Sedation Requirements Research Articles

Effects of music on sedation depth and sedative use during pediatric dental procedures

Study objectiveThe study aimed to investigate the effects of listening to music or providing sound isolation on the depth of sedation and need for sedatives in pediatric dental patients. DesignProspective, randomized, and controlled study. SettingTertiary, university hospital. PatientsIn total, 180 pediatric patients, American Society of Anesthesiologists physical status I and II, who were scheduled for dental procedures of tooth extraction, filling, amputation, and root treatment. InterventionsPatients were categorized into 3 groups: music, isolation, and control. During the procedures, the patients in the music group listened to Vivaldi’s The Four Seasons violin concertos by sound-isolating headphones, whereas the patients in the isolation group wore the headphones but did not listen to music. All patients were sedated by 0.1 mg/kg midazolam and 1 mg/kg propofol. During the procedure, an additional 0.5 mg/kg propofol was administered as required. Measurements and main resultsBispectral index was used for quantifying the depth of sedation, and total dosage of the propofol was used for sedative requirements. The patients’ heart rates, oxygen saturations, and Observer’s Assessment of Alertness and Sedation Scale and bispectral index scores, which were monitored during the operation, were similar among the groups. In terms of the amount of propofol used, the groups were similar. Prolonged postoperative recovery cases were found to be significantly frequent in the control group, according to the recovery duration measurements (P = .004). ConclusionsListening to music or providing sound isolation during pediatric dental interventions did not alter the sedation level, amount of medication, and hemodynamic variables significantly. This result might be due to the deep sedation levels reached during the procedures. However, listening to music and providing sound isolation might have contributed in shortening the postoperative recovery duration of the patients.

An open-access endoscopy screen correctly and safely identifies patients for conscious sedation.

Background and aims: Open-access scheduling is highly utilized for facilitating generally low-risk endoscopies. Preprocedural screening addresses sedation requirements; however, procedural safety may be compromised if screening is inaccurate. We sought to determine the reliability of our open-access scheduling system for appropriate use of conscious sedation.Methods: We prospectively and consecutively enrolled outpatient procedures booked at an academic center by open-access using screening after in-office gastroenterology (GI) consultation. We collected the cases inappropriately booked for conscious sedation and compared the characteristics for significant differences.Results: A total of 8063 outpatients were scheduled for procedures with conscious sedation, and 5959 were booked with open-access. Only 78 patients (0.97%, 78/8063) were identified as subsequently needing anesthesiologist-assisted sedation; 44 (56.4%, 44/78) were booked through open-access, of which chronic opioid (47.7%, 21/44) or benzodiazepine use (34.1%, 15/44) were the most common reasons for needing anesthesiologist-assisted sedation. Patients on chronic benzodiazepines required more midazolam than those not on chronic benzodiazepines (P = .03) of those patients who underwent conscious sedation. Similarly, patients with chronic opioid use required more fentanyl than those without chronic opioid use (P = .04). Advanced liver disease and alcohol use were common reasons for patients being booked after in-office consultation and were significantly higher than those booked with open-access (both P < .01).Conclusions: We observed that the majority of patients can be triaged for conscious sedation using a multi-tiered screening process. Importantly, few patients (<1.0%) were inappropriately booked for conscious sedation. The most common reasons for considering anesthesiologist-assisted sedation were chronic opioid, benzodiazepine and/or alcohol use and advanced liver disease. This suggests that these entities could be included in screening processes for open-access scheduling.

PTU-045 Device Assisted Enteroscopy in the United Kingdom: Description of A Large Tertiary Case Series Under Conscious Sedation

