Sedation Techniques Research Articles

Local anesthetic with sedation is a viable alternative to general anesthesia for lumbar spinal decompressions: A retrospective cohort feasibility study and short-term analysis of outcomes

Background: An increasing focus on value-based care in spine surgery has prompted interest in alternative anesthetics. Avoidance of general anesthesia (GA) has gained support due to reductions in postoperative symptoms. Little has been published on local anesthesia with sedation techniques. Methods: A retrospective chart review was performed to compare outcomes of lumbar decompression using local anesthesia with light intravenous sedative (LIS) and lumbar decompression using general anesthesia. Outcomes reported were 90-day adverse events, reoperations, and narcotic use. Results: A total of 65 patients who underwent lumbar decompression were identified. Patients receiving LIS were older and had more comorbidities compared with those receiving GA. Rates of peripheral vascular disease and peptic ulcer disease were higher in patients receiving LIS (P=0.004 and 0.012, respectively). The overall rate of postoperative adverse events was 30% lower in patients with LIS. There were no aborted procedures in the LIS cohort. Rates of reoperation trended towards being lower in LIS (14.3%) versus the GA group (37.8%). There was no difference in postoperative narcotic use (LIS 17.9%, GA 24.3%, P=0.530). After adjusting for age, gender, body mass index, Charlson Comorbidity Index, and peripheral vascular disease, the rate of adverse events remained lower in the LIS group (odds ratio: 0.166 [95% CI: 0.037, 0.617], P=0.011), and the trends towards lower rates of recurrent stenosis (P=0.082) and reoperation (P=0.082) remained. There was still no difference in the rate of postoperative narcotic use beyond the first follow-up (P=0.542). Conclusions: Lumbar spinal decompressions are commonly performed surgeries, and they are increasingly being performed in outpatient settings. We conclude that LIS is a safe alternative to GA. Further work is needed to identify cost savings in LIS spine surgery and define patient characteristics that identify appropriate candidates. Level of Evidence: Level III.

Analgesia – based vs conventional sedation techniques for endoscopic retrograde cholangiopancreatography: state of the art

Analgesia – based vs conventional sedation techniques for endoscopic retrograde cholangiopancreatography: state of the art

Pre-delivery Conscious Sedation with Intravenous Low Dose Thiopental Na Bolus during Spinal Anesthesia for Cesarean Section

Background: Nowadays, according to the large number of cesarean sections under spinal anesthesia, finding a simple and safe pre-delivery sedation technique which provides satisfaction for mothers with no over sedation and amnesia seems to be necessary. However, there is not enough evidence about the best choice of drug for this purpose. In the present study we aimed in evaluating the clinical effects of different concentrations (0.25, 0.5, 0.75mg/kg) of thiopental Na bolus for the mother’s satisfaction in cesarean section under spinal anesthesia. Methods: Two hundred and forty term singleton pregnant women with normal ASA physical status were scheduled for an elective term cesarean delivery under spinal anesthesia and allocated into four groups. Groups I, II, III received 0.25, 0.5, 0.75mg/kg/IV of Thiopental Na respectively and group IV as the control group received 1.5cc of sterile water,1 min after spinal anesthesia. The level of consciousness with observer assessment of alertness/sedation score (OAA/S) and mother’s satisfaction was considered as primary outcomes. Results: The level of mothers’ satisfaction in group II was significantly higher than other groups without any over sedation (P<0.001) and no adverse effect on their verbal contact was observed and they could easily communicate. All women could remember their infants. All babies were healthy with no complications and the Apgar scores were the same in all studied groups. Conclusion: Based on the results of the present study and with comparison of different concenfrations and side effects indicates pre-delivery conscious sedation with 0. 5 mg/kg/IV of Thiopental Na could be a safe and appropriate technique for sedation in cesarean sections surgery under spinal anesthesia.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children.

