A randomized controlled trial of light versus deep propofol sedation for elective outpatient colonoscopy: recall, procedural conditions, and recovery.

PubMed

Allen, Megan; Leslie, Kate; Hebbard, Geoffrey; Jones, Ian; Mettho, Tejinder; Maruff, Paul

2015-11-01

This study aimed to determine if the incidence of recall was equivalent between light and deep sedation for colonoscopy. Secondary analysis included complications, patient clinical recovery, and post-procedure cognitive impairment. Two hundred patients undergoing elective outpatient colonoscopy were randomized to light (bispectral index [BIS] 70-80) or deep (BIS < 60) sedation with propofol and fentanyl. Recall was assessed by the modified Brice questionnaire, and cognition at baseline and discharge was assessed using a Cogstate test battery. The median (interquartile range [IQR]) BIS values were different in the two groups (69 [65-74] light sedation vs 53 [46-59] deep sedation; P < 0.0001). The incidence of recall was 12% in the light sedation group and 1% in the deep sedation group. The risk difference for recall was 0.11 (90% confidence interval, 0.05 to 0.17) in the intention-to-treat analysis, thus refuting equivalence in recall between light and deep sedation (0.05 significance level; 10% equivalence margin). Overall sedation-related complications were more frequent with deep sedation than with light sedation (66% vs 47%, respectively; P = 0.008). Recovery was more rapid with light sedation than with deep sedation as determined by the mean (SD) time to reach a score of 5 on the Modified Observer's Assessment of Alertness/Sedation Scale [3 (4) min vs 7 (4) min, respectively; P < 0.001] and by the median [IQR] time to readiness for hospital discharge (65 [57-80] min vs 74 [63-86] min, respectively; P = 0.001). The incidence of post-procedural cognitive impairment was similar in those randomized to light (19%) vs deep (16%) sedation (P = 0.554). Light sedation was not equivalent to deep sedation for procedural recall, the spectrum of complications, or recovery times. This study provides evidence to inform discussions with patients about sedation for colonoscopy. This trial was registered at the Australian and New Zealand Clinical Trials Registry, number 12611000320954.

Opinions about the new law on end-of-life issues in a sample of french patients receiving palliative care.

PubMed

Boulanger, Augustin; Chabal, Théo; Fichaux, Marie; Destandau, Mireille; La Piana, Jean Marc; Auquier, Pascal; Baumstarck, Karine; Salas, Sébastien

2017-01-21

In February 2nd 2016, the French government enacted the Claeys-Leonetti law that forbade euthanasia and established the right to deep and continuous sedation for end-of-life patients. Moreover, the law also obliges clinicians to abide by any advance directives regarding treatment and investigation, except in cases where they are "obviously inappropriate" in a given medical situation, or in cases of emergency, in order to allow medical staff to take time to assess the patient's situation. Artificial feeding and hydration are considered as treatment. The aim of this report is to investigate individuals receiving palliative care about their opinion about euthanasia, about advance directives, about the right to deep and continuous sedation, and the right to stopping artificial feeding and hydration. The study was an opinion survey conducted among patients treated in two different palliative care institutions: a palliative care unit at the University Hospital (Timone, Marseille, France) and a non-profit association palliative care home ("La Maison", Gardanne, France). Face-to-face interviews were performed by two investigators. The survey included sociodemographics, clinical data, and opinions about euthanasia, deep and continuous sedation, stopping artificial feeding and hydration, and advance directives. Forty patients were interviewed. The mean age was 59.8 years (standard deviation 12). Fifty three percent reported opposition to legalized euthanasia. Eighty three percent were in favour of the right to deep and continuous sedation in patients with refractory pain, 75% when it concerns a patient unable to express their wishes, and 68% when the patient decides to stop vital treatment. Fifty eight percent reported that artificial nutrition and hydration should be considered as care. Fifty eight percent of the patients interviewed would like to see doctors follow the express wishes contained in advance care directives and 53% that advance directives should be subject to a validity period. This work demonstrates the feasibility of discussing sensitive issues such as euthanasia, continuous and deep sedation and cessation of care with patients receiving palliative care. These preliminary results point to the need to perform a larger study in order to find determinant factors in this specific situation and to incorporate them into thinking about end-of-life laws.

Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects.

PubMed

Materstvedt, Lars Johan; Bosshard, Georg

2009-06-01

Terminal sedation continues to fuel debate. When confronted with a patient for whom terminal sedation is considered a possible treatment option, decision making can be difficult. In this paper we focus on the clinical-ethical issues, with an aim to provide clinicians with ways of framing the issue from an ethical point of view. In addition to the clinical-ethical issues, terminal sedation touches upon interesting and complex questions of an essentially philosophical nature. What it means to be a "person" is one such question, and is a topic that is relevant to clinical, daily practice. Accordingly, in the latter part of this paper we draw briefly on selected philosophical positions to elucidate this question. A doctor's belief of what it means to be a "person" might well affect their actions. For example, if a doctor believes terminal sedation involves the destruction of the person, they might not be willing to proceed with it.

Early deep sedation is associated with decreased in-hospital and two-year follow-up survival.

PubMed

Balzer, Felix; Weiß, Björn; Kumpf, Oliver; Treskatsch, Sascha; Spies, Claudia; Wernecke, Klaus-Dieter; Krannich, Alexander; Kastrup, Marc

2015-04-28

There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. In this observational, matched-pair analysis, patients receiving mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond Agitation-Sedation Score (RASS) was used to assess sedation depth (light sedation: -2 to 0; deep: -3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-year follow-up survival. In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074 to 2.567; P = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351 to 2.576; P < 0.001) for two-year follow-up survival. Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-year follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.

The ‘French exception’: the right to continuous deep sedation at the end of life

PubMed Central

Horn, Ruth

2018-01-01

In 2016, a law came into force in France granting terminally ill patients the right to continuous deep sedation (CDS) until death. This right was proposed as an alternative to euthanasia and presented as the ‘French response’ to problems at the end of life. The law draws a distinction between CDS and euthanasia and other forms of sympton control at the end of life. France is the first country in the world to legislate on CDS. This short report describes the particular context and underlying social values that led to this piece of legislation, and explores its meaning in the wider French context. PMID:29056584

Complications of Moderate Sedation Versus Deep Sedation/General Anesthesia for Adolescent Patients Undergoing Third Molar Extraction.

PubMed

Inverso, Gino; Dodson, Thomas B; Gonzalez, Martin L; Chuang, Sung-Kiang

2016-03-01

To examine the complications resulting from moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction and determine whether any differences in complication risks exist between the 2 levels of sedation. We performed a prospective study of the Oral and Maxillofacial Surgery Outcomes System from January 2001 to December 2010. The primary predictor variable was the level of sedation, divided into 2 groups: moderate sedation versus deep sedation/general anesthesia. The primary outcome was the incidence of adverse complications resulting from the sedation level. Differences in the cohort characteristics were analyzed using the independent samples t test, χ(2) test, and analysis of variance, as appropriate. Multivariable logistic regression was used to measure the effect the level of sedation had on the adverse complication rate. Patients in the moderate sedation group had a complication rate of 0.5%, and patients in the deep sedation/general anesthesia group had a complication rate of 0.9%. Compared with moderate sedation, deep sedation/general anesthesia did not pose a significantly increased risk of adverse anesthesia complications (adjusted odds ratio 1.63, 95% confidence interval 0.95 to 2.81; P = .077). The results of our study have shown that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach.

PubMed

Krishna, Lalit Kumar Radha

2015-09-01

The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.

Impact of office-based intravenous deep sedation providers upon traditional sedation practices employed in pediatric dentistry.

PubMed

Tarver, Michael; Guelmann, Marcio; Primosch, Robert

2012-01-01

This survey intended to determine how the implementation of office-based IV deep sedation by a third party provider (OIVSED) impacted the traditional sedation practices employed in pediatric dentistry private practice settings. A digital survey was e-mailed to 924 members of the American Academy of Pediatric Dentistry practicing in California, Florida, and New York, chosen because these states had large samples of practicing pediatric dentists in geographically disparate locations. 151 pediatric dentists using OIVSED responded to the survey. Improved efficiency, safety and quality of care provided, and increased parental acceptance were reported advantages of this service. Although less costly than hospital-based general anesthesia, the average fee for this service was a deterrent to some parents considering this option. Sixty-four percent of respondents continued to provide traditional sedation modalities, mostly oral sedation, in their offices, as parenteral routes taught in their training programs were less often selected. OIVSED users reported both a reduction in the use of traditional sedation modalities in their offices and use of hospital-based GA services in exchange for perceived improvements in efficiency, safety and quality of care delivered. Patient costs, in the absence of available health insurance coverage, inhibited accessing this service by some parents.

Auditory processing during deep propofol sedation and recovery from unconsciousness.

PubMed

Koelsch, Stefan; Heinke, Wolfgang; Sammler, Daniela; Olthoff, Derk

2006-08-01

Using evoked potentials, this study investigated effects of deep propofol sedation, and effects of recovery from unconsciousness, on the processing of auditory information with stimuli suited to elicit a physical MMN, and a (music-syntactic) ERAN. Levels of sedation were assessed using the Bispectral Index (BIS) and the Modified Observer's Assessment of Alertness and Sedation Scale (MOAAS). EEG-measurements were performed during wakefulness, deep propofol sedation (MOAAS 2-3, mean BIS=68), and a recovery period. Between deep sedation and recovery period, the infusion rate of propofol was increased to achieve unconsciousness (MOAAS 0-1, mean BIS=35); EEG measurements of recovery period were performed after subjects regained consciousness. During deep sedation, the physical MMN was markedly reduced, but still significant. No ERAN was observed in this level. A clear P3a was elicited during deep sedation by those deviants, which were task-relevant during the awake state. As soon as subjects regained consciousness during the recovery period, a normal MMN was elicited. By contrast, the P3a was absent in the recovery period, and the P3b was markedly reduced. Results indicate that the auditory sensory memory (as indexed by the physical MMN) is still active, although strongly reduced, during deep sedation (MOAAS 2-3). The presence of the P3a indicates that attention-related processes are still operating during this level. Processes of syntactic analysis appear to be abolished during deep sedation. After propofol-induced anesthesia, the auditory sensory memory appears to operate normal as soon as subjects regain consciousness, whereas the attention-related processes indexed by P3a and P3b are markedly impaired. Results inform about effects of sedative drugs on auditory and attention-related mechanisms. The findings are important because these mechanisms are prerequisites for auditory awareness, auditory learning and memory, as well as language perception during anesthesia.

The 'French exception': the right to continuous deep sedation at the end of life.

PubMed

Horn, Ruth

2018-03-01

In 2016, a law came into force in France granting terminally ill patients the right to continuous deep sedation (CDS) until death. This right was proposed as an alternative to euthanasia and presented as the 'French response' to problems at the end of life. The law draws a distinction between CDS and euthanasia and other forms of sympton control at the end of life. France is the first country in the world to legislate on CDS . This short report describes the particular context and underlying social values that led to this piece of legislation, and explores its meaning in the wider French context. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

[Short-term deep sedation strategy in patients with spontaneous intracerebral hemorrhage: a randomized controlled trial].

PubMed

Wang, Zhuheng; Shi, Chunzhi; Sun, Liping; Guo, Qinghua; Qiao, Wei; Zhou, Guanhua

2017-11-01

To evaluate the efficacy and safety of short-term deep sedation strategy in patients with spontaneous intracerebral hemorrhage (ICH) after surgery. A perspective, randomized, parallel-group study was conducted. Adult patients with spontaneous ICH and undergoing craniotomy admitted to Daxing Teaching Hospital of Capital Medical University from December 2015 to November 2016 were enrolled. The patients who received surgery were randomly divided into a short-term deep sedation and a slight and middle sedation group. Sufentanil was used as an analgesic drug in all patients and midazolam was used as a sedative after the operation. The patients in the slight and middle sedation group received midazolam 0.05-0.10 mg/kg with a goal of mild sedation [Richmond agitation and sedation scale (RASS) score of -2-1]. The patients in the short-term deep sedation group received midazolam 0.1-0.2 mg/kg with a goal of deep sedation (RASS score of -4 to -3) and a duration of no more than 12 hours. Postoperative sedation, blood pressure changes, laboratory indexes, residual hematoma and clinical outcomes were recorded in two groups. During the study, a total of 183 patients with spontaneous ICH were collected, excluding who was older than 65 years, with shock, and with preoperative Glasgow coma score (GCS) of 3. 106 patients were enrolled in this study, and 53 patients were assigned to the short-term deep sedation group and slight and middle sedation group, respectively. In the slight and middle sedation group, 4 patients received reoperation because of repeated hemorrhage and no patient operated repeatedly in the short-term deep sedation group, and there was a significant difference between the two groups (χ 2 = 4.000, P = 0.045). The number of patients undergoing tracheotomy in the short-term deep sedation group was significantly lower than that in the slight and middle sedation group (9 cases vs. 21 cases, P < 0.05). RASS score within 12 hours after operation of the patients in the short-term deep sedation group was lower than that in slight and middle sedation group [-4 (-4, -2) vs. -2 (-3, -1) at 4 hours, -4 (-4, -2) vs. -1 (-2, 0) at 8 hours, -3 (-4, -2) vs. 0 (-2, 1) at 12 hours, all P < 0.01], sudden restlessness was significantly reduced [times: 1 (0, 1) vs. 3 (2, 3), P < 0.01], and postoperative sedation duration was significantly prolonged [hours: 14.0 (8.3, 20.8) vs. 8.9 (3.4, 15.3), P < 0.05]. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) within 12 hours after operation in the short-term deep sedation group were significantly lower than those of the slight and middle sedation group [SBP (mmHg, 1 mmHg = 0.133 kPa): 136.8±30.5 vs. 149.1±33.5, DBP (mmHg): 85.0 (70.8, 102.3) vs. 89.0 (69.2, 116.7), both P < 0.05]. There were no significant differences in the arterial blood gas, routine blood test or coagulation function between the two groups at 24 hours after operation. The volume of residual hematoma at 2, 7 and 14 days after operation in the short-term deep sedation group was significantly decreased as compared with slight and middle sedation group (mL: 16.4±15.6 vs. 38.2±22.2 at 2 days, 9.6±8.7 vs. 20.6±18.6 at 7 days, 1.2±1.0 vs. 4.4±3.6 at 14 days, all P < 0.05), number of deaths in 3 months were significantly less (5 cases vs. 13 cases), and the patients with favorable prognosis were increased significantly (39 cases vs. 12 cases, both P < 0.05). The study results showed that short-term deep sedation strategy after surgery can reduce the incidence of adverse events and improve the prognosis of patients with spontaneous ICH, so it is safe and effective.

Comparison of propofol with pentobarbital/midazolam/fentanyl sedation for magnetic resonance imaging of the brain in children.