Introduction Device assisted enteroscopy (DAE) has developed rapidly over the past decade, particularly with the advent of double balloon enteroscopy (DBE). The present study reports a case series from a tertiary centre for enteroscopy in the Southwest of the UK serving approximately 1 million people. Data was collected across three modalities of enteroscopy - DBE, Spiral enteroscopy (SE) and push enteroscopy (PE) - under conscious sedation. Methods Observational study of 343 enteroscopy procedures in 271 patients referred for enteroscopy from 2008 to 2014. Data were collected on patient demographics, procedure indications, diagnosis, sedation requirements, extent, duration, complications, tolerance and types of therapy performed. Completion rate was defined as a DAE procedure that changed patient management via therapy, diagnosis or normal finding. All patients who had procedures during the study period were included in the analysis. Ethical review was obtained from North Bristol NHS Trust local ethics committee. Comparison of numerical data was performed using t-test or one-way ANOVA analysis for comparison of multiple means. Comparison of categorical data was performed using chi-squared testing or correlation testing. Results Obscure GI bleeding (OGIB) was the commonest indication for DAE (n = 205, 59.7%). The overall yield of DAE was low (48.5%), with greater likelihood of positive findings if the indication was OGIB (55% vs 37.6%, p Conclusion Small bowel enteroscopy under conscious sedation is safe and generally well tolerated. The procedure is of low yield; however this is a complex and extensively investigated cohort of patients. Nonetheless, small bowel enteroscopy should be used primarily for therapy once a diagnosis has been made by other modalities such as wireless capsule endoscopy. Disclosure of Interest None Declared

PTU-150 Simplified Barrett’s Radiofrequency Ablation Technique in The Elderly. Consideration Should Be Given to Balancing The Increased Risks with Benefits

Introduction Barrett’s oesophagus (BO) is a major risk factor for the development of oesophageal adenocarcinoma. Radiofrequency ablation (RFA) is an established treatment option in high risk patients with high grade dysplasia (HGD). Recent simplified methods have also been shown to have equivocal treatment success with shorter treatment times. New recommendations to treat patients with low grade dysplasia have been established which will increase numbers of eligible patients. Reduction in procedure duration is attractive to accommodate the increasing referrals, and reduce sedation requirements, especially in the elderly. We aimed to assess the complications and success of simplified RFA technique in consecutive patients undergoing treatment for Barrett’s oesophagus. Methods All patients discharged from simplified RFA treatment course for BO over a 2 year period were identified. Circumferential RFA (c-RFA) or Focal Ultra RFA (u-RFA) was performed with a simplified double application of RFA (12 J/cm) - the device was not removed or cleaned. Simplified Focal RFA (f-RFA) with smaller devices was performed with a (3×15 J/cm no clean) regimen. Strict RFA medication protocol and repeat 3 month follow up was performed for each patient. Patient demographics, success of treatment, withdrawal from treatment and complications were noted. Outcomes were compared in age groups under and over 75 (Fisher’s exact test) to assess if there was a difference in complication rate. Results 36 patients discharged from simplified RFA treatment were identified (11 female; median age 71: range 46–80). 76 treatments were performed in total (22 c-RFA 11 u-RFA and 43 f-RFA). Complete eradication of Barrett’s mucosa was successful in 83.3% (30/36) patients. Median number of treatments was 2 (range 1–6). 1 patient with an incomplete response after 4 treatments was treated twice with a non simplified RFA method but after no further response the patient was discharged from RFA programme. 4/36 patients (11.1%) reported complications which resulted in discharging from programme. Reasons were: prolonged atrial-fibrillation with haemodynamic compromise (2 nd treatment u-RFA); significant oesophageal stricture (c-FRA); hypotensive fall with 7 day admission (u-RFA); prolonged post procedure pain (f-RFA). All complications lead to withdrawal from the RFA programme. 30.7% of patients aged over 75 experienced complications compared to 0% in patients under 75 (p = 0.0121). Conclusion A simplified oesophageal RFA regime is effective to remove BO, however its use in the elderly may be linked with increased complications leading to program withdrawal. Disclosure of Interest None Declared

Carbon Dioxide–Assisted Pneumodissection in Fat Grafting

Fat grafting has become a popular procedure due to its wide range of clinical applications. Several fat grafting techniques have been described to increase the survival rate of the grafted fat. This article presents carbon dioxide (CO2) pneumodissection to improve the biological microenvironment of the recipient site. A total of 40 patients were treated with CO2 pneumodissection for aesthetic and reconstructive indications. The known effects of carboxitherapy such as vasodilation, enhanced Bohr effect, and neoangiogenesis are applied to facilitate the grafting procedure and in the search for higher rate of graft uptake. Tissue pneumodissection has demonstrated reduced pain due to the fat injection process, and reduces the sedation requirements and local anesthesia infiltration requirements.