SummaryThe multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post‐1984 literature there are no published reports of aspiration‐associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus‐derived algorithm in which each patient is first risk‐stratified during their pre‐sedation assessment, using evidence‐based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Dexmedetomidine versus midazolam sedation for autistic children undergoing electroencephalogram: a prospective randomized trial

BackgroundDexmedetomidine procedural sedation for pediatric patients undergoing radiological imaging has proved to be effective and safe.ObjectiveWe compared the efficacy of outpatient sedation with intravenous dexmedetomidine versus intravenous midazolam in autistic children undergoing electroencephalogram.Patients and methodsForty pediatric autistic patients aged 6–11 years old undergoing electroencephalogram were studied. In the dexmedetomidine group, patients received a loading dose of IV dexmedetomidine 1 μg/kg slowly over 10 min followed by an IV infusion of dexmedetomidine 0.7 μg/kg/h stopped when Ramsay sedation score (RSS) reached 4. In the midazolam group (n = 20), patients received induction with a loading dose of 0.05 mg/kg midazolam given over 2 min, then wait another 2 to 5 min to evaluate the sedative effect. Additional doses of IV midazolam (0.05 mg/kg) were given until we reached RSS reached 4.Sedation score, induction time, recovery time, behavioral scores, parents’ satisfaction scores, success rate, oxygen saturation, and the incidence of complications as bradycardia and attacks of agitation were recorded.ResultsDexmedetomidine was associated with shorter induction and recovery times(< 0.001) and higher percentage of oxygen saturation compared with midazolam group (P < 0.001).The dexmedetomidine group showed higher sedation and behavioral scores as well as success rate compared with midazolam. Parents’ satisfaction scores were significantly higher in the dexmedetomidine group. The incidence of agitation was significantly higher in the midazolam group compared with the dexmedetomidine group (p = 0.035).ConclusionDexmedetomidine is a feasible sedation technique in autistic children undergoing outpatient electroencephalogram in terms of faster recovery and less incidence of complications.

Preparation for Advanced Airway Management: Preparation for Awake Intubation

Awake intubation is a key technique in anesthesia, allowing for the safe management of a patient with signs and predictors of a difficult airway/intubation. It is commonly undertaken electively, but can also be used in an emergency. An appropriate history must be taken, along with review of investigations (e.g CT scan, nasendoscopy), followed by a physical examination and development of a safe management plan. A variety of local anesthetic methods exist for topicalization of the airway (2-4% lidocaine), including nerve blocks (glossopharyngeal, recurrent laryngeal, superior laryngeal) to assist this. Sedation and amnesic techniques commonly include the use of benzodiazepines (midazolam), opioids (remifentanil infusion) and alpha agonists (dexmedetomidine). Knowledge of the side effects of these are paramount, including the cardiac and central nervous system with local anesthetic toxicity. 20% lipid emulsions are available in the event of this. This review contains 4 figures, 5 tables, and 25 references. Keywords: awake flexible bronchoscopic intubation, awake endoscopic intubation, remifentanil, dexmedetomidine, airway anesthesia, glossopharyngeal nerve block, recurrent laryngeal nerve block, superior laryngeal nerve block, local anesthetic toxicity, lipid emulation.

Sedation in Pediatric Patients: Assessment of Pediatric Knowledge

Objectives: This study aimed to evaluate the knowledge of Pediatric Dentists in the city of Fortaleza-CE about the practice of sedation. Methods: Participated 66 professional’s specialists registered in the Regional Council of Dentistry - Ceara who worked in public and private service. Data collection was performed through a structured and self-administered questionnaire. The data obtained were tabulated in the IBM SPSS Statistics program and analyzed through a descriptive and exploratory statistical analysis. Results: The results showed that 36.4% of the professionals had 5 to 10 years of specialization, 93.9% were female and 59.1% both worked in the public and private sectors. Only 21.1% had a sedation course and 33.3% used the technique. Midazolam and Cloral Hydrate were the most commonly cited drugs in the sedation technique. Allergic reactions were the most reported as risk of sedation. Conclusion: Considering the limitations of this study, it is possible to consider that the professionals have reasonable knowledge and few use the technique of sedation, mainly because they do not feel safe. Key words: Pediatric Dentistry, Anxiety, Sedation, Sedation in pediatric patients, Anxiolytics.

