary complications and hypoxaemia may aggravate the postoperative inflammatory reaction. Several drugs with anti-inflammatory properties (steroids, NSAIDs, intravenous lidocaine, ketamine and dexmedetomidine) have been used to mitigate postoperative systemic inflammation and subsequent neuro-inflammation but without definitive conclusions.1,6 Enhanced recovery after surgery (ERAS) programmes, as those recommended by the ERAS Society (www.erassociety.org) and GRACE (www.grace-asso.fr), form a multidisciplinary, multimodal approach designed to control surgical stress response including inflammatory reaction in order to hasten postoperative recovery and decrease postoperative complications.7,8 Their efficiency has been widely demonstrated in all surgical specialties. Interestingly, several studies using ERAS programmes for colorectal surgery 9,10 and orthopaedic surgery 11,12 reported a significant reduction in the incidence of POD and POCD. These observations are unsurprising as these programmes combine several measures recommended by the European Society of Anaesthesiology and Intensive Care to prevent POD in elderly patients13 by shortening pre-operative fasting, avoidance of premedication, multimodal opioid-sparing analgesia, avoidance of unnecessary indwelling catheters, early mobilisation, early nutrition and discharge to home environment. All these measures are likely to facilitate return to normal circadian rhythm, hasten the recovery of patients’ usual behaviour in hospital and after discharge and improve patient orientation.13 Recommending ERAS programmes to prevent POD, therefore, appears justified especially as elderly patients, at a higher risk of POD and POCD, benefit much from these programmes.14 Likewise, the POSE-study highlights the importance of a comprehensive peri-interventional and patient-centred management for older patients.15 Disappointingly, the literature abounds with examples of large RCTs with short-term interventions for POD/POCD but without information or incorporation of enhanced recovery programmes.1,2,16,17 In summary, future studies on the prevention of POD should, therefore, focus less on hypothetical short-term interventions unless fully implemented ERAS programmes have been instituted, based on the pathophysiological background 7,8 and positive preliminary observations.9–12

COMPARISION OF INTRAVENOUS MIDAZOLAM/ KETAMINE WITH DEXMEDETOMIDINE-PROPOFOL COMBINATION FOR SEDOANALGESIA IN ENDOSCOPIC RETROGRADE CHOLANGIO PANCREATOGRAPHY( ERCP) PROCEDURES IN TERTIARY CARE HOSPITAL

Background:Endoscopic retrograde cholangiopancreatography (ERCP), often require sedation during the procedure. The most commonly used drugs for this purpose are midazolam and propofol, which are used as sedative and hypnotic agents with minimal analgesic potential. Aims &amp; objectives:Effects of Sedoanalgesia with Midazolam/ ketamine long with Dexmedetomidine nfusion &amp; Rescue propofol alliquotes regimes on hemodynamic and respiratory variables&amp; recovery profile in patients undergoing ERCP. Methods:In this Retrospective observational study adult patients of ASA grade l- lll were enrolled after taking inform consent from patient &amp; their relatives. Premedication was given in form of inj.Midazolam 0.02 mg/kg iv in Group l,.inj ketamine 0.5 mg/kg iv was given in group ll. Inj.Dexmedetomidine ( bolus dose of 1 μg/kg over 10 min) followed by 0.5μg/kg/hour as maintenance in both the groups.intermittent Intravenous Propofol alliquotes was used for maintain BIS 70-80 in both groups. Amount of propofol used during procedure was notified.. Hemodynamic and respiratory variables, recovery time and adverse events were monitored &amp; recorded. Results:The hemodynamic and respiratory variables were similar in both groups. Total propofol consumption was significantly lower in the group ll. (205+/-80 mg vs.155+/-20 mg p &lt; 0.001). The recovery period was shorter in group ll (time to achieve the Aldrete score 9 was 9.0 ±2.2 vs. , 6.2+/-1.1min p &lt; 0.001).Adverse events were comparable between the two groups. Conclusion:Ketamine-Dexmedetomidine combination with propofol may be a safe and useful alternative for sedation for ERCP patients.

Comparative Analysis of Sedative Efficacy of Dexmedetomidine and Midazolam in Pediatric Dental Practice: A Systematic Review and Meta-Analysis.