Novel Uses for Three-Dimensional Printing in Congenital Heart Disease

Congenital heart disease affects 1–2 % of the world’s population and is the leading cause of mortality among infants in the US. The diagnosis and management of congenital heart disease are largely driven by review of two-dimensional (2D) images derived from echocardiography, cardiac magnetic resonance, and cardiac computed tomography. However, congenital heart disease is a three-dimensional (3D) problem, and 2D display methods often lack critical spatial information. Cardiologists and cardiovascular surgeons rely on mental conversion of 2D data into a 3D understanding of the spatial relationships of intracardiac structures. Over the last 10 years, significant advances in 3D printing technology have made it possible to create life-like, printed models of any part of the human anatomy, including congenital heart defects. These printed models, placed in an operator’s hands, have the potential to assist in communication of the size, location, and degree of defect and aid in procedural planning. The use of 3D models has the potential to decrease operative procedure times, decrease radiation exposure in the cardiac catheterization laboratory, and overall sedation and anesthetic requirement. In addition, they have considerable educational value wherein defects can be examined from every angle, and the complex 3D relationships of cardiac structures can be displayed in three dimensions and held in the hand.

Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study.

Endoscopic submucosal dissection (ESD) is an advanced therapy for early gastric neoplasm and requires sedation with adequate analgesia. Lidocaine is a short-acting local anesthetic, and intravenous lidocaine has been shown to have analgesic efficacy in surgical settings. The aim of this study was to assess the effects of intravenous lidocaine on analgesic and sedative requirements for ESD and pain after ESD.Sixty-six patients scheduled for ESD randomly received either intravenous lidocaine as a bolus of 1.5 mg/kg before sedation, followed by continuous infusion at a rate of 2 mg/kg/h during sedation (lidocaine group; n = 33) or the same bolus and infusion volumes of normal saline (control group; n = 33). Sedation was achieved with propofol and fentanyl. The primary outcome was fentanyl requirement during ESD. We recorded hemodynamics and any events during ESD and evaluated post-ESD epigastric and throat pain.Fentanyl requirement during ESD reduced by 24% in the lidocaine group compared with the control group (105 ± 28 vs. 138 ± 37 μg, mean ± SD; P < 0.001). The lidocaine group reached sedation faster [40 (20–100) vs. 55 (30–120) s, median (range); P = 0.001], and incidence of patient movement during ESD decreased in the lidocaine group (3% vs. 26%, P = 0.026). Numerical rating scale for epigastric pain was significantly lower at 6 hours after ESD [2 (0–6) vs. 3 (0–8), median (range); P = 0.023] and incidence of throat pain was significantly lower in the lidocaine group (27% vs. 65%, P = 0.003). No adverse events associated with lidocaine were discovered.Administration of intravenous lidocaine reduced fentanyl requirement and decreased patient movement during ESD. Moreover, it alleviated epigastric and throat pain after ESD. Thus, we conclude that the use of intravenous adjuvant lidocaine is a new and safe sedative method during ESD.

Comfort and patient-centred care without excessive sedation: the eCASH concept.

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.

Flap versus fascial closure for gastroschisis: a systematic review and meta-analysis

BackgroundFlap closure represents an alternative to fascial closure for gastroschisis. We performed a systematic review and meta-analysis of outcomes comparing these techniques. MethodsA registered systematic review (PROSPERO: CRD42015016745) of comparative studies was performed, querying multiple databases without language or date restrictions. Gray literature was sought. Outcomes analyzed included: mortality, ventilation days, feeding parameters, length of stay (LOS), wound infection, resource utilization, and umbilical hernia incidence. Multiple reviewers independently assessed study eligibility and literature quality. Meta-analysis of outcomes was performed where appropriate (Revman 5.2). ResultsTwelve studies met inclusion criteria, of which three were multi-institutional. Quality assessment revealed unbiased patient selection and exposure, but group comparability was suboptimal in four studies. Overall, 1124 patients were evaluated, of which 350 underwent flap closure (210 immediately; 140 post-silo). Meta-analysis revealed no significant differences in mortality, LOS, or feeding parameters between groups. Flap patients had less wound infections (OR 0.40 [95%CI 0.22–0.74], P=0.003). While flap patients had an increased risk of umbilical hernia, they were less likely to undergo repair (19% vs. 41%; P=0.01). ConclusionsFlap closure has equivalent or superior outcomes to fascial closure for patients with gastroschisis. Given potential advantages of bedside closure and reduced sedation requirements, flap closure may represent the preferred closure strategy.