A rare case of propofol related infusion syndrome in a neurosurgical patient

Background: For the last three decades propofol has been used in anaesthesia and as a sedation technique. Several reports have warned about its use in higher doses for prolonged durations as it can have severe side effects such as propofol related infusion syndrome (PRIS), which can be fatal.1,2,3 PRIS is a rare and complex clinical condition characterized by severe metabolic acidosis, rhabdomyolysis, cardiac, liver and kidney dysfunction, and lipidemia. In its advanced stage PRIS can lead to severe refractory bradycardia and asystole.4,5 Propofol and remifentanil total intravenous anaesthesia (TIVA) is a popular anaesthesia technique. The target controlled infusion (TCI) gives predicted and controlled drug concentration and has added to the increased use of TIVA. Not much literature is available about the use of propofol and remifentanil TIVA and occurrence of PRIS. We report a case of PRIS in a neurosurgical patient with history of dyslipidemia. Case presentation: A 46-year old man weighing 68 kg, with a known case of hyperlipidemia, presented with decreased hearing on the left side, headache, and perioral numbness. Computerized tomography (CT) of the head showed left cerebropontine angle cystic lesion. His home medications were oral sodium chloride 1200 mg three times daily and pravastatin 20 mg once daily. He was electively scheduled for surgery under general anaesthesia, which lasted for seven hours. He received a TCI with propofol and remifentanil. He remained hemodynamically stable throughout the procedure.Over 7 hours the patient received a total of 3332 mg of 1% propofol, remifentanil TCI 3–4 mcg/ml, ephedrine 18 mg, mannitol 20%–250 ml, pancuronium 16 mg, vecuronium 25 mg, cefazoline 2 g, dexamethasone 16 mg, neostigmine 5 mg, glycopyrolate 1 mg, and labetalol 25 mg. He received 2 liters of crystalloid and one liter of colloid during the surgery. Intra-operative blood sugar remained around 6–7 mmol/L and his central venous pressure was maintained between 8–11 mmHg.His first arterial blood gas showed increasing lactate and metabolic acidosis after two hours of anaesthesia and it continued to rise till the end of surgery. He was extubated and shifted to the surgical intensive care unit (SICU) with a Glasgow Coma Score of 15, spontaneously breathing and with stable hemodynamics. The serum lactate continued to rise in SICU for the first 12 hours and then slowly started to decline (Figure 1). A graph of the trends of carbon dioxide and serum bicarbonate levels is shown in Figure 2. The triglycerides level reached 11.46 (Figure 3), creatine kinase 1852 U/L and myoglobin 474 ng/ml which showed decline within the next 24 hours.He remained hemodynamically stable with adequate urine output. On day one we resumed atorvastatin 20 mg, labetalol prn, bicarbonate infusion. After 24 hours, his lactate levels were normalized and acidosis resolved. The patient was discharged without any complications.Conclusion: Propofol TIVA with TCI is a common anesthesia practice. In a known dyslipidemic patient it will increase the risk for PRIS. In our patient, other risk factors for development of PRIS were higher dose, neurosurgical procedure, and extended duration of propofol infusion. The authors believe it is the first case of PRIS in a dyslipidemic patient undergoing neurosurgery with TIVA.

Sedation and analgesia in interventional radiology: Where do we stand, where are we heading and why does it matter?