Children are particularly terrified of having dental treatment. They are physically resistant, frail, and unwilling to cooperate. This severe distress during the pre-operative phase could cause the dentist to have issues with behavior control. Additionally, it may make pediatric dental treatments less effective. In order to reduce anxiety and control behavior in children receiving dental care, sedation is a pharmacological management technique that supports the provision of effective and high-quality dental services. The aim is to compare and evaluate the efficacy of sedative agents like dexmedetomidine and midazolam in pediatric dental practice. A thorough review of the literature was conducted using electronic databases like “MEDLINE, PubMed, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as the World Health Organization International Clinical Trials Registry Platform, www.clinicaltrials.gov, conference proceedings abstracts, a bibliography of pertinent references, and manual searches of journals, conferences, and books”. There were no restrictions on the language or the date of publication when searching the electronic databases.Randomized controlled trials were included which compared dexmedetomidine and midazolam in children up to 16 years of age subjected to dental treatment. Information on procedures, participants, interventions, outcome measures, and results were independently extracted by three review writers (TS, SL, and RO). Trial authors were contacted for papers that were confusing or lacking information. The risk of bias was evaluated for each study. We adhered to the Cochrane statistical recommendations. Three trials totaling 229 participants were included. All three studies were rated as having a low risk of bias, with none of them having a high or unclear risk. Meta-analysis was done for the available data for the primary outcomes like sedation level and recovery time. We searched for randomized controlled trials up to Jan 31, 2020. Participants are randomly assigned to an intervention or control group in randomized controlled trial research. While patients in the control group often get a placebo therapy or procedure, those in the interventional group receive the treatment being studied.We found three studies eligible to include in the review. One study evaluated 73 individuals who received general anesthesia for dental treatment. There were 72 and 84 individuals in the second and third investigations, respectively. All the participants of the three studies were divided randomly into two groups and were subjected to dexmedetomidine and midazolam as sedative agents. We gave the evidence an "extremely low certainty" rating. Because there are just three short trials with unusual parameters for comparison, the results are questionable. Overall, the results do not allow us to draw any firm conclusions. Three randomized controlled trials included in this systematic review reported data with varying conclusions; hence we recommend more randomized controlled trials to be conducted on this subject matter.

Dexmedetomidine for sedation during hematopoietic stem cell harvest apheresis and leukapheresis in the PICU: Guideline development

BackgroundHematopoietic stem cell (HSC) harvest apheresis and leukapheresis are performed in the pediatric intensive care unit (PICU) for high-risk pediatric patients who require procedural sedation. Patients need central access either with their own central lines, ports or require apheresis catheter (CVL) placement. Previously, patients were either awake or emerging from sedation on PICU admission. Uncertainty regarding procedural sedation plans caused delays initiating sedation and apheresis. A guideline was developed to standardize Dexmedetomidine (DEX) for procedural sedation. We investigated if guideline implementation would improve efficiency during PICU admission as demonstrated by shorter time intervals for initiation of sedation, apheresis, PICU length of stay and less alternative sedating medication. MethodsData was collected retrospectively from electronic health records of preguideline and post-guideline patients who were admitted to the PICU for sedated apheresis. We compared demographic and clinical characteristics, time intervals for sedation, apheresis, PICU length of stay, and sedation agents between the two groups using Fisher Exact tests and Mann-Whitney tests, as appropriate. ResultsThe groups did not differ in age or weight at the time of apheresis. All intervals of time compared were shorter post-guideline. Time intervals from admission to start of sedation, admission to start of apheresis, and admission to end of apheresis were statistically significantly different. The type and number of alternative sedating medications administered did not differ between the two groups. ConclusionThis guideline implementation improved efficiency during PICU admission. This study might have been too small to demonstrate statistically significant differences in other time intervals studied.

Unilateral erector spinae plane block for procedural sedation- A case report

MRI of the spine requires the patient to stay still in lying down position. With patient on severe excruciating pain, lying down supine is not always feasible during MRI and any intervention with least possible adverse effect on the patient is preferred. Sedation in MRI suite requires MRI compatible monitors which is not readily available in all centers. The erector spinae plane block provides analgesia via its action on the ventral rami of spinal nerves. ESP block is a safe and easy procedure and it aids to overcome the side effects of administering intravenous agents for procedural sedation.