PubMed

Pershad, Jay; Wan, Jim; Anghelescu, Doralina L

2007-09-01

Propofol and pentobarbital, alone or combined with other agents, are frequently used to induce deep sedation in children for MRI. However, we are unaware of a previous comparison of these 2 agents as part of a randomized, controlled trial. We compared the recovery time of children after deep sedation with single-agent propofol with a pentobarbital-based regimen for MRI and considered additional variables of safety and efficacy. This prospective, randomized trial at a tertiary children's hospital enrolled 60 patients 1 to 17 years old who required intravenous sedation for elective cranial MRI. Patients were assigned randomly to receive a loading dose of propofol followed by continuous intravenous infusion of propofol or to receive sequential doses of midazolam, pentobarbital, and fentanyl until a modified Ramsay score of >4 was attained. A nurse who was blind to group assignment assessed discharge readiness (Aldrete score > 8) and administered a follow-up questionnaire. We compared recovery time, time to induction of sedation, total sedation time, quality of imaging, number of repeat-image sequences, adverse events, caregiver satisfaction, and time to return to presedation functional status. The groups were similar in age, gender, race, American Society of Anesthesiology physical status class, and frequency of cognitive impairment. No sedation failure or significant adverse events were observed. Propofol offered significantly shorter sedation induction time, recovery time, total sedation time, and time to return to baseline functional status. Caregiver satisfaction scores were also significantly higher in the patients in the propofol group. Propofol permits faster onset and recovery than, and comparable efficacy to, a pentobarbital/midazolam/fentanyl regimen for sedation of children for MRI.

The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study

PubMed Central

2011-01-01

Background A significant minority of dying people experience refractory symptoms or extreme distress unresponsive to conventional therapies. In such circumstances, sedation may be used to decrease or remove consciousness until death occurs. This practice is described in a variety of ways, including: 'palliative sedation', 'terminal sedation', 'continuous deep sedation until death', 'proportionate sedation' or 'palliative sedation to unconsciousness'. Surveys show large unexplained variation in incidence of sedation at the end of life across countries and care settings and there are ethical concerns about the use, intentions, risks and significance of the practice in palliative care. There are also questions about how to explain international variation in the use of the practice. This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands. The aims of the study are to explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice, and to understand the experiences of clinical staff and decedents' informal care-givers of the use of continuous sedation until death and their perceptions of its contribution to the dying process. The UNBIASED study is part of the European Association for Palliative Care Research Network. Methods/Design To realize the study aims, a two-phase study has been designed. The study settings include: the domestic home, hospital and expert palliative care sites. Phase 1 consists of: a) focus groups with health care staff and bereaved informal care-givers; and b) a preliminary case notes review to study the range of sedation therapy provided at the end of life to cancer patients who died within a 12 week period. Phase 2 employs qualitative methods to develop 30 patient-centred case studies in each country. These involve interviews with staff and informal care-givers closely involved in the care of cancer patients who received continuous sedation until death. Discussion To our knowledge, this is one of the few studies which seek to take a qualitative perspective on clinical decision making surrounding the use of continuous sedation until death and the only one which includes the perspectives of nurses, physicians, as well as bereaved informal care-givers. It has several potential strengths, weaknesses, opportunities and threats associated with the specific design of the study, as well as with the sensitive nature of the topic and the different frameworks for ethical review in the participating countries. PMID:21375747

Palliative sedation in end-of-life care.

PubMed

Maltoni, Marco; Scarpi, Emanuela; Nanni, Oriana

2013-07-01

The aim of this review was to present and comment on recent data published on palliative sedation in palliative and end-of-life care. Palliative sedation is a medical procedure used to deal with the refractory symptoms occurring in the advanced stages of cancer. It has clinical, nursing, relational and ethical implications, making it a highly sensitive issue. Over the last 12 months, a number of authors have published interesting new findings on different areas of palliative sedation, that is prevalence, indications, monitoring, duration and choice of drugs. In particular, a clear definition of palliative sedation and of its more pronounced form, deep continuous sedation (DCS), has emerged. It has been confirmed that, when performed in the correct way and with the right aims, palliative sedation does not have a detrimental impact on survival. Recent findings confirm that palliative sedation is an integral part of a medical palliative care approach and is needed in certain clinical situations. It is a legitimate clinical practice from any ethical point of view. While oncologists should have a basic knowledge of the procedure, its in depth study is a core competency for palliative care physicians.

[Do we need a more precise definition of what sedation is?].

PubMed

Sanz Rubiales, Álvaro; Barón Duarte, Francisco; del Valle Rivero, María Luisa

2015-01-01

Palliative sedation in defined as the deliberate reduction in the level of consciousness of the patient by administering the appropriate drugs in order to avoid intense suffering caused by one or more refractory symptoms; sedation in the patient who is in his last days or hours of life is assumed to be continuous and as deep as needed. Clinical experience shows specific situations where it is likely that there is some confusion of terms. We could erroneously understand as palliative sedation the cases of symptomatic treatment of hyperactive delirium in a patient in its last days (a situation that sometimes is presented as the first cause of palliative sedation) or those in which it is carried out a progressive increase in the palliative treatment that often have a sedative effect, parallel to the increased severity of symptoms because of disease progression in severe ill patients. In both scenarios, sedating drugs are used to relieve end-of-life clinical complications and suffering but the circumstances of the patient, the goal of these treatments, and the way they are used do not match the definition of sedation.

How is agitation and restlessness managed in the last 24 h of life in patients whose care is supported by the Liverpool care pathway for the dying patient?

PubMed

Gambles, M; McGlinchey, T; Latten, R; Dickman, A; Lowe, D; Ellershaw, J E

2011-12-01

Guidance regarding the patient centred management of agitation and restlessness reinforces the importance of considering underlying causes, non-pharmacological approaches to treatment and judicious use of medications titrated to patient need. In contrast, recent reports in the literature suggest that the practice of continuous deep sedation until death is prevalent in the UK. To use data from the National Care of the Dying Audit-Hospitals (NCDAH) to explore the administration of medication for management of agitation and restlessness in the last 24 h of life. Hospitals submitted data from up to 30 consecutive adult patients whose care in the final hours/days of life was supported by the Liverpool Care Pathway for the Dying Patient (LCP). Data on the total dose received in the last 24 h of life PRN and the last dose prescribed for administration via continuous subcutaneous infusion (CSCI) for agitation and restlessness were submitted. 155 hospitals provided data from 3893 patients. Median total doses in the last 24 h for midazolam, haloperidol and levomepromazine, respectively, were: PRN only, 2.5, 1.5 and 6.25 mg; CSCI only, 10, 3 and 6.25 mg; PRN+CSCI, 15, 3 and 12.5 mg. Only 51% of patients received medication to alleviate agitation and restlessness in the last 24 h of life. Median doses were low in comparison to doses recommended for continuous deep sedation, suggesting that there is no 'blanket' policy for continuous deep sedation at the end of life for patients whose care is supported by the LCP.

Personhood within the context of sedation at the end of life in Singapore.

PubMed

Krishna, Lalit Kumar Radha

2013-06-07

The concept of personhood is critical to the provision of holistic, patient-centred, palliative care yet no common definition of this term exists. Some characterise personhood by the presence of consciousness-related features such as self-awareness while others deem personhood present by virtue of Divine endowment or as a result of one's social relations. Efforts to appropriately delineate this concept come under scrutiny following suggestions that patients rendered deeply and irreversibly unconscious lack personhood and ought to be considered 'dead'. This case report studies the views of a family caring for a deeply sedated terminally ill patient, to appropriately site local views of personhood within the context of sedation at the end of life. The resultant Ring Theory of Personhood dispenses with concerns that personhood is solely dependent upon consciousness and distances sedative treatments of last resort such as continuous deep sedation from euthanasia.

Palliative sedation: the position statement of the Italian National Committee for Bioethics.

PubMed

Orsi, Luciano; Gristina, Giuseppe R

2017-05-01

In January 2016 the Italian National Bioethics Committee (NBC) published a position statement entitled Deep and continuous palliative sedation in the imminence of death, related to the use of sedation and analgesia for relief from pain and psychological distress in dying patients. In this statement the Committee points out the clinical and ethical appropriateness of palliative sedation as a therapeutic procedure. As a result, today palliative sedation has to be considered useful, scientifically safe and reliable, and acknowledged as an integral part of good clinical practice. At the same time, the position statement, once and for all, makes clear that palliative sedation cannot and must not be equated with the practice of euthanasia. Thus, this document should be known by health professionals caring for dying patients not only in palliative as well as in intensive care settings, but it should be also considered as a milestone aimed to encourage and ease a widespread implementation of this procedure in all health care settings.

Propofol and memory: a study using a process dissociation procedure and functional magnetic resonance imaging.

PubMed

Quan, X; Yi, J; Ye, T H; Tian, S Y; Zou, L; Yu, X R; Huang, Y G

2013-04-01

Thirty volunteers randomly received either mild or deep propofol sedation, to assess its effect on explicit and implicit memory. Blood oxygen level-dependent functional magnetic resonance during sedation examined brain activation by auditory word stimulus and a process dissociation procedure was performed 4 h after scanning. Explicit memory formation did not occur in either group. Implicit memories were formed during mild but not deep sedation (p = 0.04). Mild propofol sedation inhibited superior temporal gyrus activation (Z value 4.37, voxel 167). Deep propofol sedation inhibited superior temporal gyrus (Z value 4.25, voxel 351), middle temporal gyrus (Z value 4.39, voxel 351) and inferior parietal lobule (Z value 5.06, voxel 239) activation. Propofol only abolishes implicit memory during deep sedation. The superior temporal gyrus is associated with explicit memory processing, while the formation of both implicit and explicit memories is associated with superior and middle temporal gyri and inferior parietal lobule activation. Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland.

Sedation Depth During Spinal Anesthesia and the Development of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Repair

PubMed Central

Sieber, Frederick E.; Zakriya, Khwaji J.; Gottschalk, Allan; Blute, Mary-Rita; Lee, Hochang B.; Rosenberg, Paul B.; Mears, Simon C.

2010-01-01

OBJECTIVE: To determine whether limiting intraoperative sedation depth during spinal anesthesia for hip fracture repair in elderly patients can decrease the prevalence of postoperative delirium. PATIENTS AND METHODS: We performed a double-blind, randomized controlled trial at an academic medical center of elderly patients (≥65 years) without preoperative delirium or severe dementia who underwent hip fracture repair under spinal anesthesia with propofol sedation. Sedation depth was titrated using processed electroencephalography with the bispectral index (BIS), and patients were randomized to receive either deep (BIS, approximately 50) or light (BIS, ≥80) sedation. Postoperative delirium was assessed as defined by Diagnostic and Statistical Manual of Mental Disorders (Third Edition Revised) criteria using the Confusion Assessment Method beginning at any time from the second day after surgery. RESULTS: From April 2, 2005, through October 30, 2008, a total of 114 patients were randomized. The prevalence of postoperative delirium was significantly lower in the light sedation group (11/57 [19%] vs 23/57 [40%] in the deep sedation group; P=.02), indicating that 1 incident of delirium will be prevented for every 4.7 patients treated with light sedation. The mean ± SD number of days of delirium during hospitalization was lower in the light sedation group than in the deep sedation group (0.5±1.5 days vs 1.4±4.0 days; P=.01). CONCLUSION: The use of light propofol sedation decreased the prevalence of postoperative delirium by 50% compared with deep sedation. Limiting depth of sedation during spinal anesthesia is a simple, safe, and cost-effective intervention for preventing postoperative delirium in elderly patients that could be widely and readily adopted. Trial Registration: clinicaltrials.gov Identifier: NCT00590707 PMID:20042557

Palliative sedation until death: an approach from Kant's ethics of virtue.

PubMed

Hasselaar, Jeroen G J

2008-01-01

This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does not destroy capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation--for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons.

Effect of rocuronium on the bispectral index under anesthesia and tracheal intubation.

PubMed

Yue, Hui; Han, Jinyu; Liu, Ling; Wang, Kaiyuan; Li, Jincheng

2016-12-01

The aim of the present study was to investigate the effect of various doses of rocuronium on bispectral index (BIS) responses to propofol induction and tracheal intubation, as well as the role of the non-depolarization muscle relaxant rocuronium on the depth of sedation. A total of 72 patients (American Society of Anesthesiologists physical status I-II) were anaesthetized with propofol using a target-controlled infusion, and randomly divided into two sedation level groups (n=36). The patients were divided into 2 groups according to the BIS value: A normal sedation group (group 1), with a stable BIS value at 40-60, and a deep sedation group (group 2), with a BIS value <20 or with burst suppression. Each group was randomly divided into 4 subgroups A-D (n=9) according to the various doses of rocuronium (0.3, 0.6, 0.9 and 1.2 mg/kg). Tracheal intubation was performed after 2 min of rocuronium administration. BIS, electromyography (EMG), heart rate (HR) and mean arterial pressure (MAP) were recorded continuously and averaged over 1 min during baseline (T1), steady state (T2), 2 min after rocuronium infusion (T3), and 0, 2 and 5 min after tracheal intubation. The results demonstrated that HR and MAP decreased significantly at T2 and T3 compared with T1. Following tracheal intubation (L0), HR and MAP significantly increased compared with T2 and T3, and returned to levels similar to those prior to intubation after 5 min. In group 1C and 1D, BIS was significantly decreased at T3 compared with T2; BIS was significantly increased at L0 compared with T3 in group 1A and 1B. EMG at earlier stages of anesthesia was significantly higher compared with other points, and was significantly increased at L0 compared with T3 in group 1A and 1B. These results demonstrated that BIS response may be associated with the dosage of rocuronium in the normal sedation group, although no association was observed with the deep sedation group. Tracheal intubation resulted in marked hemodynamic changes under both normal and deep sedation.

How safe is deep sedation or general anesthesia while providing dental care?

PubMed

Bennett, Jeffrey D; Kramer, Kyle J; Bosack, Robert C

2015-09-01

Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesiologists. The goal of deep sedation or general anesthesia is to establish a safe environment in which the patient is comfortable and cooperative. This requires meticulous care in which the practitioner balances the patient's depth of sedation and level of responsiveness while maintaining airway integrity, ventilation, and cardiovascular hemodynamics. Using the available data and informational reports, the authors estimate that the incidence of death and brain injury associated with deep sedation or general anesthesia administered by all dentists most likely exceeds 1 per month. Airway compromise is a significant contributing factor to anesthetic complications. The American Society of Anesthesiology closed claim analysis also concluded that human error contributed highly to anesthetic mishaps. The establishment of a patient safety database for anesthetic management in dentistry would allow for a more complete assessment of morbidity and mortality that could direct efforts to further increase safe anesthetic care. Deep sedation and general anesthesia can be safely administered in the dental office. Optimization of patient care requires appropriate patient selection, selection of appropriate anesthetic agents, utilization of appropriate monitoring, and a highly trained anesthetic team. Achieving a highly trained anesthetic team requires emergency management preparation that can foster decision making, leadership, communication, and task management. Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.