The aims of this review were to describe the rationale and the techniques of sedation in interventional radiology, and to compile the safety and efficacy results available so far in the literature. A systematic MEDLINE/PubMed literature search was performed. Preliminary results from several studies demonstrated the feasibility, the efficacy and the safety of using sedative techniques in interventional radiology. Beyond pharmacological sedation and clinical hypnosis, digital sedation could reduce the anxiety and pain associated with interventional radiology procedures.

Substance abuse and conscious sedation: theoretical and practical considerations.

Substance abuse is an issue that has been widely recognised both in the medical and dental professions. Many different recreational drugs exist and their use can have important consequences in relation to conscious sedation. As the use of illicit drugs is growing, it is important to have an understanding of the impact of substance abuse on determining if a patient is a suitable candidate for conscious sedation. It is important to appreciate that while human studies in this area are limited, animal studies and observation of the reactions of substance abusers to sedative agents demonstrate a potential link between illicit drug use and conscious sedation through drug interaction. This paper aims to discuss the importance of understanding substance abuse, the potential effects such substances can have in relation to conscious sedation and appropriate management techniques for substance abusers in order to provide optimum safe care when undergoing conscious sedation techniques.

A case series analysing patients with dental anxiety: a patient-centred model based on psychological profiling

Anxiety and distress can jeopardize dental care experience of patients and may affect the clinical result. Although a wide range of sedation and analgesia techniques are currently available to relieve distress and pain during dental procedures, operative models to choose the most effective sedation-analgesic strategies are lacking. This case series proposes a patient-centred model to optimize patients' cooperation during dental care delivery. We describe how to achieve correct anaesthesia by using the least sedative procedure, accounting for the dental procedure needed and patient's psychological profile. Five patients were considered as paradigmatic to show the balance between patients' subjective experiences and the clinical procedures: a patient with low stress, good compliance (case 1); moderate stress and reduction in compliance (case 2); anxious patient (case 3); patient with acute anxiety and emotional distress (case 4); anguished patient (case 5). A multimodal treatment of emotional and behavioural condition and a patient-centred model approach contributed to achieve the best patient satisfaction in the five cases detailed here.

The Deep Sedation Conundrum and Paediatric Endoscopy.