Optimal bispectral index level of sedation and cerebral oximetry in traumatic brain injury: a non-invasive individualized approach in critical care?

BackgroundImpaired cerebral autoregulation has been linked with worse outcomes, with literature suggesting that current therapy guidelines fail to significantly impact cerebrovascular reactivity. The cerebral oximetry index (COx_a) is a surrogate measure of cerebrovascular reactivity which can in theory be obtained non-invasively using regional brain tissue oxygen saturation and arterial blood pressure. The goal of this study was to assess the relationship between objectively measured depth of sedation through BIS and autoregulatory capacity measured through COx_a.MethodsIn a prospectively maintained observational study, we collected continuous regional brain tissue oxygen saturation, intracranial pressure, arterial blood pressure and BIS in traumatic brain injury patients. COx_a was obtained using the Pearson’s correlation between regional brain tissue oxygen saturation and arterial blood pressure and ranges from − 1 to 1 with higher values indicating impairment of cerebrovascular reactivity. Using BIS values and COx_a, a curve-fitting method was applied to determine the minimum value for the COx_a. The associated BIS value with the minimum COx_a is called BISopt. This BISopt was both visually and algorithmically determined, which were compared and assessed over the whole dataset.ResultsOf the 42 patients, we observed that most had a parabolic relationship between BIS and COx_a. This suggests a potential “optimal” depth of sedation where COx_a is the most intact. Furthermore, when comparing the BISopt algorithm with visual inspection of BISopt, we obtained similar results. Finally, BISopt % yield (determined algorithmically) appeared to be independent from any individual sedative or vasopressor agent, and there was agreement between BISopt found with COx_a and the pressure reactivity index (another surrogate for cerebrovascular reactivity).ConclusionsThis study suggests that COx_a is capable of detecting disruption in cerebrovascular reactivity which occurs with over-/under-sedation, utilizing a non-invasive measure of determination and assessment. This technique may carry implications for tailoring sedation in patients, focusing on individualized neuroprotection.

Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium.

Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists. Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI. Retrospective analysis of prospectively collected data. The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017. Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined. Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method. A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time. Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time. 4 TECHNICAL EFFICACY: Stage 5.

Intranasal Dexmedetomidine as Sedative for Non-Invasive Pediatric Diagnostic Procedures Outside Operating Room

Background: Children often require sedation for long non-invasive diagnostic procedures. Dexmedetomidine is a highly selective alpha 2-adrenoceptor agonist with sedative, anxiolytic and analgesic properties. It mimics natural sleep and allows patients to easily arouse with minimal effects on respiration and airway patency. Objective: To assess the successful completion of pediatric non-invasive diagnostic procedures with intranasal dexmedetomidine as a sedative agent. Methods: Seventy-nine subjects of age six months to twelve years scheduled for non-invasive diagnostic procedures were included. Dexmedetomidine (4 mcg/kg) was administered intranasally 25 minutes before the scheduled time of procedure. A sedation score of two or above as per the MICHIGAN sedation scale was considered satisfactory for starting the procedure. Results: Seventy-four (95%) out of the seventy-nine subjects were successfully sedated with Intranasal dexmedetomidine (p

The 50% and 95% effective doses of remimazolam tosilate with adjuvant sufentanil for sedation in patients with liver cirrhosis undergoing oesophagogastric varices screening endoscopy.