Effect of melatonin on duration of delirium in organophosphorus compound poisoning patients: A double-blind randomised placebo controlled trial.

Background and Aims:Organophosphate compound poisoning (OPCP) is associated with high incidence of delirium. Melatonin has been tried in the treatment of delirium and has shown a beneficial effect in OPCP. This study was conducted to know the effect of melatonin on duration of delirium and recovery profile in OPCP patients.Methods:Double-blind randomised placebo control trial in which 56 patients of OPCP confirmed by history and syndrome of OPCP with low plasma pseudocholinesterase, aged >18 years and weighing between 50 and 100 kg, and Acute Physiology and Chronic Health Evaluation II score of <20 were studied. Group M (n = 26) received tablet melatonin 3 mg and Group C (n = 30) received placebo tablet at 9 PM, every night throughout the Intensive Care Unit (ICU) stay. Delirium was assessed using the Confusion Assessment Method for ICU, thrice a day. Sedation was provided with injection midazolam, fentanyl and lorazepam. Duration of mechanical ventilation, vital parameters, ICU stay, sedative and atropine requirement, were recorded.Results:The time taken to be delirium free was significantly lower in Group M (6 ± 2.92 days) compared to Group C (9.05 ± 2.75 days) (P = 0.001) and prevalence of delirium was significantly decreased in Group M compared to Group C from day 3 onwards. The requirement of midazolam (Group M - 2.98 ± 4.99 mg/day, Group C - 9.68 ± 9.17 mg/day, P < 0.001) and fentanyl (Group M - 94.09 ± 170.05 μg/day, Group C - 189.33 ± 156.38 μg/day, P = 0.03) decreased significantly in Group M. There was no significant difference in the average atropine consumption (P = 0.27), duration of mechanical ventilation (P = 0.26), ICU stay (P = 0.21) and the number of patients requiring mechanical ventilation (P = 0.50).Conclusion:Orally given melatonin in organophosphate compound poisoning patients reduces the duration of delirium and the requirement of sedation and analgesia.

Identification of factors associated with sedation tolerance in 5000 patients undergoing outpatient colonoscopy: Canadian tertiary center experience

AIMTo develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.METHODSA retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St. Paul’s Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives. Potential predictor variables including age, gender, endoscopy indication, high sedation requirements during previous endoscopies, difficulty of the procedure, bowel preparation quality, interventions, findings as well as current use of benzodiazepines, opioids and alcohol were analyzed. The outcome of study was the use of high dose of sedation agents for the procedure. In particular, the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.RESULTSAnalysis of 5282 patients (mean age 57 ± 12, 49% female) was performed. Most common indication for the procedure was screening colonoscopy (57%). Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg. Logistic regression models identified the following variables associated with high sedation: Younger age (OR = 0.95 95%CI: 0.94-0.95; P < 0.0001); abdominal pain (OR = 1.45, 95%CI: 1.08-1.96); P = 0.01) and Inflammatory Bowel Disease (OR = 1.45, 95%CI: 1.04-2.03; P = 0.02) as indications for the procedure; difficult procedure as defined by gastroenterologist (OR = 1.73, 95%CI: 1.48-2.03; P < 0.0001); past history of abdominal surgery (OR = 1.33, 95%CI: 1.17-1.52; P <0.0001) and previous colonoscopy (OR = 1.39, 95%CI: 1.21-1.60; P = 0.0001) and alcohol use (OR = 1.26, 95%CI: 1.03-1.54; P = 0.02). Age and gender adjusted analysis yielded inflammatory bowel disease as an indication (OR = 3.17, 95%CI: 1.58-6.37; P = 0.002); difficult procedure as defined by an endoscopist (OR = 5.13 95%CI: 2.97-8.85; P = 0.0001) and current use of opioids, benzodiazepines or antidepressants (OR = 2.88, 95%CI: 1.74-4.77; P = 0.001) having the highest predictive value of high sedation requirements. Our prediction model using the following pre-procedural variables including age, gender, indication for the procedure, medication/substance use, previous surgeries, previous high sedation requirements for colonoscopy yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.CONCLUSIONPre-procedural planning is the key in conducting successful, efficient colonoscopy. Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement: Younger age, female gender, difficult endoscopy, specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines. Age and gender adjusted analysis yielded similar results. These patients are more likely to need a longer recovery periods post-endoscopy, which could result in additional time and personnel requirements. The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg. The external validity of this model is planned to be tested in another center.