Intention, procedure, outcome and personhood in palliative sedation and euthanasia.

PubMed

Materstvedt, Lars Johan

2012-03-01

Palliative sedation at the end of life has become an important last-resort treatment strategy for managing refractory symptoms as well as a topic of controversy within palliative care. Furthermore, palliative sedation is prominent in the public debate about the possible legalisation of voluntary assisted dying (physician-assisted suicide and euthanasia). This article attempts to demonstrate that palliative sedation is fundamentally different from euthanasia when it comes to intention, procedure, outcome and the status of the person. Nonetheless, palliative sedation in its most radical form of terminal deep sedation parallels euthanasia in one respect: both end the experience of suffering. However, only the latter intentionally ends life and also has this as its goal. There is the danger that deep sedation could bring death forward in time due to particular side effects of the treatment. Still that would, if it happens, not be intended, and accordingly is defensible in view of the doctrine of double effect.

Current debates on end-of-life sedation: an international expert elicitation study.

PubMed

Papavasiliou, Evangelia Evie; Payne, Sheila; Brearley, Sarah

2014-08-01

End-of-life sedation, though increasingly prevalent and widespread internationally, remains one of the most highly debated medical practices in the context of palliative medicine. This qualitative study aims to elicit and record the perspectives of leading international palliative care experts on current debates. Twenty-one professionals from diverse backgrounds, sharing field-specific knowledge/expertise defined by significant scholarly contribution on end-of-life sedation, were recruited. Open-ended, semi-structured interviews, following a topic-oriented structure reflecting on current debates, were conducted. Results were analysed using thematic content analysis. Three main aspects of sedation were identified and discussed as potentially problematic: (a) continuous deep sedation as an extreme facet of end-of-life sedation, (b) psycho-existential suffering as an ambivalent indication for sedation and (c) withdrawal or withholding of artificial nutrition and hydration as potentially life-shortening. On these grounds, concerns were reported over end-of-life sedation being morally equivalent to euthanasia. Considerable emphasis was placed on intentions as the distinguishing factor between end-of-life acts, and protective safeguards were introduced to distance sedation from euthanasia. This study shows that, despite the safeguards introduced, certain aspects of sedation, including the intentions associated with the practice, are still under question, parallels being drawn between end-of-life sedation and euthanasia. This reaffirms the existence of a grey area surrounding the two practices, already evidenced in countries where euthanasia is legalized. More clarity over the issues that generate this grey area, with their causes being uncovered and eliminated, is imperative to resolve current debates and effectively inform research, policy and practice of end-of-life sedation.

Terminal sedation and euthanasia: a comparison of clinical practices.

PubMed

Rietjens, Judith A C; van Delden, Johannes J M; van der Heide, Agnes; Vrakking, Astrid M; Onwuteaka-Philipsen, Bregje D; van der Maas, Paul J; van der Wal, Gerrit

2006-04-10

An important issue in the debate about terminal sedation is the extent to which it differs from euthanasia. We studied clinical differences and similarities between both practices in the Netherlands. Personal interviews were held with a nationwide stratified sample of 410 physicians (response rate, 85%) about the most recent cases in which they used terminal sedation, defined as administering drugs to keep the patient continuously in deep sedation or coma until death without giving artificial nutrition or hydration (n = 211), or performed euthanasia, defined as administering a lethal drug at the request of a patient with the explicit intention to hasten death (n = 123). We compared characteristics of the patients, the decision-making process, and medical care of both practices. Terminal sedation and euthanasia both mostly concerned patients with cancer. Patients receiving terminal sedation were more often anxious (37%) and confused (24%) than patients receiving euthanasia (15% and 2%, respectively). Euthanasia requests were typically related to loss of dignity and a sense of suffering without improving, whereas requesting terminal sedation was more often related to severe pain. Physicians applying terminal sedation estimated that the patient's life had been shortened by more than 1 week in 27% of cases, compared with 73% in euthanasia cases. Terminal sedation and euthanasia both are often applied to address severe suffering in terminally ill patients. However, terminal sedation is typically used to address severe physical and psychological suffering in dying patients, whereas perceived loss of dignity during the last phase of life is a major problem for patients requesting euthanasia.

Burst Suppression on Processed Electroencephalography as a Predictor of Post-Coma Delirium in Mechanically Ventilated ICU Patients

PubMed Central

Andresen, Jennifer M.; Girard, Timothy D.; Pandharipande, Pratik P.; Davidson, Mario A.; Ely, E. Wesley; Watson, Paula L.

2015-01-01

Objectives Many patients, due to a combination of illness and sedatives, spend a considerable amount of time in a comatose state that can include time in burst suppression. We sought to determine if burst suppression measured by processed electroencephalography (pEEG) during coma in sedative-exposed patients is a predictor of post-coma delirium during critical illness. Design Observational convenience sample cohort Setting Medical and surgical ICUs in a tertiary care medical center Patients Cohort of 124 mechanically ventilated ICU patients Measurements and Main Results Depth of sedation was monitored twice daily using the Richmond Agitation-Sedation Scale and continuously monitored by pEEG. When non-comatose, patients were assessed for delirium twice daily using Confusion Assessment Method for the ICU (CAM-ICU). Multiple logistic regression and Cox proportional hazards regression were used to assess associations between time in burst suppression and both incidence and time to resolution of delirium, respectively, adjusting for time in deep sedation and a principal component score consisting of APACHE II score and cumulative doses of sedatives while comatose. Of the 124 patients enrolled and monitored, 55 patients either never had coma or never emerged from coma yielding 69 patients for whom we performed these analyses; 42 of these 69 (61%) had post-coma delirium. Most patients had burst-suppression during coma, though often short-lived [ median (intraquartile range) time in burst suppression, 6.4 (1-58) minutes]. After adjusting for covariates, even this short time in burst suppression independently predicted a higher incidence of post-coma delirium [odds ratio 4.16; 95% confidence interval (CI) 1.27-13.62; p=0.02] and a lower likelihood (delayed) resolution of delirium (hazard ratio 0.78; 95% CI 0.53-0.98; p=0.04). Conclusions Time in burst suppression during coma, as measured by processed EEG, was an independent predictor of incidence and time to resolution of post-coma/post-deep sedation delirium. These findings of this single center investigation support lighter sedation strategies. PMID:25072756

Adaptive-servo ventilation combined with deep sedation is an effective strategy during pulmonary vein isolation.

PubMed

Murakami, Takashi; Yamaji, Hirosuke; Numa, Kenji; Kawamura, Hiroshi; Murakami, Masaaki; Higashiya, Shunichi; Kamikawa, Shigeshi; Hina, Kazuyoshi; Hirohata, Satoshi; Kusachi, Shozo

2013-07-01

Pulmonary vein isolation (PVI) by catheter ablation for atrial fibrillation (AF) requires suppression of patient restlessness by sufficient sedation in addition to maintaining stable respiration. We applied adaptive-servo ventilation (ASV) and examined the effects of ASV combined with deep propofol sedation on PVI using a NavX. We analysed 75 paroxysmal AF (PAF) patients (62 ± 11 years; 53 men and 22 women) who underwent PVI for treatment of PAF using an ASV system combined with deep sedation (ASV group). Control patients included 75 consecutive PAF patients (62 ± 11 years; 51 men and 24 women) who underwent PVI just before introduction of the ASV system. Deep sedation was defined as a Ramsay sedation score of 6. The ASV group had a lower frequency of restless body movements compared with the control group during PVI (1.5 ± 0.7 vs. 7.8 ± 1.4 times, P < 0.01). The frequency of respiratory compensation and EnGuide alignment of catheter position by the NavX was lower in the ASV (4.2 ± 3.3 and 8.8 ± 7.1 times) than control group (7.1 ± 5.1 and 15.2 ± 10.0 times, P < 0.05 and <0.01, respectively). Consequently, significantly lower total electrical energy supply (48.7 ± 6.0 KJ) was required in the ASV than control group (64.5 ± 24.9 KJ, P < 0.01). Further, significantly shorter fluoroscopy and procedural times were observed in the ASV (28 ± 5 and 109 ± 25 min) than the control group (33 ± 6 and 141 ± 38 min, respectively, P < 0.01) and the AF recurrence rate was significantly lower in the ASV than the control group (12 vs. 25%, P < 0.01). ASV combined with deep sedation is an effective strategy during PVI using the NavX in patients with PAF.

Demand in Pediatric Dentistry for Sedation and General Anesthesia by Dentist Anesthesiologists: A Survey of Directors of Dentist Anesthesiologist and Pediatric Dentistry Residencies

PubMed Central

Hicks, C. Gray; Jones, James E.; Saxen, Mark A.; Maupome, Gerardo; Sanders, Brian J.; Walker, LaQuia A.; Weddell, James A.; Tomlin, Angela

2012-01-01

This study describes what training programs in pediatric dentistry and dental anesthesiology are doing to meet future needs for deep sedation/general anesthesia services required for pediatric dentistry. Residency directors from 10 dental anesthesiology training programs in North America and 79 directors from pediatric dentistry training programs in North America were asked to answer an 18-item and 22-item online survey, respectively, through an online survey tool. The response rate for the 10 anesthesiology training program directors was 9 of 10 or 90%. The response rate for the 79 pediatric dentistry training program directors was 46 of 79 or 58%. Thirty-seven percent of pediatric dentistry programs use clinic-based deep sedation/general anesthesia for dental treatment in addition to hospital-based deep sedation/general anesthesia. Eighty-eight percent of those programs use dentist anesthesiologists for administration of deep sedation/general anesthesia in a clinic-based setting. Pediatric dentistry residency directors perceive a future change in the need for deep sedation/general anesthesia services provided by dentist anesthesiologists to pediatric dentists: 64% anticipate an increase in need for dentist anesthesiologist services, while 36% anticipate no change. Dental anesthesiology directors compared to 2, 5, and 10 years ago have seen an increase in the requests for dentist anesthesiologist services by pediatric dentists reported by 56% of respondents (past 2 years), 63% of respondents (past 5 years), and 88% of respondents (past 10 years), respectively. Predicting the future need of dentist anesthesiologists is an uncertain task, but these results show pediatric dentistry directors and dental anesthesiology directors are considering the need, and they recognize a trend of increased need for dentist anesthesiologist services over the past decade. PMID:22428968

Demand in pediatric dentistry for sedation and general anesthesia by dentist anesthesiologists: a survey of directors of dentist anesthesiologist and pediatric dentistry residencies.

PubMed

Hicks, C Gray; Jones, James E; Saxen, Mark A; Maupome, Gerardo; Sanders, Brian J; Walker, Laquia A; Weddell, James A; Tomlin, Angela

2012-01-01

This study describes what training programs in pediatric dentistry and dental anesthesiology are doing to meet future needs for deep sedation/general anesthesia services required for pediatric dentistry. Residency directors from 10 dental anesthesiology training programs in North America and 79 directors from pediatric dentistry training programs in North America were asked to answer an 18-item and 22-item online survey, respectively, through an online survey tool. The response rate for the 10 anesthesiology training program directors was 9 of 10 or 90%. The response rate for the 79 pediatric dentistry training program directors was 46 of 79 or 58%. Thirty-seven percent of pediatric dentistry programs use clinic-based deep sedation/general anesthesia for dental treatment in addition to hospital-based deep sedation/general anesthesia. Eighty-eight percent of those programs use dentist anesthesiologists for administration of deep sedation/general anesthesia in a clinic-based setting. Pediatric dentistry residency directors perceive a future change in the need for deep sedation/general anesthesia services provided by dentist anesthesiologists to pediatric dentists: 64% anticipate an increase in need for dentist anesthesiologist services, while 36% anticipate no change. Dental anesthesiology directors compared to 2, 5, and 10 years ago have seen an increase in the requests for dentist anesthesiologist services by pediatric dentists reported by 56% of respondents (past 2 years), 63% of respondents (past 5 years), and 88% of respondents (past 10 years), respectively. Predicting the future need of dentist anesthesiologists is an uncertain task, but these results show pediatric dentistry directors and dental anesthesiology directors are considering the need, and they recognize a trend of increased need for dentist anesthesiologist services over the past decade.

Oxygenation and ventilation characteristics in obese sedated dogs before and after weight loss: a clinical trial.

PubMed

Mosing, M; German, A J; Holden, S L; MacFarlane, P; Biourge, V; Morris, P J; Iff, I

2013-11-01

This prospective clinical study examined the effect of obesity and subsequent weight loss on oxygenation and ventilation during deep sedation in pet dogs. Data from nine dogs completing a formalised weight loss programme were evaluated. Dual-energy X-ray absorptiometry (DEXA) was used to quantify body fat mass prior to and after weight loss. Dogs were deeply sedated and positioned in dorsal recumbency. Sedation was scored using a semi-objective scheme. As part of the monitoring of sedation, arterial oxygen partial pressure (PaO2) and arterial carbon dioxide partial pressure (PaCO2) were measured after 10 min in dorsal recumbency. Oxygen saturation of haemoglobin (SpO2) was monitored continuously using pulse oximetry, starting oxygen supplementation where indicated (SpO2<90%) via a face mask. Morphometric measurements were taken from DEXA images and compared before and after weight loss. Several oxygen indices were calculated and correlated with body fat variables evaluated by DEXA. All body fat variables improved significantly after weight loss. PaO2 increased from 27.9±19.2 kPa to 34.8±24.4 kPa, while FiO2 decreased from 0.74±0.31 to 0.66±0.35. Morphometric measurements improved significantly after weight loss. PaO2/FiO2 (inspired oxygen fraction) and Pa/AO2 (ratio of PaO2 to alveolar PO2) also improved significantly, but there was no change in f-shunt and PaCO2 after weight loss. On multiple linear regression analysis, all oxygen indices were negatively associated with thoracic fat percentage. In conclusion, obesity decreases oxygenation in dogs during deep sedation. Oxygenation status improves with successful weight loss, but ventilation is not influenced by obesity. Copyright © 2013 Elsevier Ltd. All rights reserved.

Office-based deep sedation for pediatric ophthalmologic procedures using a sedation service model.

PubMed

Lalwani, Kirk; Tomlinson, Matthew; Koh, Jeffrey; Wheeler, David

2012-01-01

Aims. (1) To assess the efficacy and safety of pediatric office-based sedation for ophthalmologic procedures using a pediatric sedation service model. (2) To assess the reduction in hospital charges of this model of care delivery compared to the operating room (OR) setting for similar procedures. Background. Sedation is used to facilitate pediatric procedures and to immobilize patients for imaging and examination. We believe that the pediatric sedation service model can be used to facilitate office-based deep sedation for brief ophthalmologic procedures and examinations. Methods. After IRB approval, all children who underwent office-based ophthalmologic procedures at our institution between January 1, 2000 and July 31, 2008 were identified using the sedation service database and the electronic health record. A comparison of hospital charges between similar procedures in the operating room was performed. Results. A total of 855 procedures were reviewed. Procedure completion rate was 100% (C.I. 99.62-100). There were no serious complications or unanticipated admissions. Our analysis showed a significant reduction in hospital charges (average of $1287 per patient) as a result of absent OR and recovery unit charges. Conclusions. Pediatric ophthalmologic minor procedures can be performed using a sedation service model with significant reductions in hospital charges.