Sedation is routinely provided for patients undergoing gastrointestinal endoscopy. Remimazolam tosilate is a novel and short-acting sedative agent that has been used for sedation during endoscopic procedures. The optimal dose of remimazolam in gastrointestinal endoscopy for patients with liver cirrhosis has not been elucidated. To determine the effective dose of remimazolam tosilate with adjuvant sufentanil for sedation in patients with liver cirrhosis undergoing oesophagogastric varices screening endoscopy. Patients aged 18-65 years with liver cirrhosis undergoing screening endoscopy for oesophagogastric varices were recruited. Sufentanil 0.15 μg/kg was given intravenously at 2min before administration of remimazolam tosilate. The initial dose of remimazolam was 0.1mg/kg and adjusted by 0.025 mg/kg as a step size, based on the Dixon and Massay up-and-down sequential method. Inclusion of patients was stopped after eight crossovers and the calculated median effective dose (ED50 ) of remimazolam for successful endoscopy was obtained by calculating the mean of midpoint of all crossovers. Furthermore, a probit regression was applied to establish the dose-response curve of remimazolam and further assess the 95% effective dose (ED95 ) of remimazolam. The calculated ED50 of remimazolam for successful endoscopy using the mean of midpoint of all crossovers was 0.097 mg/kg (95% CI, 0.004-0.099 mg/kg). Using the probit regression analysis, the ED50 and ED95 of remimazolam for successful endoscopy was 0.097 mg/kg (95% CI, 0.004-0.099 mg/kg) and 0.107 mg/kg (95% CI, 0.103-0.336 mg/kg), respectively. No adverse events were observed throughout the study period. This pilot study suggests that the ED50 and ED95 of remimazolam tosilate with adjuvant sufentanil for sedation in liver cirrhosis patients undergoing oesophagogastric varices screening endoscopy was 0.097 and 0.107 mg/kg, respectively.

Dexmedetomidine versus ketamine infusion to alleviate propofol injection pain

Introduction: Propofol a widely used anesthetic agent administered for induction and maintenance of anesthesia, post operative and ICU sedation and anticonvulsant agent. Pain on injection is a common complain during propofol administration. Many drugs like local anesthetic, opiates, esmolol, clonidine, ketamine have been tried to alleviate propofol injection pain. Here we have compared the effect of dexmedetomidine and ketamine in alleviating propofol injection pain. Materials and methods: 108 patients of either sexes, in the age groups 20-50 years, posted for routine surgical procedure under general anaesthesia were included in the study. The cases were randomly divided into 2 groups of 54 each. Group-D:-Patients received dexmedetomidine 0.5µg/kg in 20 ml Normal saline at a rate of 120 ml / hr Infused over 10 min. Group-K:- Patient received ketamine 0.5mg/kg in 20ml Normal saline at a rate of 120ml/hr infused over 10 mins. Immediately after infusion, 1% propofol in a dose of 2mg/kg IV was given over 20 seconds. Starting from the time of injection, the patients were assessed for pain by asking an open ended question, “Does it Hurts” in every 5 seconds until the patient become unresponsive. Degree of pain score was advocated by “McCririck and Hunter Scale.

Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations.

AimThis systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV).BackgroundNIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation.MethodsElectronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done.Review resultsSixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile.ConclusionCurrent evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations.How to cite this articleKarim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938–948.

Frequencies, Modalities, Doses and Duration of Computerized Prescriptions for Sedative, Analgesic, Anesthetic and Paralytic Drugs in Neonates Requiring Intensive Care: A Prospective Pharmacoepidemiologic Cohort Study in 30 French NICUs From 2014 to 2020.

Objectives: No consensus exists about the doses of analgesics, sedatives, anesthetics, and paralytics used in critically ill neonates. Large-scale, detailed pharmacoepidemiologic studies of prescription practices are a prerequisite to future research. This study aimed to describe the detailed prescriptions of these drug classes in neonates hospitalized in neonatal intensive care units (NICU) from computerized prescription records and to compare prescriptions by gestational age. Materials and Methods: We included all neonates requiring intensive care in 30 French level III units from 2014 through 2020 with a computerized prescription for an analgesic, sedative, anesthetic, or paralytic agent. We described frequencies of prescription, methods of administration, concomitant drug prescriptions, and dosing regimen, and compared them across gestational ages. Results: Among 65,555 neonates, 29,340 (44.8%) were prescribed at least one analgesic (acetaminophen in 37.2% and opioids in 17.8%), sedative (9.8%), anesthetic (8.5%), and/or paralytic agent (1%). Among preterm infants born before 28 weeks, 3,771/4,283 (88.0%) were prescribed at least one of these agents: 69.7% opioids, 41.2% sedatives, 32.5% anesthetics, and 5.8% paralytics. The most frequently prescribed agents were sufentanil (in 10.3% of neonates) and morphine (in 8.0% of neonates) for opioids, midazolam (9.3%) for sedatives, ketamine (5.7%) and propofol (3.3%) for anesthetics. In most neonates, opioids and sedatives were prescribed as continuous infusion, whereas anesthetics were prescribed as single doses. Opioids, sedatives and paralytics were mostly prescribed in association with another agent. Doses varied significantly by gestational age but within a limited range. Gestational age was inversely related to the frequency, cumulative dose and duration of prescriptions. For example, morphine prescriptions showed median (IQR) cumulative doses of 2601 (848–6750) vs. 934 (434–2679) µg/kg and median (IQR) durations of 7 (3–15) vs. 3 (2–5) days in infants born <28 vs. ≥ 37 weeks of gestation, respectively (p-value<0.001). Conclusion: The prescriptions of analgesic, sedative, anesthetic, or paralytic agent were frequent and often combined in the NICU. Lower gestational age was associated with higher frequencies, longer durations and higher cumulative doses of these prescriptions. Dose-finding studies to determine individualized dosing regimens and studies on long-term neurodevelopmental outcome according to received cumulative doses are required.