Cold bupivacaine versus magnesium sulfate added to room temperature bupivacaine in sonar-guided femoral and sciatic nerve block in arthroscopic anterior cruciate ligament reconstruction surgery.

Background:Cooling of local anesthetic potentiates its action and increases its duration. Magnesium sulfate (MgSo4) added to local anesthetic prolongs the duration of anesthesia and postoperative analgesia with minimal side effects.Aim:The aim of this prospective, randomized, double-blind study was to compare the effect of cold to 4°C bupivacaine 0.5% and Mg added to normal temperature (20–25°C) bupivacaine 0.5% during sonar-guided combined femoral and sciatic nerve blocks on the onset of sensory and motor block, intraoperative anesthesia, duration of sensory and motor block, and postoperative analgesia in arthroscopic anterior cruciate ligament (ACL) reconstruction surgery.Patients and Methods:A total of 90 American Society of Anesthesiologists classes I and II patients who were scheduled to undergo elective ACL reconstruction were enrolled in the study. The patients were randomly allocated to 3 equal groups to receive sonar-guided femoral and sciatic nerve blocks. In Group I, 17 ml of room temperature (20–25°C) 0.5% bupivacaine and 3 ml of room temperature saline were injected for each nerve block whereas in Group II, 17 ml of cold (4°C) 0.5% bupivacaine and 3 ml of cold saline were injected for each nerve block. In Group III, 17 ml of room temperature 0.5% bupivacaine and 3 ml of MgSo4 5% were injected for each nerve block. The onset of sensory and motor block was evaluated every 3 min for 30 min. Surgery was started after complete sensory and motor block were achieved. Intraoperatively, the patients were evaluated for heart rate and mean arterial pressure, rescue analgesic and sedative requirements plus patient and surgeon satisfaction. Postoperatively, hemodynamics, duration of analgesia, resolution of motor block, time to first analgesic, total analgesic consumption, and the incidence of side effects were recorded.Results:There was no statistically significant difference in demographic data, mean arterial pressure, heart rate, and duration of surgery. Onset of both sensory and motor block was significantly shorter in both Groups II and III compared to Group I. Intraoperative anesthetic quality was comparable between groups with good patient and surgeon satisfaction. The time to first analgesia was significantly longer in Groups II and III compared to Group I with nonsignificant difference between each other. Moreover, the total opioid consumption was significantly lower in Groups II and III and duration of analgesia and motor block were significantly longer in Groups II and III compared to Group I. There was no difference in the incidence of side effects.Conclusions:The use of cold 0.5% bupivacaine or the addition of Mg to normal temperature 0.5% bupivacaine prolongs the sensory and motor block duration without increasing side effects and enhances the quality of intra- and post-operative analgesia with better patient satisfaction in sonar-guided femoral and sciatic nerve block for arthroscopic ACL reconstruction surgery.

Efficacy of dexmedetomidine as an adjuvant to ropivacaine in pediatric caudal epidural block.