Day-to-day care in palliative sedation: survey of nurses' experiences with decision-making and performance.

PubMed

Arevalo, Jimmy J; Rietjens, Judith A; Swart, Siebe J; Perez, Roberto S G M; van der Heide, Agnes

2013-05-01

Continuous palliative sedation has been the focus of extensive international debates in the field of end-of-life decision making. Although nurses may be important participants in the performance of continuous palliative sedation, research has focused primarily on the role and experience of physicians. Nurses' experiences differ from that of physicians; they more often describe that continuous palliative sedation is used with the intention of hastening death and to have experienced serious emotional burden. Therefore, it is important to understand the experience of nurses in continuous palliative sedation. To describe nurses' experiences with the decision-making and performance of continuous palliative sedation in terminally ill patients. Cross-sectional study. In 2008, a structured questionnaire was sent to 576 nurses in six professional home care organizations, ten units for palliative care in nursing homes and in-patient hospices and seven hospitals in the western region of the Netherlands. Respondents provided information about the last patient receiving continuous palliative sedation whom they had cared for. Two-hundred seventy-seven questionnaires were returned and 199 (71.84%) reported a case of continuous palliative sedation. Nurses felt involved in the decision to use sedation in 84% of cases, albeit to a lesser extent in home care (68.75%, p=0.002). They agreed with the performance of continuous palliative sedation in 95.97% of cases and they proposed the use of continuous palliative sedation in 16.16%. Nurses were present at the start of sedation in 81.40% of cases and reported physicians to be present in 45.22%. In 72.77%, arrangements had been made among caregivers about the coordination of health care regarding the sedation. Nurses seem to play an important role in the use of continuous sedation. This role is mainly supportive toward physicians and patients during the decision-making process, but shifts to an active performance of sedation, particularly in settings where they explicitly participate as members of a team. Nurses could develop the practice of palliative sedation by anticipating procedural obstacles in the performance of continuous palliative sedation. We recommend them to become more active participants in the decision-making to improve the care of patients receiving continuous palliative sedation. Copyright © 2012 Elsevier Ltd. All rights reserved.

Correlation Between Body Movements and Salivary Secretion During Sedation.

PubMed

Sasaki, Yoko; Kato, Seiichi; Miura, Masaaki; Fukayama, Haruhisa

2016-01-01

During dental sedation, control of the cough reflex is crucial for a safe and smooth procedure. Accumulated saliva is one of the predisposing factors for coughing. Body movements during dental sedation appear to enhance salivation. Therefore, the aim of this study was to investigate the difference in salivary secretion between the with-movements state and the without-movements state during sedation. Salivary weight for 1 min was measured 3 times in 27 patients with intellectual disability during dental treatment under deep sedation with midazolam and propofol. The observed variables were body movements, bispectral index (BIS), and predicted propofol effect-site concentration. A total of 81 measurements were classified into the with-movements state (n = 39; ie, measurements during which body movements were observed) or the without-movements state (n = 42; ie, measurements during which no body movements were observed). The median salivary weight was significantly smaller in the without-movements state compared with the with-movements state (0.03 vs 0.11 g, P < .0001). The BIS was significantly lower in the without-movements state. There was no significant difference in the predicted propofol effect-site concentration between the 2 states. Significant correlation was observed between salivary weight and BIS in the with-movements state (r = 0.44, P = .004). The findings indicate that salivary secretion decreased according to deep sedation. Furthermore, immobility also reduced salivary secretion. We concluded that one reason that immobility is beneficial is because of the resulting decreased salivary secretion during dental treatment under deep sedation.

Electroencephalogram spindle activity during dexmedetomidine sedation and physiological sleep.

PubMed

Huupponen, E; Maksimow, A; Lapinlampi, P; Särkelä, M; Saastamoinen, A; Snapir, A; Scheinin, H; Scheinin, M; Meriläinen, P; Himanen, S-L; Jääskeläinen, S

2008-02-01

Dexmedetomidine, a selective alpha(2)-adrenoceptor agonist, induces a unique, sleep-like state of sedation. The objective of the present work was to study human electroencephalogram (EEG) sleep spindles during dexmedetomidine sedation and compare them with spindles during normal physiological sleep, to test the hypothesis that dexmedetomidine exerts its effects via normal sleep-promoting pathways. EEG was continuously recorded from a bipolar frontopolar-laterofrontal derivation with Entropy Module (GE Healthcare) during light and deep dexmedetomidine sedation (target-controlled infusions set at 0.5 and 3.2 ng/ml) in 11 healthy subjects, and during physiological sleep in 10 healthy control subjects. Sleep spindles were visually scored and quantitatively analyzed for density, duration, amplitude (band-pass filtering) and frequency content (matching pursuit approach), and compared between the two groups. In visual analysis, EEG activity during dexmedetomidine sedation was similar to physiological stage 2 (S2) sleep with slight to moderate amount of slow-wave activity and abundant sleep spindle activity. In quantitative EEG analyses, sleep spindles were similar during dexmedetomidine sedation and normal sleep. No statistically significant differences were found in spindle density, amplitude or frequency content, but the spindles during dexmedetomidine sedation had longer duration (mean 1.11 s, SD 0.14 s) than spindles in normal sleep (mean 0.88 s, SD 0.14 s; P=0.0014). Analysis of sleep spindles shows that dexmedetomidine produces a state closely resembling physiological S2 sleep in humans, which gives further support to earlier experimental evidence for activation of normal non-rapid eye movement sleep-promoting pathways by this sedative agent.

'Palliative sedation'? A retrospective cohort study on the use and labelling of continuously administered sedatives on a palliative care unit.

PubMed

Schildmann, Eva; Pörnbacher, Sebastian; Kalies, Helen; Bausewein, Claudia

2018-03-01

Sedatives are frequently used towards the end of life. However, there is scarce information when their use is labelled as 'palliative sedation'. To assess the use and labelling of 'continuous administration of sedatives within the last 7 days of life', based on objective operational criteria, on a palliative care unit. Retrospective cohort study, using medical records. Explorative statistical analysis (SPSS 23). Patients who died on a palliative care unit from August 2014 to July 2015. Sedatives recorded were benzodiazepines, levomepromazine, haloperidol ⩾5 mg/day and propofol. Of the 192 patients, 149 (78%) patients received continuous sedatives within the last week of life. The prevalence of delirium/agitation was significantly higher in patients with continuous sedatives compared to those without continuous sedatives at admission to the unit (35% vs 16%, p = 0.02) and on the day before death (58% vs 40%, p = 0.04). The term '(palliative) sedation' was used in the records for 22 of 149 (15%) patients with continuous sedatives. These patients had significantly higher total daily midazolam doses 2 days before death (median (range), 15.0 (6.0-185.0) mg vs 11.5 (1.0-70.0) mg, p = 0.04) and on the day of death (median (range), 19.5 (7.5-240.0) mg vs 12.5 (2.0-65.0) mg, p = 0.01). The dose range was large in both groups. The prevalence of delirium/agitation was associated with the administration of continuous sedatives. There was no consistent pattern regarding labelling the use of continuous sedatives as '(palliative) sedation'. Multicentre mixed-methods research is needed for a better characterization of sedation practices in palliative care.

Continuous deep sedation and homicide: an unsolved problem in law and professional morality.

PubMed

den Hartogh, Govert

2016-06-01

When a severely suffering dying patient is deeply sedated, and this sedated condition is meant to continue until his death, the doctor involved often decides to abstain from artificially administering fluids. For this dual procedure almost all guidelines require that the patient should not have a life expectancy beyond a stipulated maximum of days (4-14). The reason obviously is that in case of a longer life-expectancy the patient may die from dehydration rather than from his lethal illness. But no guideline tells us how we should describe the dual procedure in case of a longer life-expectancy. Many arguments have been advanced why we should not consider it to be a form of homicide, that is, ending the life of the patient (with or without his request). I argue that none of these arguments, taken separately or jointly, is persuasive. When a commission, even one that is not itself life-shortening, foreseeably renders a person unable to undo the life-shortening effects of another, simultaneous omission, the commission and the omission together should be acknowledged to kill her. I discuss the legal and ethical implications of this conclusion.

Sedative techniques for endoscopic retrograde cholangiopancreatography.

PubMed

Garewal, Davinder; Powell, Steve; Milan, Stephen J; Nordmeyer, Jonas; Waikar, Pallavi

2012-06-13

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable therapeutic procedure that cannot be performed without adequate sedation or general anaesthesia. A considerable number of ERCPs are performed annually in the UK (at least 48,000) and many more worldwide. The primary objective of our review was to evaluate and compare the efficacy and safety of sedative or anaesthetic techniques used to facilitate the procedure of ERCP in adult (age > 18 years) patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 8); MEDLINE (1950 to September 2011); EMBASE (1950 to September 2011); CINAHL, Web of Science and LILACS (all to September 2011). We searched for additional studies drawn from reference lists of retrieved trial materials and review articles and conference proceedings. We considered all randomized or quasi-randomized controlled studies where the main procedures performed were ERCPs. The three interventions we searched for were (1) conscious sedation (using midazolam plus opioid) versus deep sedation (using propofol); (2) conscious sedation versus general anaesthesia; and (3) deep sedation versus general anaesthesia. We considered all studies regardless of which healthcare professional administered the sedation. We reviewed 124 papers and identified four randomized trials (with a total of 510 participants) that compared the use of conscious sedation using midazolam and meperidine with deep sedation using propofol in patients undergoing ERCP procedures. All sedation was administered by non-anaesthetic personnel. Due to the clinical heterogeneity of the studies we decided to review the papers from a narrative perspective as opposed to a full meta-analysis. Our primary outcome measures included mortality, major complications and inability to complete the procedure due to sedation-related problems. Secondary outcomes encompassed sedation efficacy and recovery. No immediate mortality was reported. There was no significant difference in serious cardio-respiratory complications suffered by patients in either sedation group. Failure to complete the procedure due to sedation-related problems was reported in one study. Three studies found faster and better recovery in patients receiving propofol for their ERCP procedures. Study protocols regarding use of supplemental oxygen, intravenous fluid administration and capnography monitoring varied considerably. The studies showed either moderate or high risk of bias. Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.

Suboptimal palliative sedation in primary care: an exploration.

PubMed

Pype, Peter; Teuwen, Inge; Mertens, Fien; Sercu, Marij; De Sutter, An

2018-02-01

Palliative sedation is a therapeutic option to control refractory symptoms in terminal palliative patients. This study aims at describing the occurrence and characteristics of suboptimal palliative sedations in primary care and at exploring the way general practitioners (GPs) experience suboptimal palliative sedation in their practice. We conducted a mixed methods study with a quantitative prospective survey in primary care and qualitative semi-structured interviews with GPs. The research team defined suboptimal palliative sedation as a time interval until deep sleep >1.5 h and/ or >2 awakenings after the start of the unconsciousness. Descriptive statistics were calculated on the quantitative data. Thematic analysis was used to analyse interview transcripts. We registered 63 palliative sedations in 1181 home deaths, 27 forms were completed. Eleven palliative sedations were suboptimal: eight due to the long time span until deep sleep; three due the number of unintended awakenings. GPs' interview analysis revealed two major themes: the shifting perception of failure and the burden of responsibility. Suboptimal palliative sedation occurs frequently in primary palliative care. Efficient communication towards family members is needed to prevent them from having unrealistic expectations and to prevent putting pressure on the GP to hasten the procedure. Sharing the burden of decision-making during the procedure with other health care professionals might diminish the heavy responsibility as perceived by GPs.

Continuous palliative sedation until death: practice after introduction of the Dutch national guideline.

PubMed

Swart, Siebe J; van der Heide, Agnes; Brinkkemper, Tijn; van Zuylen, Lia; Perez, Roberto; Rietjens, Judith

2012-09-01

In 2005, a national palliative guideline was launched in The Netherlands. The authors describe the practice of continuous palliative sedation until death (CPS) after the introduction of this guideline. In 2008, a random sample of physicians (n=1580) were asked to fill out a questionnaire regarding the last patient in whom they had provided CPS until death. The response was 38%. In all, 82% of the respondents were aware of the existence of the national guideline. Dyspnoea, pain and physical exhaustion were most often mentioned as decisive indications for continuous sedation. The decision to use sedation was discussed with all competent patients, but in 18% this merely involved informing the patient. Life expectancy at the start of continuous sedation was estimated to be less than 2 weeks in 97% of the cases. In 14%, the physicians had felt pressure to start the sedation, predominantly from patients and relatives. Physicians were present at the start of the sedation in 81% of the cases. Midazolam was used to induce the sedation in 92%. Overall, 41% of the physicians estimated that continuous sedation had hastened death to some extent. Most physicians thought that patients' complaints were adequately relieved by continuous sedation, that relatives were satisfied and that a good quality of dying was achieved. Continuous palliative sedation practice in The Netherlands largely reflects the recommendations from the national guideline. Issues needing further attention are the pressure felt by physicians to start continuous sedation and the potential life-shortening effect as mentioned by the physicians.

Viability of single balloon enteroscopy performed under endoscopist-directed sedation.

PubMed

López Rosés, Leopoldo; Álvarez, Beatriz; González Ramírez, Abel; López Baz, Alina; Fernández López, Alexia; Alonso, Sara; Dacal, Andrés; Martí, Eva; Albines, Gino; Fernández Molina, Julieta; Lancho, Ángel

2018-04-01

there is a lot of controversy with regard to who should be responsible for sedation during digestive endoscopy, particularly in advanced procedures that require deep sedation such as enteroscopy. The aim of this study was to evaluate the endoscopist-directed sedation viability during single balloon enteroscopy. this was a prospective, observational study of a series of consecutive enteroscopies. The clinical staff included an endoscopist, scrub nurse and a nurse in charge of monitoring and sedative administration. The following parameters were monitored: pulse oximetry, blood pressure (every five minutes), electrocardiogram and respiratory rate. There was continuous supplemental oxygen and CO2 insufflation. The patient was in the left lateral decubitus position and a fluoroscopic control was used. forty-four explorations were performed in 39 patients, 24 were male and 15 female. The median age was 74 (18-89) and the ASA score was I in 12 cases, II in 23 cases and III in nine cases. Comorbidities were present in 68% of cases. The drugs used included propofol in 23 cases, propofol and midazolam in ten cases, propofol/midazolam/fentanyl in two cases, propofol and fentanyl in two cases, and midazolam/fentanyl in seven cases. All procedures were complete. The length of the procedure was 52 minutes (20-120). There were diagnostic findings in 65.9% of cases and therapeutic measures in 47.7%. There were no severe complications and the rate of complications derived from sedation was 22.7%. endoscopist-directed sedation is effective and safe for single balloon enteroscopy. Multi-center and wider studies are needed in order to better assess the efficacy, safety and efficiency of sedation controlled by a non-anesthetist during advanced endoscopy in this field.

Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery

PubMed Central

2017-01-01

Background Anxiety control remains an important concern in dental practice. We evaluated the incidence, nature, and sequelae of complications during and after minor oral surgeries performed under intravenous midazolam and fentanyl sedation using the titration technique. Methods The medical records of patients who had undergone minor oral surgeries under moderate intravenous midazolam and fentanyl sedation at our institution between January 1, 2015 and December 31, 2015 were retrospectively evaluated. Age, sex, body mass index, medical history, American Society of Anesthesiologists (ASA) classification, indications for sedation, amount of sedative used, surgical duration, and recovery time were evaluated for all patients. Results In total, 107 patients aged 9–84 years were included. ASA class I and class II were observed for 56.1% and 43.9% patients, respectively. Complications associated with sedation occurred in 11 (10.2%) patients. There were no serious adverse events. Oxygen saturation reached 95% during the procedure in six patients; this was successfully managed by stimulating the patients to take a deep breath. Two patients exhibited deep sedation and one exhibited paradoxical excitement. After the procedure, one patient experienced nausea without vomiting and one exhibited a prolonged recovery time. The surgical procedures were completed in all patients. Obesity was found to be significantly associated with sedation-related complications. Conclusions Our results suggest that complications associated with intravenous midazolam and fentanyl sedation using the titration technique for minor oral surgeries are mostly minor and can be successfully managed with no prolonged sequelae. PMID:29090250

Dreaming in sedation during spinal anesthesia: a comparison of propofol and midazolam infusion.

PubMed

Kim, Duk-Kyung; Joo, Young; Sung, Tae-Yun; Kim, Sung-Yun; Shin, Hwa-Yong

2011-05-01

Although sedation is often performed during spinal anesthesia, the details of intraoperative dreaming have not been reported. We designed this prospective study to compare 2 different IV sedation protocols (propofol and midazolam infusion) with respect to dreaming during sedation. Two hundred twenty adult patients were randomly assigned to 2 groups and received IV infusion of propofol or midazolam for deep sedation during spinal anesthesia. Patients were interviewed on emergence and 30 minutes later to determine the incidence, content, and nature of their dreams. Postoperatively, patient satisfaction with the sedation was also evaluated. Two hundred fifteen patients (108 and 107 in the propofol and midazolam groups, respectively) were included in the final analysis. The proportion of dreamers was 39.8% (43/108) in the propofol group and 12.1% (13/107) in the midazolam group (odds ratio=4.78; 95% confidence interval: 2.38 to 9.60). Dreams of the patients receiving propofol were more memorable and visually vivid than were those of the patients receiving midazolam infusion. The majority of dreams (36 of 56 dreamers, 64.3%) were simple, pleasant ruminations about everyday life. A similarly high level of satisfaction with the sedation was observed in both groups. In cases of spinal anesthesia with deep sedation, dreaming was almost 5 times more common in patients receiving propofol infusion than in those receiving midazolam, although this did not influence satisfaction with the sedation. Thus, one does not need to consider intraoperative dreaming when choosing propofol or midazolam as a sedative drug in patients undergoing spinal anesthesia. © 2011 International Anesthesia Research Society

Contesting the Equivalency of Continuous Sedation until Death and Physician-assisted Suicide/Euthanasia: A Commentary on LiPuma.

PubMed

Raho, Joseph A; Miccinesi, Guido

2015-10-01

Patients who are imminently dying sometimes experience symptoms refractory to traditional palliative interventions, and in rare cases, continuous sedation is offered. Samuel H. LiPuma, in a recent article in this Journal, argues that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia based on a higher brain neocortical definition of death. We contest his position that continuous sedation involves killing and offer four objections to the equivalency thesis. First, sedation practices are proportional in a way that physician-assisted suicide/euthanasia is not. Second, continuous sedation may not entirely abolish consciousness. Third, LiPuma's particular version of higher brain neocortical death relies on an implausibly weak construal of irreversibility--a position that is especially problematic in the case of continuous sedation. Finally, we explain why continuous sedation until death is not functionally equivalent to neocortical death and, hence, physician-assisted suicide/euthanasia. Concluding remarks review the differences between these two end-of-life practices. © The Author 2015. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Enteral vs. intravenous ICU sedation management: study protocol for a randomized controlled trial.

PubMed

Mistraletti, Giovanni; Mantovani, Elena S; Cadringher, Paolo; Cerri, Barbara; Corbella, Davide; Umbrello, Michele; Anania, Stefania; Andrighi, Elisa; Barello, Serena; Di Carlo, Alessandra; Martinetti, Federica; Formenti, Paolo; Spanu, Paolo; Iapichino, Gaetano

2013-04-03

A relevant innovation about sedation of long-term Intensive Care Unit (ICU) patients is the 'conscious target': patients should be awake even during the critical phases of illness. Enteral sedative administration is nowadays unusual, even though the gastrointestinal tract works soon after ICU admission. The enteral approach cannot produce deep sedation; however, it is as adequate as the intravenous one, if the target is to keep patients awake and adapted to the environment, and has fewer side effects and lower costs. A randomized, controlled, multicenter, single-blind trial comparing enteral and intravenous sedative treatments has been done in 12 Italian ICUs. The main objective was to achieve and maintain the desired sedation level: observed RASS = target RASS ± 1. Three hundred high-risk patients were planned to be randomly assigned to receive either intravenous propofol/midazolam or enteral melatonin/hydroxyzine/lorazepam. Group assignment occurred through online minimization process, in order to balance variables potentially influencing the outcomes (age, sex, SAPS II, type of admission, kidney failure, chronic obstructive pulmonary disease, sepsis) between groups. Once per shift, the staff recorded neurological monitoring using validated tools. Three flowcharts for pain, sedation, and delirium have been proposed; they have been designed to treat potentially correctable factors first, and, only once excluded, to administer neuroactive drugs. The study lasted from January 24 to December 31, 2012. A total of 348 patients have been randomized, through a centralized website, using a specific software expressly designed for this study. The created network of ICUs included a mix of both university and non-university hospitals, with different experience in managing enteral sedation. A dedicated free-access website was also created, in both Italian and English, for continuous education of ICU staff through CME courses. This 'educational research' project aims both to compare two sedative strategies and to highlight the need for a profound cultural change, improving outcomes by keeping critically-ill patients awake. Clinicaltrials.gov #NCT01360346.

Peripheral Nerve Block as a Supplement to Light or Deep General Anesthesia in Elderly Patients Receiving Total Hip Arthroplasty: A Prospective Randomized Study.

PubMed

Mei, Bin; Zha, Hanning; Lu, Xiaolong; Cheng, Xinqi; Chen, Shishou; Liu, Xuesheng; Li, Yuanhai; Gu, Erwei

2017-12-01

Peripheral nerve block combined with general anesthesia is a preferable anesthesia method for elderly patients receiving hip arthroplasty. The depth of sedation may influence patient recovery. Therefore, we investigated the influence of peripheral nerve blockade and different intraoperative sedation levels on the short-term recovery of elderly patients receiving total hip arthroplasty. Patients aged 65 years and older undergoing total hip arthroplasty were randomized into 3 groups: a general anesthesia without lumbosacral plexus block group, and 2 general anesthesia plus lumbosacral plexus block groups, each with a different level of sedation (light or deep). The extubation time and intraoperative consumption of propofol, sufentanil, and vasoactive agent were recorded. Postoperative delirium and early postoperative cognitive dysfunction were assessed using the Confusion Assessment Method and Mini-Mental State Examination, respectively. Postoperative analgesia was assessed by the consumption of patient-controlled analgesics and visual analog scale scores. Discharge time and complications over a 30-day period were also recorded. Lumbosacral plexus block reduced opioid intake. With lumbosacral plexus block, intraoperative deep sedation was associated with greater intake of propofol and vasoactive agent. In contrast, patients with lumbosacral plexus block and intraoperative light sedation had lower incidences of postoperative delirium and postoperative cognitive decline, and earlier discharge readiness times. The 3 groups showed no difference in complications within 30 days of surgery. Lumbosacral plexus block reduced the need for opioids and offered satisfactory postoperative analgesia. It led to better postoperative outcomes in combination with intraoperative light sedation (high bispectral index).

Drug-induced sleep endoscopy with target-controlled infusion using propofol and monitored depth of sedation to determine treatment strategies in obstructive sleep apnea.

PubMed

Heiser, Clemens; Fthenakis, Phillippe; Hapfelmeier, Alexander; Berger, Sebastian; Hofauer, Benedikt; Hohenhorst, Winfried; Kochs, Eberhard F; Wagner, Klaus J; Edenharter, Guenther M

2017-09-01

Drug-induced sleep endoscopy (DISE) has become an important diagnostic examination tool in the treatment decision process for surgical therapies in the treatment of obstructive sleep apnea (OSA). Currently, there is a variety of regimes for the performance of DISE, which renders comparison and assessment across results difficult. It remains unclear how the different regimes influence the findings of the examination and the resulting conclusions and treatment recommendations. This study aimed to investigate the correlation between increasing levels of sedation (i.e., light, medium, and deep) induced by propofol using a target-controlled infusion (TCI) pump, with the obstruction patterns at the levels of the velum, oropharynx, tongue base, and epiglottis (i.e., VOTE classification). A second goal was the establishment of a sufficient sedation level to enable a reliable decision regarding treatment recommendations. Forty-three patients with OSA underwent a DISE procedure using propofol TCI. Three levels of sedation were defined, depending on entropy levels and assessment of sedation: light sedation, medium sedation, and deep sedation. The evaluation of the upper airway at each level, with increasing sedation, was documented using the VOTE classification. The elapsed time at which each assessment was performed was recorded. Upper airway changes occurred and were measured throughout the DISE procedure. Clinically useful determinations of airway closure occurred at medium sedation; this level of sedation was most probably achieved with a blood propofol concentration of 3.2 μg/ml. In all 43 patients, definite treatment decisions could be made at medium sedation level. Increasing sedation did not result in changes in the treatment decision. Changes in upper airway collapse during DISE with propofol TCI occur at levels of medium sedation. Decisions regarding surgical treatment could be made at this level of sedation. Upper Airway Collapse in Patients with Obstructive Sleep Apnea Syndrome by Drug Induced Sleep Endoscopy (URL: https://clinicaltrials.gov/ct2/results?term=NCT02588300&Search=Search ) REGISTRATION NUMBER: NCT02588300.

Euthanasia and physician-assisted suicide in amyotrophic lateral sclerosis: a prospective study.

PubMed

Maessen, Maud; Veldink, Jan H; Onwuteaka-Philipsen, Bregje D; Hendricks, Henk T; Schelhaas, Helenius J; Grupstra, Hepke F; van der Wal, Gerrit; van den Berg, Leonard H

2014-10-01

The objective of this study is to determine if quality of care, symptoms of depression, disease characteristics and quality of life of patients with amyotrophic lateral sclerosis (ALS) are related to requesting euthanasia or physician-assisted suicide (EAS) and dying due to EAS. Therefore, 102 ALS patients filled out structured questionnaires every 3 months until death and the results were correlated with EAS. Thirty-one percent of the patients requested EAS, 69% of whom eventually died as a result of EAS (22% of all patients). Ten percent died during continuous deep sedation; only one of them had explicitly requested death to be hastened. Of the patients who requested EAS, 86% considered the health care to be good or excellent, 16% felt depressed, 45% experienced loss of dignity and 42% feared choking. These percentages do not differ from the number of patients who did not explicitly request EAS. The frequency of consultations of professional caregivers and availability of appliances was similar in both groups. Our findings do not support continuous deep sedation being used as a substitute for EAS. In this prospective study, no evidence was found for a relation between EAS and the quality and quantity of care received, quality of life and symptoms of depression in patients with ALS. Our study does not support the notion that unmet palliative care needs are related to EAS.

Obstructive sleep apnea and sedation in the endoscopy suite.

PubMed

Moos, Daniel D

2006-01-01

Patients with obstructive sleep apnea are at risk of mortality and morbidity related to the administration of sedatives, anesthetics, and opioids. Commonly employed sedatives and analgesics promote pharyngeal collapse and alter normal respiratory responses to obstruction and apnea. Literature concerning patients with obstructive sleep apnea undergoing moderate and deep sedation in the endoscopy suite is lacking. The purpose of this article is to provide the reader with a review of normal airway patency, the effects of obstructive sleep apnea on airway patency, and the impact that analgesics and sedatives may impart on the airway of patients with obstructive sleep apnea. The goal of this article is to increase awareness, stimulate discussions within the gastroenterological community, and encourage research regarding sedation in this at-risk population.

Sedative music facilitates deep sleep in young adults.

PubMed

Chen, Chih-Kuang; Pei, Yu-Cheng; Chen, Ning-Hung; Huang, Li-Ting; Chou, Shih-Wei; Wu, Katie P; Ko, Pei-Chih; Wong, Alice M K; Wu, Chih-Kuan

2014-04-01

To investigate the effect of sedative music on the different stages of the sleep cycle in young adults with various sleep latencies by using polysomnography (PSG). Prospective, randomized, controlled, crossover study. Sleep center of a teaching hospital. Young adults with different sleep latencies. Poor sleepers (Pittsburgh Sleep Quality Index score ≥5) were excluded. Each participant stayed one night in the sleep center for adaptation and on each of the following two nights was assigned to (1) music and (2) control (without music) conditions in random order. In the music condition, sedative music composed by certified music therapists was played on a compact disc player for the first hour the participant was in bed. Sleep measures recorded with PSG, including sleep latency and durations of sleep stages. Twenty-four young adults (mean±standard deviation, 24.5±2.6 years) participated. They were classified into the short sleep latency (SL) group if the baseline SL of the adaptation night was shorter than 10 minutes or into the long SL group if the baseline SL was 10 minutes or longer. Sedative music did not alter the SL in either group. Sedative music reduced stage II sleep in both SL groups (main effect of music, p=0.03; interaction effect, p=0.87) but increased the duration of deep sleep (stages III and IV) only in the long SL group (main effect of music, p=0.15; interaction effect, p=0.02). In participants with long SL, sedative music improved the quality of sleep by prolonging the duration of deep sleep. This effect provides an alternative and noninvasive way to improve sleep in selected persons experiencing sleep problems.

Development of Process Control Methodology for Tracking the Quality and Safety of Pain, Agitation, and Sedation Management in Critical Care Units.