Effect of Ketamine on Vasopressor Needs in Mechanically Ventilated Patients: A Retrospective Study

Background: Ketamine has many recognized effects that may be beneficial in patients undergoing mechanical ventilation. While ketamine provides sedation and analgesia, it has additional sympathomimetic properties that may help support critically ill patients in shock. We hypothesized patients undergoing mechanical ventilation with continuous ketamine infusion as an adjunct to sedation agents would be associated with a lower vasopressor requirement. Methods: We performed a retrospective cohort study on 200 mechanically-ventilated patients (205 hospital encounters) in two academic hospitals between 2015 to 2019. Patients on ketamine as an adjunct (K-G) to another sedative were utilized as the intervention group. Patients on both propofol and fentanyl (PF-G), a common sedation regimen, were used as the control group. The primary outcome was vasopressor requirements before and after initiation of ketamine or propofol and fentanyl. Secondary outcomes included all-cause mortality, 30-day mortality, ICU length-of-stay (LOS), hospital LOS, and ventilator-free days. Results: The overall proportion of males was 63.4% (p-value =0.5016). The norepinephrine average dose (up to 48 hours after initiating sedatives) was lower in K-G (8.7 mcg/kg/min) when compared with PF-G (14.2 mcg/kg/min), p-value&lt;0.0001. The ICU, 30-day or any time all-cause mortality was similar in both groups (22.0, 21.5 and 32.2%, p-value=0.8952, 0.9709, 0.8019, respectively). The average ICU and hospital stay overall were 8.8 (p-value=0.5174) and 16.6 (p-value=0.9280) days, respectively. The average ventilator-free days for K-G was 22.8 days compared to 23.2 days in PF-G (p-value=0.5567). Conclusions: In our study, ketamine as an adjunct sedation agent was associated with decreased vasopressor requirements in patients on mechanical ventilation when compared to the standard use of propofol and fentanyl. Further prospective research is necessary before ketamine can be broadly recommended as an adjunct to sedation in critically ill patients with shock.

Ambulatory spinal anesthesia in infants ≤ six months of age: A retrospective review of outcomes and safety

PurposeTo review experience with outpatient spinal anesthesia (SA) from a single center in infants ≤6 months of age. MethodsRetrospective review of all SAs performed in the ambulatory setting in the outpatient surgery centers in infants ≤6 months of age from 2016 to 2020, focusing on success rate, adverse events, post-anesthesia care unit (PACU) times, and emergency department (ED) or urgent care (UC) returns within 7 days of the operation. ResultsThe study cohort included 175 SAs performed on 173 patients ≤6 months of age. One hundred and sixty-two patients (93%) were able to undergo their respective surgical procedures under SA without conversion to general anesthesia. One hundred and thirty-six patients (78%) did not require additional sedation or analgesic agents. The median time from entering the operating room until the start of surgical procedure was 17 min. One hundred and twenty-six patients (72%) were able to bypass Phase I of the PACU. One hundred and forty-seven patients (86%) were discharged in less than two hours postoperatively. Only one complication related to SA was noted. This was a patient who returned on postoperative day 2 with a possible CSF leak noted by ultrasound. After overnight hospital floor admission, he was discharged the next day after receiving intravenous fluids without further sequelae. ConclusionsSA is a viable option for anesthetic care in infants ≤6 months of age presenting for outpatient surgery. Advantages included the ability to bypass PACU Phase I and facilitation of hospital discharge. Level of evidenceIV. Retrospective cohort treatment study.