Context:Caudal analgesia is a reliable and an easy method to provide intraoperative and postoperative analgesia for infraumbilical surgeries in pediatric population but with the disadvantage of short duration of action after single injection. Many additives were used in combination with local anesthetics in the caudal block to prolong the postoperative analgesia.Aim:We compared the analgesic effects and side effects of dexmedetomidine added to ropivacaine in pediatric patients undergoing lower abdominal surgeries.Settings and Design:Double-blinded randomized controlled trial.Materials and Methods:Sixty patients (2-10 years) were evenly and randomly assigned into two groups in a double-blinded manner. After sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.25% (1 ml/kg) combined with either dexmedetomidine 2 μg/kg in normal saline 0.5 ml, or corresponding volume of normal saline according to group assignment. Hemodynamic variables, end-tidal sevoflurane, and emergence time were monitored. Postoperative analgesia, requirement of additional analgesic, sedation, and side effects were assessed during the first 24 h.Results:The duration of postoperative analgesia was significantly longer (P = 0.001) and total consumption of rescue analgesic was significantly lower in Group RD compared with Group R (P < 0.05). Group RD have better quality of sleep and prolonged duration of sedation (P = 0.001). No significant difference was observed in the incidence of hemodynamic changes or side effects.Conclusion:Addition of dexmedetomidine to caudal ropivacaine significantly prolongs analgesia in children undergoing lower abdominal surgeries without an increase in the incidence of side effects.

Lidocaine versus dexmedetomidine infusion in diagnostic laparoscopic gynecologic surgery: a comparative study

Background The aim of this study was to assess the effectiveness of intraoperative lidocaine versus dexmedetomidine infusion on hemodynamic stability during pneumoperitoneum, as well as the recovery profile of diagnostic laparoscopic gynecologic surgeries. Patients and methods A total of 60 female patients of American Society of Anesthesiologist (ASA) physical status I were included in the study and divided into two groups: group L and group D. Group L received lidocaine hydrochloride 2%, and group D received dexmedetomidine hydrochloride. The hemodynamic changes during pneumoperitoneum as well as the recovery profile (postoperative sedation, pain scores, and analgesic requirements) were recorded. Results During pneumoperitoneum, group D patients showed a statistically significant decrease in mean heart rate compared with group L patients. However, the mean systolic blood pressure, diastolic blood pressure, and mean blood pressure in group L patients showed statistically and clinically nonsignificant changes compared with those of group D patients. As regards the recovery profile, group D patients recorded a significantly higher median sedation score compared with group L patients, and the postoperative pain scores were significantly better in group L than in group D patients after 30 min, 1 h from arrival at the postanesthesia care unit, and at 2 h in the ward. However, this resulted in a statistically nonsignificant number of patients requiring pethidine in the postanesthesia care unit, as well as statistically nonsignificant total pethidine requirements of less than 50 mg. Conclusion Lidocaine offers hemodynamic stability during pneumoperitoneum, as well as a decrease in the intensity of postoperative pain with opioid sparing, offering a less sedated patient than dexmedetomidine during day-case diagnostic laparoscopic gynecologic surgery.

Intranasally Administered Adjunctive Dexmedetomidine Reduces Perioperative Anesthetic Requirements in General Anesthesia.

PurposeIntranasal dexmedetomidine is an effective sedative for premedication and is regularly used to reduce preoperative tension and anxiety in children. This study aimed to assess the effect of intranasally adjunctive dexmedetomidine on perioperative sedative and analgesic requirements in adults.Materials and MethodsPatients were randomly divided into four groups to receive preoperative administration of saline, intranasal dexmedetomidine 1 µg/kg and 2 µg/kg, and intravenous dexmedetomidine 1 µg/kg, respectively. Propofol and remifentanil were target-controlled infused to maintain intraoperative bispectral index at 45–55 and blood pressure at baseline value±20%. Sufentanil was administered to maintain postoperative visual analogue scale ≤3. Perioperative anesthetics requirements were compared using nonparametric tests.ResultsIntranasal dexmedetomidine significantly attenuated propofol requirements for anesthesia induction and maintenance in a dose-dependent manner. Patients given intranasal dexmedetomidine 2 µg/kg required less remifentanil for anesthesia maintenance. The first postoperative request for sufentanil analgesia was delayed in patients given intranasal dexmedetomidine 2 µg/kg. The anesthetics-sparing effect of intranasal dexmedetomidine was significantly weaker than intravenous dexmedetomidine at the same dose of 1 µg/kg. The incidences of adverse events, including hemodynamic instability and delayed recovery, were comparable with and without intranasal dexmedetomidine.ConclusionIntranasal administration of dexmedetomidine can reduce perioperative anesthetic requirements, and a dose of dexmedetomidine 2 µg/kg produces a better effect in adults. The anesthetics-sparing effect of intranasal dexmedetomidine 1 µg/kg is less than that with the same intravenous dose of dexmedetomidine.