See “Dexamethasone Reduces Postoperative Nausea in Pediatric Upper Endoscopy With Deep Sedation: A Randomized Controlled Trial” by Moheimani and Yaseri on page 281. There is a definition of “deep sedation” that must be understood—propofol administration, for instance, is essentially general anaesthesia (GA), as is ketamine use and “total intravenous anaesthesia” (TIVA). “Deep sedation” in children is invariably a synonym for GA. Postprocedure nausea with these techniques is common. Its prevention is important. Moheimani and Yaseri (1) describe the reduction in postendoscopy nausea with dexamethasone after endoscopy in children under deep sedation. Single-dose dexamethasone is 1 element of nausea prevention and management following GA (2). Prevention and treatment strategies for postoperative nausea and vomiting include both pharmacological and nonpharmacological therapies. Pharmacological agents include 5-HT3 receptor antagonists, neurokinin-1 receptor blockers, anti-histamine H1 antagonists, haloperidol and droperidol, prokinetic agents such as metoclopramide, dexamethasone, and a variety of other agents. Nausea after procedures under so-called “deep sedation” is infrequently studied when compared with nausea after GA—one could identify these techniques as similar, however, as noted above. Nausea affects at least 30% of patients after GA with volatile agents but after intravenous anaesthesia with propofol the incidence of early nausea (0–6 hours) is reduced (3). It is likely that comparable patient and procedure factors influence postoperative nausea after procedures performed under sedation or GA. The observation that nausea after procedural sedation for endoscopy was reduced with the coadministration of dexamethasone is comparable with studies observing dexamethasone prophylaxis administered in GA (4). Indeed, an antiemetic policy should form part of the procedure as a standard in children. Moheimani and Yaseri (1) describe provided “deep sedation” for upper gastrointestinal endoscopy. Sedation and anaesthesia are not binary options but represent a continuum from awake to unconsciousness. The American Society of Anesthesiology has defined 4 levels of pharmacologically induced sedation: mild; moderate; deep; and anaesthesia. Differentiation between “deep sedation” and anaesthesia depends upon the presence or absence of a response to painful stimuli. Processed EEG techniques may also differentiate between levels of sedation. A Spanish group observed the processed EEG signal provided with the bispectral index (BIS) during paediatric upper gastrointestinal endoscopy (5). Endoscopy success was likely with a BIS index < 59—a BIS value that represents anaesthesia (6,7). Differentiation between “deep sedation” and anaesthesia is more than semantics, it is about risk. Moheimani and Yaseri (1) reported 4.1% of subjects developed either laryngospasm or bronchospasm—and airway complications can be challenging and costly (8). Invasive diagnostic and therapeutic procedures provided by endoscopy have evolved and may be delivered in a theatre or nontheatre environment. Anaesthetic techniques and agents have also evolved alongside these techniques, with intravenous techniques being deliverable in nontheatre environments with minimal equipment. Traditional airway interventions such as supraglottic devices and formal intubation are being supplanted by the delivery of oxygen through a face mask, nasal cannulae, or high-flow oxygen devices—heated high-flow therapy. Procedural respiratory and cardiac risks can be mitigated through presedation assessment and adherence to published professional standards and guidelines for sedation and anaesthesia (9). Notwithstanding the delivery of “deep sedation” or GA, the objective of the process is to provide an environment acceptable to both operator and patient. This requires care from the practitioner that balances the depth of sedation whilst avoiding respiratory and cardiovascular deterioration. The delivery of “deep sedation” probably carries no less risk than GA (10). The use of volatile agents requires the exhaustion of the waste gases, which is challenging with mask anaesthesia and may compromise the safety of personnel in the immediate environment (11). The avoidance of airway manipulation, such as intubation or supraglottic airways, does not mitigate airway risks. The delivery of the procedure in a formal theatre environment does not reduce the cost of delivery of the procedure. The application of volatile anaesthesia increases the risks of early nausea when compared with propofol-based sedation techniques. Therefore the delivery of a deep sedation technique for upper gastrointestinal endoscopy needs to have careful consideration of the aims and objectives of the service. Deaths are rare, and unlikely to be observed in the small sample reported by Moheimani and Yaseri (1). The benefits of the delivery of a sevoflurane-based anaesthetic technique in a theatre environment are not clear, although the adoption of an antiemetic policy may lead to an improvement in outcomes (12).

Techniques and complications of awake fibre-optic intubation – A Survey of Difficult Airway Society members

BackgroundAwake fibre-optic intubation (AFOI) is a recommended option for managing the anticipated difficult intubation; however, there is no recommended standard technique. We investigated current practice of AFOI among Difficult Airway Society members. MethodsA survey was distributed to members of the Difficult Airway Society (DAS). Questions focussed on technique, complications and caseload within the previous 2 years. ResultsOf 588 respondents, most (313; 53%) had performed less than 5 AFOI in the previous 2 years; 61 (10%) had not performed any AFOI and were excluded from further analysis. Of those who had performed AFOI within the preceding 2 years (527), remifentanil was used most commonly for single-agent sedation (237; 45%). Most anaesthetists (253; 48%) combined co-phenylcaine and lidocaine for airway topicalisation. A spray-as–you-go technique for topical anaesthesia was used most frequently (398; 76%). Of respondents, 109 (21%) encountered complications. Of these, the most frequently reported complications were requiring three or more attempts (41) followed by desaturation <80% (34) and failed AFOI (32). There was no statistically significant difference in complication rate between sedation techniques. ConclusionAFOI remains the gold standard technique for anticipated difficult airway management, but low case numbers is a cause for concern for skill maintenance and difficult airway training. A wide variation in anaesthetic technique for AFOI may be aided by national guidelines for awake tracheal intubation.