PubMed

Walsh, Timothy S; Kydonaki, Kalliopi; Lee, Robert J; Everingham, Kirsty; Antonelli, Jean; Harkness, Ronald T; Cole, Stephen; Quasim, Tara; Ruddy, James; McDougall, Marcia; Davidson, Alan; Rutherford, John; Richards, Jonathan; Weir, Christopher J

2016-03-01

To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Eight Scottish ICUs over a 12-month period. Mechanically ventilated patients. None. The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman ρ = 0.75) and were reliable in clinician-clinician (weighted kappa; κ = 0.66) and clinician-researcher (κ = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale (ρ = 0.24) and was reliable in clinician-clinician (κ = 0.58) and clinician-researcher (κ = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale (ρ = 0.54), and reliability in clinician-clinician (κ = 0.29) and clinician-researcher (κ = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time.

Use of the Draeger Apollo to Deliver Bilevel Positive Pressure Ventilation During Awake Frontal Craniotomy for a Patient with Severe Chronic Obstructive Pulmonary Disease.

PubMed

Lee, Susie So-Hyun; Berman, Mitchell F

2015-12-01

In this case report, we describe the use of the Draeger Apollo anesthesia machine to deliver bilevel positive airway pressure (BiPAP) to a patient with severe chronic obstructive pulmonary disease and a history of lung resection undergoing frontal craniotomy for the removal of a brain tumor under moderate to deep sedation. BiPAP in the perioperative period has been described for purposes of preoxygenation and postextubation recruitment. Although its utility as a mode of ventilation during moderate to deep sedation has been demonstrated, it has not come into widespread use. We describe the intraoperative use of pressure support mode on the anesthesia machine to deliver noninvasive positive pressure ventilation through a standard anesthesia mask. Given its ease of access and effectiveness, it is our belief that intraoperative BiPAP may reduce hypoxemia and/or hypercarbia in patients with chronic obstructive pulmonary disease and obstructive sleep apnea undergoing moderate to deep sedation.

Intravenous magnesium sulphate infusion in the management of very severe tetanus in a child: a descriptive case report.

PubMed

Puliyel, Mammen M; Pillai, Rajappan; Korula, Sophy

2009-02-01

We report a 7-year-old boy with very severe tetanus treated with continuous infusion of magnesium sulphate for the control of spasms and severe autonomic dysfunction which was refractory to deep sedation and mechanical ventilation. The infusion was not associated with any adverse effects and he made an uneventful recovery. We recommend the use of intravenous magnesium sulphate infusion as an inexpensive and highly effective modality in severe tetanus.

Continued midazolam versus diphenhydramine in difficult-to-sedate patients: a randomized double-blind trial.

PubMed

Sachar, Hamita; Pichetshote, Nipaporn; Nandigam, Kavitha; Vaidya, Keta; Laine, Loren

2018-05-01

Current guidelines recommend diphenhydramine in patients undergoing endoscopy who are not adequately sedated with a benzodiazepine and opioid combination. Because this practice has not been adequately assessed, we performed a randomized, double-blind trial comparing diphenhydramine with continued midazolam in such patients. Patients undergoing elective colonoscopy with moderate sedation were eligible. Sedation was measured with the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score with adequate sedation defined as 3 on a 0- to 5-point scale. Patients not adequately sedated with midazolam 5 mg and fentanyl 100 μg were randomly assigned to diphenhydramine 25 mg versus continued midazolam 1.5 mg. Adequacy of sedation was assessed 3 minutes after each study medication dose. If MOAA/S was 4 to 5, study medication was repeated, to a maximum of 3 doses. The primary endpoint was adequate sedation. The planned enrollment of 200 patients (100 in each study group) was attained. Adequate sedation was achieved less often with diphenhydramine than midazolam (27% vs 65%, difference = -38%; 95% CI, -50% to -24%; P < .0001). After study medications were completed, more patients required additional medication for sedation or analgesia with diphenhydramine versus midazolam (84% vs 68%, P = .008), whereas the time to discharge from the recovery unit was similar (134 vs 129 minutes). Treatment effect was consistent across subgroups including age ≤55, substance abuse, benzodiazepine use, opioid use, and psychiatric medication use. Endoscopists performing moderate sedation should continue midazolam rather than switching to diphenhydramine in patients who do not achieve adequate sedation with usual doses of midazolam and an opioid. (Clinical trial registration number: NCT01769586.). Published by Elsevier Inc.

Ketamine, propofol and low dose remifentanil versus propofol and remifentanil for ERCP outside the operating room: Is ketamine not only a “rescue drug”?

PubMed Central

Fabbri, Lea Paola; Nucera, Maria; Marsili, Massimo; Al Malyan, Mohamed; Becchi, Chiara

2012-01-01

Summary Background Endoscopic retrograde cholangiopancreatography ERCP is a painful and long procedure requiring transient deep analgesia and conscious sedation. An ideal anaesthetic that guarantees a rapid and smooth induction, good quality of maintenance, lack of adverse effects and rapid recovery is still lacking. This study aimed to compare safety and efficacy of a continuous infusion of low dose remifentanil plus ketamine combined with propofol in comparison to the standard regimen dose of remifentanil plus propofol continuous infusion during ERCP. Material/Methods 322 ASAI-III patients, 18–85 years old and scheduled for planned ERCP were randomized. Exclusion criteria were a predictable difficult airway, drug allergy, and ASA IV–V patients. We evaluated Propofol 1 mg/kg/h plus Remifentanil 0.25 μg/kg/min (GR) vs. Propofol 1 mg/kg/h plus Ketamine 5 μg/kg/min and Remifentanil 0.1 μg/kg/min (GK). Main outcome measures were respiratory depression, nausea/vomiting, quality of intraoperative conditions, and discharge time. P≤0.05 was statistically significant (95% CI). Results Respiratory depression was observed in 25 patients in the GR group compared to 9 patients in the GK group (p=0.0035). ERCP was interrupted in 9 cases of GR vs. no cases in GK; patients ventilated without any complication. Mean discharge time was 20±5 min in GK and 35±6 min in GR (p=0.0078) and transfer to the ward delayed because of nausea and vomiting in 30 patients in GR vs. 5 patients in GK (p=0.0024). Quality of intraoperative conditions was rated highly satisfactory in 92% of GK vs. 67% of GR (p=0.028). Conclusions The drug combination used in GK confers clinical advantages because it avoids deep sedation, maintains adequate analgesia with conscious sedation, and achieves lower incidence of postprocedural nausea and vomiting with shorter discharge times. PMID:22936194

Anesthetic dreaming, anesthesia awareness and patient satisfaction after deep sedation with propofol target controlled infusion: A prospective cohort study of patients undergoing day case breast surgery

PubMed Central

Cascella, Marco; Fusco, Roberta; Caliendo, Domenico; Granata, Vincenza; Carbone, Domenico; Muzio, Maria Rosaria; Laurelli, Giuseppe; Greggi, Stefano; Falcone, Francesca; Forte, Cira Antonietta; Cuomo, Arturo

2017-01-01

Background Anesthetic dreaming and anesthesia awareness are well distinct phenomena. Although the incidence of intraoperative awareness is more common among patients who reported a dream after surgery, the exact correlation between the two phenomena remains an unsolved rebus. The main purpose of this study was to investigate anesthetic dreaming, anesthesia awareness and psychological consequences eventually occurred under deep sedation. Intraoperative dreaming experiences were correlated with dream features in natural sleep. Methods Fifty-one patients, undergoing surgical excision of fibroadenomas under a Bispectral index-guided deep sedation anesthesia with propofol target controlled infusion, were enrolled into this prospective study. Psychological assessment was performed through the State Trait Anxiety Inventory. A questionnaire was adopted to register dreaming and anesthesia awareness. Data were collected after emergence (t0), 24 hours (t1), 1 month (t2), 6 months (t3). Results Six patients (12%) reported anesthetic dreaming at t0 confirming the response at each subsequent evaluation. One patient (2%) confirmed dreaming during anesthesia in all, but denied it at t0. There was a high correlation between the intraoperative dream contents and the features of dreams in natural sleep. No cases of anesthesia awareness were detected. A similar level of satisfaction was observed in dreaming and no-dreaming patients. Conclusions Anesthetic dreaming does not seem to influence satisfaction of patients undergoing deep sedation with propofol target controlled infusion. A psychological assessment would seem to improve the evaluation of possible psychological consequences in dreamer patient. PMID:29108303

Anesthetic dreaming, anesthesia awareness and patient satisfaction after deep sedation with propofol target controlled infusion: A prospective cohort study of patients undergoing day case breast surgery.

PubMed

Cascella, Marco; Fusco, Roberta; Caliendo, Domenico; Granata, Vincenza; Carbone, Domenico; Muzio, Maria Rosaria; Laurelli, Giuseppe; Greggi, Stefano; Falcone, Francesca; Forte, Cira Antonietta; Cuomo, Arturo

2017-10-03

Anesthetic dreaming and anesthesia awareness are well distinct phenomena. Although the incidence of intraoperative awareness is more common among patients who reported a dream after surgery, the exact correlation between the two phenomena remains an unsolved rebus. The main purpose of this study was to investigate anesthetic dreaming, anesthesia awareness and psychological consequences eventually occurred under deep sedation. Intraoperative dreaming experiences were correlated with dream features in natural sleep. Fifty-one patients, undergoing surgical excision of fibroadenomas under a Bispectral index-guided deep sedation anesthesia with propofol target controlled infusion, were enrolled into this prospective study. Psychological assessment was performed through the State Trait Anxiety Inventory. A questionnaire was adopted to register dreaming and anesthesia awareness. Data were collected after emergence (t0), 24 hours (t1), 1 month (t2), 6 months (t3). Six patients (12%) reported anesthetic dreaming at t0 confirming the response at each subsequent evaluation. One patient (2%) confirmed dreaming during anesthesia in all, but denied it at t0. There was a high correlation between the intraoperative dream contents and the features of dreams in natural sleep. No cases of anesthesia awareness were detected. A similar level of satisfaction was observed in dreaming and no-dreaming patients. Anesthetic dreaming does not seem to influence satisfaction of patients undergoing deep sedation with propofol target controlled infusion. A psychological assessment would seem to improve the evaluation of possible psychological consequences in dreamer patient.

A Prospective, Randomized Trial in the Emergency Department of Suggestive Audio-Therapy under Deep Sedation for Smoking Cessation.

PubMed

Rodriguez, Robert M; Taylor, Opal; Shah, Sushma; Urstein, Susan

2007-08-01

In a sample of patients undergoing procedural deep sedation in the emergency department (ED), we conducted a prospective, randomized, single-blinded trial of audio-therapy for smoking cessation. We asked subjects about their smoking, including desire to quit (0-10 numerical scale) and number of cigarettes smoked per day. Subjects were randomized to either a control tape (music alone) or a tape with repeated smoking-cessation messages over music. Tapes were started with first doses of sedation and stopped with patient arousal. Telephone follow-up occurred between two weeks and three months to assess the number of cigarettes smoked per day. Study endpoints were self-reported complete cessation and decrease of half or more in total cigarettes smoked per day. One hundred eleven patients were enrolled in the study, 54 to intervention and 57 to control. Mean desire to quit was 7.15 +/- 2.6 and mean cigarettes per day was 17.5 +/- 12.1. We successfully contacted 69 (62%) patients. Twenty-seven percent of intervention and 26% of control patients quit (mean difference = 1%; 95% CI: -22.0% to 18.8%). Thirty-seven percent of intervention and 51% of control patients decreased smoking by half or more (mean difference = 14.6%; 95% CI: -8.7% to 35.6%). Suggestive audio-therapy delivered during deep sedation in the ED did not significantly decrease self-reported smoking behavior.

Dental treatment in patients with severe gag reflex using propofol-remifentanil intravenous sedation

PubMed Central

Shin, Sooil

2017-01-01

Patients with severe gag reflex (SGR) have difficulty getting the treatment they require in local clinics, and many tend to postpone the start of their treatment. To address this problem, dentists have used behavioral techniques and/or pharmacological techniques for treatment. Among the pharmacological methods available, propofol IV sedation is preferred over general anesthesia because it is a simpler procedure. Propofol in combination with remifentanil is characterized by stable sedative effects and quick recovery, leading to a deep sedation. Remifentanil acts to reduce the pain caused by lipid-soluble propofol on injection. The synergistic effects of propofol-remifentanil include reduction in the total amount of drug required to achieve a desired sedation level and anti-emetic effects. In this case report, we outline how the use of propofol-remifentanil IV sedation enabled us to successfully complete a wide range of dental treatments in a patient with SGR. PMID:28879331

Dental treatment in patients with severe gag reflex using propofol-remifentanil intravenous sedation.

PubMed

Shin, Sooil; Kim, Seungoh

2017-03-01

Patients with severe gag reflex (SGR) have difficulty getting the treatment they require in local clinics, and many tend to postpone the start of their treatment. To address this problem, dentists have used behavioral techniques and/or pharmacological techniques for treatment. Among the pharmacological methods available, propofol IV sedation is preferred over general anesthesia because it is a simpler procedure. Propofol in combination with remifentanil is characterized by stable sedative effects and quick recovery, leading to a deep sedation. Remifentanil acts to reduce the pain caused by lipid-soluble propofol on injection. The synergistic effects of propofol-remifentanil include reduction in the total amount of drug required to achieve a desired sedation level and anti-emetic effects. In this case report, we outline how the use of propofol-remifentanil IV sedation enabled us to successfully complete a wide range of dental treatments in a patient with SGR.

The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study.

PubMed

Robijn, Lenzo; Seymour, Jane; Deliens, Luc; Korfage, Ida; Brown, Jayne; Pype, Peter; Van Der Heide, Agnes; Chambaere, Kenneth; Rietjens, Judith

2018-04-01

Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. Qualitative case studies using interviews. Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician's role was largely limited to evaluating if and when the medical criteria were met. Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care.

Comparison between chloral hydrate and propofol-ketamine as sedation regimens for pediatric auditory brainstem response testing.

PubMed

Abulebda, Kamal; Patel, Vinit J; Ahmed, Sheikh S; Tori, Alvaro J; Lutfi, Riad; Abu-Sultaneh, Samer

2017-10-28

The use of diagnostic auditory brainstem response testing under sedation is currently the "gold standard" in infants and young children who are not developmentally capable of completing the test. The aim of the study is to compare a propofol-ketamine regimen to an oral chloral hydrate regimen for sedating children undergoing auditory brainstem response testing. Patients between 4 months and 6 years who required sedation for auditory brainstem response testing were included in this retrospective study. Drugs doses, adverse effects, sedation times, and the effectiveness of the sedative regimens were reviewed. 73 patients underwent oral chloral hydrate sedation, while 117 received propofol-ketamine sedation. 12% of the patients in the chloral hydrate group failed to achieve desired sedation level. The average procedure, recovery and total nursing times were significantly lower in the propofol-ketamine group. Propofol-ketamine group experienced higher incidence of transient hypoxemia. Both sedation regimens can be successfully used for sedating children undergoing auditory brainstem response testing. While deep sedation using propofol-ketamine regimen offers more efficiency than moderate sedation using chloral hydrate, it does carry a higher incidence of transient hypoxemia, which warrants the use of a highly skilled team trained in pediatric cardio-respiratory monitoring and airway management. Copyright © 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Do sedation and analgesia contribute to long-term cognitive dysfunction in critical care survivors?