Variation of Anesthetic Sedation Requirements in Children Undergoing Auditory Brainstem Response (ABR) Test: A Retrospective Cross-sectional Study

Objective: To explore the association between anesthetic requirements of children subjected to ABR test and the degree of abnormality discovered by the test. Methods: Operative anesthetic data including propofol and midazolam dosages were collected retrospectively for children undergoing ABR tests. Propofol doses were log transformed and entered as dependent variable in linear regression models with weight, height, body mass index, intelligence quotient, CARS score and the extent of lesion by ABR (none, unilateral or bilateral) as covariates and gender as a factor. Independent variables with significant associations were used in multiple regression models. Results: In 227 total study cases, no lesion was identified in 62 cases, a unilateral lesion was identified in 80 cases, and bilateral lesions were identified in 85 cases. Autism was diagnosed in 31% of children. Simple regression showed significant association of weight, extent of lesion and midazolam dose with the log propofol dose. In multiple regression, the three variables retained their significant association with coefficients and 95% CI of (-0.013) and (-0.024)-(-0.003), 0.111 and 0.034-0.183, and (-0.197) and (-0.271)-(-0.124) respectively. Recovery time was similar among the lesion groups indicating a real need for larger doses. Conclusion: Children with autistic lesions may require larger doses of propofol for sedation. ABR testing may provide key clinical information about the anesthetic requirements in autistic patients. More studies are required to assess the safety of anesthesia in children requiring larger doses of medication for sedation.

Fluoroscopy-guided intervertebral disc biopsy with a coaxial drill system.

Percutaneous biopsy of discitis-osteomyelitis is performed to isolate the causative microorganism and exclude alternative diagnoses. We compared drill-assisted and manual fluoroscopy-guided intervertebral disc biopsies with respect to conscious sedation requirements and histologic quality of obtained specimens. Medical records of all single-level, fluoroscopy-guided intervertebral disc biopsies supervised by one of two musculoskeletal radiologists between January 2010 and March 2015 were reviewed. Duration and cumulative medication doses required for each biopsy were recorded. Pathology reports were reviewed to determine whether the obtained specimens were adequate for histopathologic evaluation. Microbiology reports were reviewed to determine whether the causative organism was isolated from the biopsy specimen. During the study period, 21 drill-assisted and 20 manual biopsies were performed. The median duration of conscious sedation for drill-assisted biopsies was 30min (range, 17-40min) compared with 39min (range, 20-90min) for manual biopsies (p < 0.01). Drill-assisted biopsies also required lower median cumulative doses of intravenous midazolam [2mg (range, 0-5mg) vs. 3mg (range, 0-9mg); p = 0.02]. All drill-assisted biopsy specimens were adequate for histopathologic evaluation. One manual biopsy specimen (5%; 1/20) was inadequate for histopathologic evaluation owing to crush artifact. The microbiology yields of drill-assisted and manual biopsies were comparable [14% (3/21) vs. 20% (4/20); p = 0.62]. Fluoroscopically-guided intervertebral disc biopsies performed with drill assistance require less conscious sedation compared with manual biopsies and yield specimens that are adequate for histopathologic evaluation.

Randomized-Controlled Trial Comparing Adenoma Detection Rate Using Water Exchange Versus Air Insufflation Colonoscopy in a U.S. Community-Based Setting