Comparison of Three Anxiety Management Protocols for Extraction of Third Molars With the Use of Midazolam, Diazepam, and Nitrous Oxide: A Randomized Clinical Trial

The objective of the present study was to compare 3 sedation protocols using diazepam, midazolam, and nitrous oxide. A total of 120 patients with an indication for extraction of third molars were selected. All 120 patients had had moderate to severe levels of anxiety according to the Corah Dental Anxiety Scale. The patients were randomly divided into 3 groups. The patients' vital signs were measured, and the results analyzed by descriptive statistical analysis and statistical tests of comparison. No statistically significant differences were found in the patients' heart rate. However, the differences in the systolic and diastolic blood pressure were statistically significant after 15minutes of nitrous oxide sedation. The oximetry data showed no differences among the 3 sedation protocols. We also found no statistically significant differences in the retrograde amnesia test. The differences in anxiety from preoperatively to postoperatively were statistically significant for all techniques, demonstrating their effectiveness in anxiety control. All 3 preoperative sedation techniques for anxious patients undergoing extraction of third molars used in the present study were effective in controlling the anxiety, with little effect on the patients' vital signs and retrograde amnesia.

Conscious sedation in children: the need to strengthen the evidence base remains.

Data sources Cochrane Oral Health's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase. The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and World Health Organisation International Clinical Trials Registry Platform were searched for ongoing trials. Reference lists of eligible studies were checked for additional studies and specialists in the field contacted for any unpublished data. No restrictions were placed on language or publication date.Study selection Studies were selected which met the following criteria: randomised controlled trials of conscious sedation undertaken by a dentist, anaesthetist or one of the dental team comparing two or more drugs/techniques/placebo in children (up to 16 years of age) receiving dental treatment. Crossover trials and studies involving complex surgical procedures were excluded. Data extraction and synthesis Two authors independently selected studies for inclusion, extracted data and assessed for risk of bias. Results were compared and inconsistencies noted, with disagreements resolved by discussion. Where information was unclear or incomplete the authors of trials were contacted for clarification. Results Fifty studies (3704 participants) were included and grouped into placebo-controlled, dosage and head-to-head comparisons. There was wide variation in sedation technique and agent(s) employed across studies (34 different sedatives with or without nitrous oxide). Risk of bias was high for forty studies (81%), low for one study and unclear for the remaining nine studies (18%). Meta-analysis of available data for the primary outcome measure (behaviour) was possible for oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo. It was not possible to draw conclusions regarding secondary outcome measures (completion of treatment, postoperative anxiety, adverse events) due to inconsistent and/or inadequate reporting.Conclusions There is some moderate-certainty evidence that oral midazolam is an effective sedative for dental treatment in children. Improvements and greater consistency in the design and reporting of future research will enable further evaluation of sedation agents and their potential implications for practice; with it being suggested future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Awake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Awake fiberoptic intubation is one of the recommended strategies for surgical patients with anticipated difficult airway, especially when concurrent difficult ventilation is expected. We performed the first systematic review of randomized controlled trials assessing different protocols for awake fiberoptic intubation in anticipated difficult airway, including studies investigating elective awake fiberoptic intubation for scheduled surgery; randomized controlled trials comparing different methods for performing awake fiberoptic intubation; and adult patients with anticipated difficult airway. We excluded studies in the nonoperating theater settings, randomized controlled trials comparing awake fiberoptic intubation with other techniques, and studies based on simulation. Primary outcomes were success rate and death; secondary outcomes were major adverse events. Thirty-seven randomized controlled trials evaluating 2045 patients and 4 areas were identified: premedication, local anesthesia, sedation, and ancillary techniques to facilitate awake fiberoptic intubation. Quality of evidence was moderate-low and based on small-sampled randomized controlled trials. Overall, 12 of 2045 intubation failures (0.59%) and 7 of 2045 severe adverse events (0.34%) occurred, with no permanent consequences or death. All evaluated methods to achieve local anesthesia performed similarly well. No differences were observed in success rate with different sedatives. Dexmedetomidine resulted in fewer desaturation episodes compared to propofol and opioids with or without midazolam (relative risk, 0.51 [95% CI, 0.28-0.95]; P = .03); occurrence of desaturation was similar with remifentanil versus propofol, while incidence of apnoea was lower with sevoflurane versus propofol (relative risk, 0.43 [95% CI, 0.22-0.81]; P = .01). A high degree of efficacy and safety was observed with minimal differences among different protocols; dexmedetomidine might offer a better safety profile compared to other sedatives.