PubMed

Fernandez-Gonzalo, S; Turon, M; De Haro, C; López-Aguilar, J; Jodar, M; Blanch, L

2018-03-01

Deep sedation during stay in the Intensive Care Unit (ICU) may have deleterious effects upon the clinical and cognitive outcomes of critically ill patients undergoing mechanical ventilation. Over the last decade a vast body of literature has been generated regarding different sedation strategies, with the aim of reducing the levels of sedation in critically ill patients. There has also been a growing interest in acute brain dysfunction, or delirium, in the ICU. However, the effect of sedation during ICU stay upon long-term cognitive deficits in ICU survivors remains unclear. Strategies for reducing sedation levels in the ICU do not seem to be associated with worse cognitive and psychological status among ICU survivors. Sedation strategy and management efforts therefore should seek to secure the best possible state in the mechanically ventilated patient and lower the prevalence of delirium, in order to prevent long-term cognitive alterations. Copyright © 2017 Elsevier España, S.L.U. y SEMNIM. All rights reserved.

Determinants of the administration of continuous palliative sedation: a systematic review.

PubMed

van Deijck, Rogier H P D; Hasselaar, Jeroen G J; Verhagen, Stans C A H H V M; Vissers, Kris C P; Koopmans, Raymond T C M

2013-12-01

Little is known about the determining factors related to the administration of continuous palliative sedation. Knowledge of these determinants may assist physicians in identifying patients who are at high risk of developing refractory symptoms, enable physicians to inform patients, and optimize close monitoring. The aim of this systematic review was to identify determinants of the administration of continuous palliative sedation. A systematic review of PubMed, EMBASE, and CINAHL was performed to identify English, Dutch, and German language papers published from January 1990 through April 2011. Inclusion was based on the following criteria: patient-based research on continuous palliative sedation, studies investigating determinants of palliative sedation and/or comparison between sedated and nonsedated cohorts, and studies using multivariate analyses and of fair to good or good methodological quality. In total, eight papers were reviewed. The following nine factors were found to be associated with the administration of continuous palliative sedation: younger age, male sex, having cancer, feelings of hopelessness, dying in a hospital, living in a Dutch speaking community setting, very nonreligious or extremely nonreligious physicians, physicians working in "other hospital" specialties, and physicians in favor of assisted death. Given the variation in study designs and the limitations of the included studies, the outcomes should be interpreted carefully. Further research is needed, particularly regarding factors that can be influenced and that may alter the course of a patient's symptoms and the patient's eventual need for palliative sedation.

Practice patterns and outcomes associated with early sedation depth in mechanically ventilated patients: a systematic review protocol.

PubMed

Stephens, Robert J; Dettmer, Matthew R; Roberts, Brian W; Fowler, Susan A; Fuller, Brian M

2017-06-09

Mechanical ventilation is a commonly performed intervention in critically ill patients. Frequently, these patients experience deep sedation early in their clinical course. Emerging data suggest that the practice of early deep sedation may negatively impact patient outcomes. The purpose of this review is to assess the world's literature to describe and determine the impact of early deep sedation on the outcomes of mechanically ventilated patients. Randomised controlled trials and non-randomised studies will be eligible for inclusion in this systematic review. With the assistance of a medical librarian, we will comprehensively search MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, and Cochrane Database of Systematic Reviews for peer-reviewed literature. Grey literature from appropriate professional society conferences, held from 2010 to 2017, will be reviewed manually. Two authors will independently review all search results, and disagreements will be resolved through arbitration by a third author. If appropriate, meta-analysis will be used for quantitative analysis of the data. Heterogeneity between studies will be assessed using the I 2 statistic. The proposed systematic review will not collect data that are associated with individual patients and does not require ethical approval. Results of this study will contribute to the understanding of early sedation, identify future research targets and guide early care in mechanically ventilated patients. This systematic review has been registered in the international prospective register of systematic reviews (PROSPERO #CRD42017057264). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Factors that facilitate or constrain the use of continuous sedation at the end of life by physicians and nurses in Belgium: results from a focus group study.

PubMed

Raus, Kasper; Anquinet, Livia; Rietjens, Judith; Deliens, Luc; Mortier, Freddy; Sterckx, Sigrid

2014-04-01

Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this 'paradigm case' was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation.

Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists.

PubMed

Delgado, Jorge; Toro, Rodrigo; Rascovsky, Simon; Arango, Andres; Angel, Gabriel J; Calvo, Victor; Delgado, Jorge A

2015-01-01

Chloral hydrate is a sedative that has been used for magnetic resonance imaging (MRI). To evaluate the use, effectiveness and safety of chloral hydrate administered by radiologists for the sedation of children who require MRI procedures. We retrospectively reviewed the clinical charts for all patients ages 0 - 10 years old who underwent sedation with chloral hydrate for MRI from January 2000 to December 2010. Demographic factors, dose information, indication for MRI, therapeutic failures and adverse reactions to the drug were reviewed. One thousand, seven hundred and three children (946 males, 757 females) with a median age of 2.5 years (range: 4 days - 9.91 years) received chloral hydrate. Moderate to deep sedation was achieved in 1,618/1,703 (95%) of the patients, 35/1,703 (2.1%) of the patients failed to achieve moderate to deep sedation, and 47/1,703 (2.8%) of the patients woke up during MRI examination. Adverse reactions were present in 31/1,703 (1.8%) of the patients. Three severe adverse reactions occurred (0.18%). A single dose of chloral hydrate (40-60 mg/kg) was administered to 1,477/1,703 patients (86.7%). An additional dose of chloral hydrate (10-20 mg/kg), given 15 min after the first dose or when the patient woke up during the MRI examination, was required in 226/1,703 patients (13.3%). The likelihood of requiring an additional dose in children older than 2 years was 2.2 times the likelihood compared to children younger than 2 years (OR = 2.2 [95%CI: 1.6-3.0]). The use of a reduced dose (<50 mg/kg) was not associated with a higher therapeutic failure rate (OR = 1.04 [95%CI 0.57-1.89]). Chloral hydrate is an appropriate sedation option for pediatric patients in MRI services when strict patient selection criteria are met. The use of a reduced dose does not affect the effectiveness of sedation. The lack of data regarding the presence of transient oxygen desaturation, the time to induce sedation and the exact duration of sedation are limitations of this study.

Dutch physicians on the role of the family in continuous sedation.

PubMed

van Tol, Donald G; Kouwenhoven, Pauline; van der Vegt, Bea; Weyers, Heleen

2015-03-01

In order to relieve intractable suffering of a terminal patient, doctors may decide to continuously sedate a patient until the end of life. Little research is done on the role the family plays during the process of continuous sedation. This study aims to get a view of doctors' experiences with continuous sedation, and the role of the family throughout that process. We held in-depth interviews with 48 doctors (19 general practitioners, 16 nursing home doctors and 18 medical specialists). Participants were selected varying in experience and opinions concerning end-of-life decisions. Dutch physicians experience the role of family in continuous sedation as important and potentially difficult. Difficulties may rise especially during the final stages when the patient is no longer conscious and family members are waiting for death to come. Disagreement may arise between physician and family, concerning the dignity of the dying process or the question whether the sedated patient is suffering or not. Some physicians report they hastened the dying process, in order to relieve the families' suffering. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction

PubMed Central

2017-01-01

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy. PMID:29142513

Continuous palliative sedation for cancer and noncancer patients.

PubMed

Swart, Siebe J; Rietjens, Judith A C; van Zuylen, Lia; Zuurmond, Wouter W A; Perez, Roberto S G M; van der Maas, Paul J; van Delden, Johannes J M; van der Heide, Agnes

2012-02-01

Palliative care is often focused on cancer patients. Palliative sedation at the end of life is an intervention to address severe suffering in the last stage of life. To study the practice of continuous palliative sedation for both cancer and noncancer patients. In 2008, a structured questionnaire was sent to 1580 physicians regarding their last patient receiving continuous sedation until death. A total of 606 physicians (38%) filled out the questionnaire, of whom 370 (61%) reported on their last case of continuous sedation (cancer patients: n=282 [76%] and noncancer patients: n=88 [24%]). More often, noncancer patients were older, female, and not fully competent. Dyspnea (odds ratio [OR]=2.13; 95% confidence interval [CI]: 1.22, 3.72) and psychological exhaustion (OR=2.64; 95% CI: 1.26, 5.55) were more often a decisive indication for continuous sedation for these patients. A palliative care team was consulted less often for noncancer patients (OR=0.45; 95% CI: 0.21, 0.96). Also, preceding sedation, euthanasia was discussed less often with noncancer patients (OR=0.42; 95% CI: 0.24, 0.73), whereas their relatives more often initiated discussion about euthanasia than relatives of cancer patients (OR=3.75; 95% CI: 1.26, 11.20). The practice of continuous palliative sedation in patients dying of cancer differs from patients dying of other diseases. These differences seem to be related to the less predictable course of noncancer diseases, which may reduce physicians' awareness of the imminence of death. Increased attention to noncancer diseases in palliative care practice and research is, therefore, crucial as is more attention to the potential benefits of palliative care consultation. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Titrated propofol induction vs. continuous infusion in children undergoing magnetic resonance imaging.

PubMed

Cho, J E; Kim, W O; Chang, D J; Choi, E M; Oh, S Y; Kil, H K

2010-04-01

Propofol is the popular intravenous (i.v.) anaesthetic for paediatric sedation because of its rapid onset and recovery. We compared the efficacy and safety of a single dose and conventional infusion of propofol for sedation in children who underwent magnetic resonance imaging (MRI). This was a double-blind, randomized-controlled study. One hundred and sixty children were assigned to group I (single dose) or II (infusion). Sedation was induced with i.v. propofol 2 mg/kg, and supplemental doses of propofol 0.5 mg/kg were administered until adequate sedation was achieved. After the induction of sedation, we treated patients with a continuous infusion of normal saline at a rate of 0.3 ml/kg/h in group I and the same volume of propofol in group II. In case of inadequate sedation, additional propofol 0.5 mg/kg was administered and the infusion rate was increased by 0.05 ml/kg/h. Induction time, sedation time, recovery time, additional sedation and adverse events were recorded. Recovery time was significantly shorter in group I compared with group II [0 (0-3) vs. 1 (0-3), respectively, P<0.001]. Group I (single dose) had significantly more patients with recovery time 0 compared with group II (infusion) (65/80 vs. 36/80, respectively, P<0.001). Induction and sedation times were not significantly different between groups. There was no significant difference in the frequency of additional sedation and adverse events between groups. A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min.

The Future of Intensive Care Unit Sedation: A Report of Continuous Infusion Ketamine as an Alternative Sedative Agent.

PubMed

Benken, Scott T; Goncharenko, Alexandra

2017-10-01

This report describes a patient case utilizing a nontraditional sedative, continuous infusion ketamine, as an alternative agent for intensive care unit (ICU) sedation. A 27-year-old female presented for neurosurgical management of a coup contrecoup injury, left temporal fracture, epidural hemorrhage (EDH), and temporal contusion leading to sustained mechanical ventilation. The patient experienced profound agitation during mechanical ventilation and developed adverse effects with all traditional sedatives: benzodiazepines, dexmedetomidine, opioids, and propofol. Ketamine was titrated to effect and eliminated the need for other agents. This led to successful ventilator weaning, extubation, and transition of care. Given the unique side effect profile of ketamine, it is imperative that information is disseminated on potential utilization of this agent. More information is needed regarding dosing, monitoring, and long-term effects of utilizing ketamine as a continuous ICU sedative, but given the analgesia, anesthesia, and cardiopulmonary stability, future utilization of this medication for this indication seems promising.

Continuous sedation until death: the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium.

PubMed

Raus, Kasper; Brown, Jayne; Seale, Clive; Rietjens, Judith A C; Janssens, Rien; Bruinsma, Sophie; Mortier, Freddy; Payne, Sheila; Sterckx, Sigrid

2014-02-20

Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. The participants' responses can be captured as different dimensions of 'closeness', i.e. the degree to which one feels connected or 'close' to a certain decision or event. We distinguished four types of 'closeness', namely emotional, physical, decisional, and causal. Using these four dimensions of 'closeness' it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia.

Continuous sedation until death: the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium

PubMed Central

2014-01-01

Background Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. Methods This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. Results The participants’ responses can be captured as different dimensions of ‘closeness’, i.e. the degree to which one feels connected or ‘close’ to a certain decision or event. We distinguished four types of ‘closeness’, namely emotional, physical, decisional, and causal. Using these four dimensions of ‘closeness’ it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. Conclusion Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia. PMID:24555871

Endoscopy and sedation: an inseparable binomial for the gastroenterologist.

PubMed

Crespo, Javier; Terán, Álvaro

2018-04-01

The development of endoscopy and its increasing demand among the population have led to a growing need for propofol-based sedation techniques. Benefit is indisputable for both patients and endoscopists, but some aspects require considering the "who" and "how" of sedation as related to safety and health care costs. Propofol is first-choice in endoscopy for the European Society of Gastrointestinal Endoscopy because of its fast onset of action and short half-life, and many reports exist on its safety when used by gastroenterologists rather than anesthesiologists. In this issue of REED several originals support the efficiency and safety of propofol even for complex, high-risk, or protracted procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and enteroscopy. Propofol may be safely and effectively administered by a team with specific skills acquired through education and using a specific procedure. However, difficulties arise in real-world clinical practice that preclude such training, which in Spain should be included in the MIR (médico interno residente) specialization program curriculum. The Comisión Nacional de Digestivo (Spanish National Commission on Digestive Diseases), sensitive to this training gap, has included in their latest version of the MIR program (under assessment) four additional competences, with number 145 (training in deep sedation) being most relevant here. In addition, the Spanish Society of Gastrointestinal Endoscopy (SEED) has invested significant efforts in sedation training, with over 50 courses on sedation for endoscopists and nurses. Continuing education and training in this field (for instance, refresher courses on advanced cardiopulmonary resuscitation) should be a goal for all endoscopy units. Because of the diversity found among hospitals, with single or multiple endoscopy rooms, efforts should be made to persuade those in charge of gastroenterology and anesthesiology departments to establish the necessary care circuits in order to guarantee patient safety by developing accurate protocols and promoting consensus among the scientific societies involved (Spanish Society for Digestive Diseases [SEPD], SEED and Spanish Society of Anaesthesiology, Resuscitation and Pain Management [SEDAR]) and their respective national commissions.

Pharmacokinetics and effects of alfaxalone after intravenous and intramuscular administration to cats.