Dexmedetomidine:” Role in Pediatric Dentistry

A number of sedative agents have been in use in pediatric dentistry to gain a child’s cooperation with dental treatment. Dexmedetomidine is one such agent that was introduced as a sedative in the dental practice in 2005 due to a more stable respiratory drive and higher success rates in allowing pediatric dentists to carry out non-painful dental examinations and procedures compared to other sedatives such as chloral hydrate and midazolam. The most distinguishing feature of this sedative is its ability to produce a form of sedation that mimics natural sleep. The high safety margin of dexmedetomidine and its satisfactory sedative action makes it important for us to review its potential applications in pediatric dentistry.

Systematic review and meta-analysis comparing the efficacy of dexmedetomidine to midazolam as premedication and a sedative agent in pediatric patients undergoing dental procedures.

Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs like dexmedetomidine (DEX) and midazolam (MID) is a common pharmacological behavior managing technique. We conducted this meta-analysis to evaluate the efficacy of both these drugs in current literature. A thorough literature search was conducted on PubMed, MEDLINE, Google Scholar, and Cochrane's database for randomized studies that compared sedative efficacy of dexmedetomidine with midazolam in children of 0-15 years of age undergoing dental surgeries. Sedation in children during dental procedure, when used as a premedication, at the time of separation from parents and at the time of mask induction, onset time, duration of anesthesia, and surgery were evaluated. The mean differences (MDs), odds ratio (OR), and their 95% confidence intervals (CIs) were calculated both for continuous and dichotomous outcome data using random-effects model. Seven studies met out inclusion criteria and were analyzed. Results of premedication with DEX was associated with more anxiolysis (OR=0.29, 95% CI: 0.17-0.52, p=0.0001; I2=0%) and at the time of separation from parents (OR=0.36, 95% CI: 0.19-0.69, p=0.002; I2=52%) in comparison to MID. No significant differences in results were seen at mask induction (OR=0.63, 95% CI: 0.34-1.18, p=0.15; I2=47%) and for sedation in children during dental procedures (OR=0.52, 95% CI: 0.07-3.70, p=0.51; I2=72%). Also, there were no significant differences in onset time, duration of anesthesia, and surgery between the two agents. DEX proved to be a better premedicant than MID for pediatric patients. No significant difference in efficacy of both sedative agents was observed in children undergoing dental treatment. More clinical trials need to be conducted to see its efficacy in dental surgeries in children of standardized ages and with standard doses.

Adverse Hemodynamic Effects of Dexmedetomidine in Critically Ill Elderly Adults

Background: Dexmedetomidine is a currently recommended first-line sedative agent for critically ill patients requiring mechanical ventilation. Recent trials demonstrated no difference in clinical outcomes between patients treated with dexmedetomidine vs usual care, but significantly more hemodynamic adverse effects in the dexmedetomidine group. One subgroup analysis suggested a 90-day mortality benefit in elderly patients, but no distinction was made between groups regarding age when reporting adverse effects. Given potential decreased baroreceptor function in the elderly, adverse hemodynamic effects of dexmedetomidine may impact them more. Objective: To assess the incidence of adverse hemodynamic effects of dexmedetomidine in elderly ICU patients compared to other sedative agents to clarify the role of dexmedetomidine in this patient population. Methods: This was a single-center, retrospective study including mechanically ventilated elderly patients requiring sedative agents for ≥12 hours. The primary outcome evaluated was composite end point of incidence of bradycardia and hypotension. Secondary outcomes included incidence of each adverse event individually, hospital and ICU length of stay, and duration of mechanical ventilation. Results: There was no difference in adverse events between the two groups (58.7% vs 74.1% in the dexmedetomidine vs usual care groups, P =.074). There was no difference in hospital or ICU length of stay. Patients in the dexmedetomidine group were on the ventilator longer than patients in the usual care group with a median of 6 vs 3 days, respectively (P = 0.004). Conclusion: In this single-center, retrospective study dexmedetomidine had a similar incidence of adverse events in elderly patients compare to the usual care group.

Analgesia and Sedation in Critically Ill Patients With Burns.

Analgesia and Sedation in Critically Ill Patients With Burns.