Introduction: Efforts are underway to improve adenoma detection rate during screening colonoscopies, especially in the right colon. Water exchange colonoscopy has demonstrated promising results, purportedly by better cleansing of the colon, and has also resulted in less patient discomfort. Majority of these studies were conducted in a predominantly male and Caucasian VA population. We report the first community-based RCT in the USA that includes female and minority populations, comparing water exchange with air insufflation method in assessing adenoma detection rate. Methods: A prospective sample of 178 patients above 50 years of age presenting for screening and surveillance colonoscopies at a community-based endoscopy center, with no personal or family history of colon cancer, familial polyposis syndromes, inflammatory bowel disease, or prior history of colonic surgery, who consented for the study were blinded and randomized to either water exchange (n=88) or air insufflation colonoscopy (n=88). Four endoscopists participated in the trial. All patients received adequate sedation prior to scope insertion, followed by sequential doses as needed. All patient received a split bowel prep. Prep quality was assessed by the Boston Bowel Prep Score. Post-procedure pain and recovery time were assessed by a nurse blinded to the colonoscopy technique. All colon polyps were assessed by expert GI pathologists. Sessile serrated lesions were reported when found. Advanced adenomas were defined as villous or tubulovillous in histology, or size > 1 cm. Adenomas found proximal to splenic flexure were reported as proximal adenomas. Results: Of 178 patients, 3 were excluded from final analysis, 1 in the air group diagnosed with FAP, and 2 in the water group requiring switch to pediatric colonoscopes due to tortuous sigmoids. There were no statistically significant differences between the 2 groups in terms of sex, race (Caucasian, Black, Hispanic, Asian), age, BMI, alcohol and tobacco use, bowel prep quality, sedation requirement, abdominal pressure application, patient position change, endoscope stiffner use, or scope length at cecum. The cecum was intubated in all patients. Conclusion: Water exchange colonoscopy is a viable technique in a busy community-based endoscopy center. It demonstrated a trend towards higher polyp, adenoma, sessile serrated lesion and advanced adenoma detections. It resulted in significantly lower post procedure pain and recovery time, without significantly increasing procedure time.Table 1: Baseline patient characteristicsTable 2: Polyp detection rates, procedure and recovery times, and post procedure pain

Elipse™, a Procedureless Gastric Balloon for Weight Loss: a Proof-of-Concept Pilot Study.

Endoscopic gastric balloons have been used effectively as weight loss devices for decades, but the requirement for endoscopy and sedation poses several limitations. The goal of this pilot study was to evaluate the safety and performance of a prototype version of Elipse™, a procedureless gastric balloon. Eight patients (mean BMI = 31.0 kg/m(2)) participated in this study. Each patient swallowed one Elipse™ balloon intended to remain in the stomach for 6 weeks, self-empty, and then pass. Each balloon was filled with 450 mL of filling fluid. Patients returned every 2 weeks for abdominal ultrasound. No specific diet or exercise plan was prescribed. All eight patients successfully swallowed the device. The most common adverse events were nausea and vomiting. There were no serious adverse events, and all balloons were excreted safely. Despite not being prescribed a diet or exercise plan, all eight patients lost weight. In 6/8 patients, the balloon remained full through 6 weeks, self-emptied, and passed. In one patient, the balloon appeared partially collapsed on ultrasound after 11 days and was endoscopically punctured. One asymptomatic patient elected to have the balloon endoscopically punctured after 19 days. Both balloons passed in the stool after 4 days. In both cases, endoscopic examination of the upper GI tract showed no abnormalities. This pilot study demonstrates the safety and performance of Elipse™, a procedureless gastric balloon for weight loss. Future studies will test a commercial design filled to 550 mL intended to last in the stomach for at least 12 weeks.

The role of digital subtraction cerebral angiography and the Wada test in the pediatric population

Catheter cerebral angiography in the pediatric population remains the 'gold standard' diagnostic modality for assess- ment of a number of neurovascular disorders. Although its use has declined due to advances in noninvasive imaging techniques, its ability to resolve and provide dynamic assessment of small vessels, vascular lesions and arteriovenous shunts/fistulae makes it an invaluable tool in the assessment and treatment planning for a number of cerebrovascular disorders. A number of subtle and significant differences exist between pediatric and adult cerebral catheter angiography, including methods of vascular access, catheter selection, contrast administration, and sedation requirements. Similarly, the indications for cerebral angiography are more varied compared with adults. Understanding the differences between pediatric and adult cerebral catheter angiography is essential to ensure safe and appropriate use of the investigation, and to minimize the associated risks. The selective intracar- otid administration of sodium amytal (Wada) test is a tool for assessment of language dominance and memory in a select group of patients for preoperative epilepsy surgery planning. In addition to discussing the principles of the test, indications and contra- indications, a number of specific issues pertaining to performing the Wada test in the pediatric population will also be addressed.