Diagnostic échographique des fractures peu déplacées du condyle huméral chez l’enfant : une nouvelle technique

IntroductionManagement of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies. HypothesisTransverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures. Materials and methodsWe retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed. ResultsAccording to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement. ConclusionTransverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle. Level of evidenceIV, retrospective cohort study.

Effects of Cannabis Use on Sedation Requirements for Endoscopic Procedures.

Cannabis (or marijuana) became legal for recreational use in Colorado in 2012, and this legislation change has created both challenges and opportunities in medicine. More patients are using cannabis, and more patients are now willing to admit cannabis use than in the past, which increases the likelihood that they will be forthcoming about use during medical questioning. Cannabis use may have implications during medical care, including procedural sedation. To determine whether regular cannabis use had any effect on the dose of medication needed for sedation during endoscopic procedures. A total of 250 medical records were reviewed from 1 endoscopy center and 1 endoscopist to minimize the variability in sedation technique for the study purposes. The cohort was reviewed with regard to age and gender to determine whether differences were present among different groups as to the relative amount of sedation medication required in cannabis users vs nonusers. Medical records from 250 patients were reviewed, and researchers found that compared with people who did not regularly use cannabis, people who regularly used cannabis required an amount of sedation for endoscopic procedures that was significantly higher (P=.05). The statistical significance persisted when adjusted for age, sex, and use of alcohol, benzodiazepines, and opiates. Determining cannabis use before procedural sedation can be an important tool for planning patient care and assessing both medication needs and possible risks related to increased dosage requirements during endoscopic procedures.

A novel transverse ultrasonography technique for minimally displaced lateral humeral condyle fractures in children

IntroductionManagement of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies. HypothesisTransverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures. Materials and methodsWe retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed. ResultsAccording to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement. ConclusionTransverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle. Level of evidenceIV, retrospective cohort study.

Low-dose midazolam and propofol use for conscious sedation during diagnostic endoscopy.

To find the right sedation technique for different types of treatment methods and the right amount of sedatives so the chances of side effects happening can be reduced. This was a retrospective cohort analysis conducted on prospectively collected data. Patients who underwent esophagogastroduodenoscopy only (E group) were sub-divided into two subgroups: (a) Those who received 0.5 mg/kg of propofol (E-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (E-b). Patients who underwent esophagogastroduodenoscopy with colonoscopy (EC group) were also sub-divided into three subgroups: (a) Those who received 0.5 mg/kg of propofol (EC-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (EC-b), (c) Those who received 25 mg (12.5 mg if body weight < 50 kg or age > 70) of meperidine and 0.025 mg/kg of midazolam along with 0.5 mg/kg of propofol (EC-c). When the level of target was not reached, 10-20 mg of propofol was additionally injected. Sedation efficacy and safety were then compared among groups. E-b and EC-b decreased the overall amount of propofol and reduced side effect of temporary hypoxemia compared to E-a and EC-a. EC-b shortened patient recovery time compared to EC-c and reduced paradoxical reaction. In terms of the patient satisfaction and patient cooperation by endoscopists, there were no significant differences between EC-b and EC-c. Concomitant use of low dosages of both propofol and midazolam is found to be useful and safe when endoscopy needs to be performed.