PubMed

Rodrigo-Mocholí, D; Escudero, E; Belda, E; Laredo, F G; Hernandis, V; Marín, P

2018-07-01

To determine the pharmacokinetics, and anaesthetic and sedative effects of alfaxalone after I/V and I/M administration to cats. Six European shorthair cats, three males and three females, with a mean weight of 4.21 (SD 0.53) kg and aged 3.8 (SD 0.9) years were enrolled in this crossover, two-treatment, two-period study. Alfaxalone at a dose of 5 mg/kg was administered either I/V or I/M. Blood samples were collected between 2-480 minutes after drug administration and analysed for concentrations of alfaxalone by HPLC. The plasma concentration-time curves were analysed by non-compartmental analysis. Sedation scores were evaluated between 5-120 minutes after drug administration using a numerical rating scale (from 0-18). Intervals from drug administration to sit, sternal and lateral recumbency during the induction phase, and to head-lift, sternal recumbency and standing position during recovery were recorded. The mean half-life and mean residence time of alfaxalone were longer after I/M (1.28 (SD 0.21) and 2.09 (SD 0.36) hours, respectively) than after I/V (0.49 (SD 0.07) and 0.66 (SD 0.16) hours, respectively) administration (p<0.05). Bioavailability after I/M injection of alfaxalone was 94.7 (SD 19.8)%. The mean intervals to sternal and lateral recumbency were longer in the I/M (3.73 (SD 1.99) and 6.12 (SD 0.90) minutes, respectively) compared to I/V (0 minutes for all animals) treated cats (p<0.01). Sedation scores indicative of general anaesthesia (scores >15) were recorded from 5-15 minutes after I/V administration and deep sedation (scores 11-15) at 20 and 30 minutes. Deep sedation was observed from 10-45 minutes after I/M administration. One cat from each group showed hyperkinesia during recovery, and the remainder had an uneventful recovery. Alfaxalone administered I/V in cats provides rapid and smooth induction of anaesthesia. After I/M administration, a longer exposure to the drug and an extended half life were obtained compared to I/V administration. Therefore I/M administration of alfaxalone could be a reliable, suitable and easy route in cats, taking into account that alfaxalone has a slower onset of sedation than when given I/V and achieves deep sedation rather than general anaesthesia.

Continuous Positive Airway Pressure Prevents Hypoxia in Dental Patient with Obstructive Sleep Apnea Syndrome under Intravenous Sedation.

PubMed

Kasatkin, Anton A; Reshetnikov, Aleksei P; Urakov, Aleksandr L; Baimurzin, Dmitrii Y

2017-01-01

Use of sedation in patients with obstructive sleep apnea (OSA) in dentistry is limited. Hypoxia may develop during medication sleep in dental patients with OSA because of repetitive partial or complete obstruction of the upper airway. In this regard, anesthesiologists prefer not to give any sedative to surgical patients with OSA or support the use of general anesthesia due to good airway control. We report a case where we could successfully sedate a dental patient with OSA using intraoperative continuous positive airway pressure (CPAP) without hypoxia. Use of sedation and intraoperative CPAP in patients with OSA may be considered only if the effectiveness at home CPAP therapy is proven.

Dissociating speech perception and comprehension at reduced levels of awareness

PubMed Central

Davis, Matthew H.; Coleman, Martin R.; Absalom, Anthony R.; Rodd, Jennifer M.; Johnsrude, Ingrid S.; Matta, Basil F.; Owen, Adrian M.; Menon, David K.

2007-01-01

We used functional MRI and the anesthetic agent propofol to assess the relationship among neural responses to speech, successful comprehension, and conscious awareness. Volunteers were scanned while listening to sentences containing ambiguous words, matched sentences without ambiguous words, and signal-correlated noise (SCN). During three scanning sessions, participants were nonsedated (awake), lightly sedated (a slowed response to conversation), and deeply sedated (no conversational response, rousable by loud command). Bilateral temporal-lobe responses for sentences compared with signal-correlated noise were observed at all three levels of sedation, although prefrontal and premotor responses to speech were absent at the deepest level of sedation. Additional inferior frontal and posterior temporal responses to ambiguous sentences provide a neural correlate of semantic processes critical for comprehending sentences containing ambiguous words. However, this additional response was absent during light sedation, suggesting a marked impairment of sentence comprehension. A significant decline in postscan recognition memory for sentences also suggests that sedation impaired encoding of sentences into memory, with left inferior frontal and temporal lobe responses during light sedation predicting subsequent recognition memory. These findings suggest a graded degradation of cognitive function in response to sedation such that “higher-level” semantic and mnemonic processes can be impaired at relatively low levels of sedation, whereas perceptual processing of speech remains resilient even during deep sedation. These results have important implications for understanding the relationship between speech comprehension and awareness in the healthy brain in patients receiving sedation and in patients with disorders of consciousness. PMID:17938125

End-of-life, euthanasia, and assisted suicide: An update on the situation in France.

PubMed

Aubry, R

2016-12-01

On February 2, 2016, the French parliament adopted legislation creating new rights for the terminally ill. The text modifies and reinforces the rights of patients to end-of-life care and strengthens the status of surrogate decision makers. Under the new regulations, advance directives become legally binding though not unenforceable. Two types of advance directives are distinguished depending on whether the person is suffering or not from a serious illness when drafting them. The attending physician must abide by the patient's advance directives except in three situations: there is a life-threatening emergency; the directives are manifestly inappropriate; the directives are not compatible with the patient's medical condition. There is no time limit on the validity of advance directives. They are to be written in concordance with a model elaborated by the French superior health authority. This model takes into account the person's knowledge (or not) of having a serious illness when drafting his/her advance directives. In all likelihood, physicians will be called upon to help patients elaborate their advance directives. The law also has a provision for a national registry - potentially the shared medical file - to be designed as a reference source to facilitate storage, accessibility and safety of advance directives. The law introduces the right to continuous deep sedation until death in three specific situations: (i) at the patient's request when the short-term prognosis is death and continuous deep sedation is the only alternative for relieving the patient's suffering or one or more otherwise uncontrollable symptoms; (ii) at the patient's request when the patient chooses to withdraw artificial life-sustaining treatment and such withdrawal would be rapidly life-shortening and susceptible to cause unbearable suffering; (iii) when the patient is unable to express his/her wishes and the collegiate medical decision is to withdraw aggressive futile life-sustaining treatment; continuous deep sedation is mandatory when the patient presents signs of suffering or when the patient's suffering cannot be evaluated due to the patient's cerebral or cognitive state. The law stipulates prior control of such practices, implying the development of a new type of collegiate procedure for medical decision-making. Satisfactory application of this new law will depend greatly on the implementing decrees. It will also depend on the implementation of a genuine policy for the development of palliative care. Professional guidelines will be needed. Several issues relevant to the field of neurology remain unresolved or are introduced by the new regulations. Further in-depth reflection and research are need. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

A new method for determining levels of sedation in dogs: A pilot study with propofol and a novel neuroactive steroid anesthetic.

PubMed

Youngblood, B L; Ueyama, Y; Muir, W W; Belfort, G M; Hammond, R H; Dai, J; Salituro, F G; Robichaud, A J; Doherty, J J

2018-05-22

Different levels of consciousness are required in order to perform different medical procedures. Sedation scales established to objectively define various levels of sedation in humans have not been thoroughly characterized in non-human species. Postural changes in rats or dogs are useful as gross measures of sedation but are inadequate for quantitative assessment since graded levels of sedation are difficult to delineate and obscured by movement abnormalities. A new canine sedation scoring (CSS) method was developed based on the modified observer's assessment of alertness and sedation score (MOAA/S) used in humans. The method employed a combination of physical, auditory and somatosensory stimuli of increasing intensity. Cardiovascular, respiratory, and a neurophysiological measure of sedation (bispectral index: BIS) data were recorded. Validation studies were performed following intravenous loading and constant rate infusion of propofol or a novel synthetic neuroactive steroid (SGE-746). Four levels of consciousness were identified: 1) Awake, 2) Moderate Sedation (MS), 3) Deep Sedation (DS) and 4) General Anesthesia (GA). Cardiorespiratory measurements obtained after bolus administration of propofol and SGE-746 and at the end of each CRI remained within normal limits. Canine sedation scores correlated with BIS for SGE-746. SGE-746 exhibited a more gradual exposure-response relationship than propofol. Larger increases in the plasma concentration from awake values were required to achieve different levels of sedation with SGE-746 compared to propofol. No other canine sedation scoring methods are widely accepted. A CSS method, based on the human MOAA/S scale defined four levels of consciousness in dogs and provided better resolution of sedation depth than BIS alone. Copyright © 2018 Elsevier B.V. All rights reserved.

High-Flow Nasal Oxygen in Patient With Obstructive Sleep Apnea Undergoing Awake Craniotomy: A Case Report.

PubMed

Wong, Jaclyn W M; Kong, Amy H S; Lam, Sau Yee; Woo, Peter Y M

2017-12-15

Patients with obstructive sleep apnea are frequently considered unsuitable candidates for awake craniotomy due to anticipated problems with oxygenation, ventilation, and a potentially difficult airway. At present, only a handful of such accounts exist in the literature. Our report describes the novel use of high-flow nasal oxygen therapy for a patient with moderate obstructive sleep apnea who underwent an awake craniotomy under deep sedation. The intraoperative application of high-flow nasal oxygen therapy achieved satisfactory oxygenation, maintained the partial carbon dioxide pressure within a reasonable range even during periods of deep sedation, permitted responsive patient monitoring during mapping, and provided excellent patient and surgeon satisfaction.

Regional entropy of functional imaging signals varies differently in sensory and cognitive systems during propofol-modulated loss and return of behavioral responsiveness.

PubMed

Liu, Xiaolin; Lauer, Kathryn K; Ward, B Douglas; Roberts, Christopher J; Liu, Suyan; Gollapudy, Suneeta; Rohloff, Robert; Gross, William; Xu, Zhan; Chen, Shanshan; Wang, Lubin; Yang, Zheng; Li, Shi-Jiang; Binder, Jeffrey R; Hudetz, Anthony G

2018-05-08

The level and richness of consciousness depend on information integration in the brain. Altered interregional functional interactions may indicate disrupted information integration during anesthetic-induced unconsciousness. How anesthetics modulate the amount of information in various brain regions has received less attention. Here, we propose a novel approach to quantify regional information content in the brain by the entropy of the principal components of regional blood oxygen-dependent imaging signals during graded propofol sedation. Fifteen healthy individuals underwent resting-state scans in wakeful baseline, light sedation (conscious), deep sedation (unconscious), and recovery (conscious). Light sedation characterized by lethargic behavioral responses was associated with global reduction of entropy in the brain. Deep sedation with completely suppressed overt responsiveness was associated with further reductions of entropy in sensory (primary and higher sensory plus orbital prefrontal cortices) but not high-order cognitive (dorsal and medial prefrontal, cingulate, parietotemporal cortices and hippocampal areas) systems. Upon recovery of responsiveness, entropy was restored in the sensory but not in high-order cognitive systems. These findings provide novel evidence for a reduction of information content of the brain as a potential systems-level mechanism of reduced consciousness during propofol anesthesia. The differential changes of entropy in the sensory and high-order cognitive systems associated with losing and regaining overt responsiveness are consistent with the notion of "disconnected consciousness", in which a complete sensory-motor disconnection from the environment occurs with preserved internal mentation.

The risk of shorter fasting time for pediatric deep sedation.

PubMed

Clark, Mathew; Birisci, Esma; Anderson, Jordan E; Anliker, Christina M; Bryant, Micheal A; Downs, Craig; Dalabih, Abdallah

2016-01-01

Current guidelines adopted by the American Academy of Pediatrics calls for prolonged fasting times before performing pediatric procedural sedation and analgesia (PSA). PSA is increasingly provided to children outside of the operating theater by sedation trained pediatric providers and does not require airway manipulation. We investigated the safety of a shorter fasting time compared to a longer and guideline compliant fasting time. We tried to identify the association between fasting time and sedation-related complications. This is a prospective observational study that included children 2 months to 18 years of age and had an American Society of Anesthesiologists physical status classification of I or II, who underwent deep sedation for elective procedures, performed by pediatric critical care providers. Procedures included radiologic imaging studies, electroencephalograms, auditory brainstem response, echocardiograms, Botox injections, and other minor surgical procedures. Subjects were divided into two groups depending on the length of their fasting time (4-6 h and >6 h). Complication rates were calculated and compared between the three groups. In the studied group of 2487 subjects, 1007 (40.5%) had fasting time of 4-6 h and the remaining 1480 (59.5%) subjects had fasted for >6 h. There were no statistically significant differences in any of the studied complications between the two groups. This study found no difference in complication rate in regard to the fasting time among our subjects cohort, which included only healthy children receiving elective procedures performed by sedation trained pediatric critical care providers. This suggests that using shorter fasting time may be safe for procedures performed outside of the operating theater that does not involve high-risk patients or airway manipulation.

Euthanasia and palliative sedation in Belgium.

PubMed

Cohen-Almagor, Raphael; Ely, E Wesley

2018-01-04

The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Fine-Grained Parcellation of Brain Connectivity Improves Differentiation of States of Consciousness During Graded Propofol Sedation.

PubMed

Liu, Xiaolin; Lauer, Kathryn K; Ward, B Douglas; Roberts, Christopher J; Liu, Suyan; Gollapudy, Suneeta; Rohloff, Robert; Gross, William; Xu, Zhan; Chen, Guangyu; Binder, Jeffrey R; Li, Shi-Jiang; Hudetz, Anthony G

2017-08-01

Conscious perception relies on interactions between spatially and functionally distinct modules of the brain at various spatiotemporal scales. These interactions are altered by anesthesia, an intervention that leads to fading consciousness. Relatively little is known about brain functional connectivity and its anesthetic modulation at a fine spatial scale. Here, we used functional imaging to examine propofol-induced changes in functional connectivity in brain networks defined at a fine-grained parcellation based on a combination of anatomical and functional features. Fifteen healthy volunteers underwent resting-state functional imaging in wakeful baseline, mild sedation, deep sedation, and recovery of consciousness. Compared with wakeful baseline, propofol produced widespread, dose-dependent functional connectivity changes that scaled with the extent to which consciousness was altered. The dominant changes in connectivity were associated with the frontal lobes. By examining node pairs that demonstrated a trend of functional connectivity change between wakefulness and deep sedation, quadratic discriminant analysis differentiated the states of consciousness in individual participants more accurately at a fine-grained parcellation (e.g., 2000 nodes) than at a coarse-grained parcellation (e.g., 116 anatomical nodes). Our study suggests that defining brain networks at a high granularity may provide a superior imaging-based distinction of the graded effect of anesthesia on consciousness.

Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model.

PubMed

Hoffman, George M; Nowakowski, Rhonda; Troshynski, Todd J; Berens, Richard J; Weisman, Steven J

2002-02-01

Guidelines for risk reduction during procedural sedation from the American Academy of Pediatrics (AAP) and the American Society of Anesthesiologists (ASA) rely on expert opinion and consensus. In this article, we tested the hypothesis that application of an AAP/ASA-structured model would reduce the risk of sedation-related adverse events. Prospectively coded sedation records were abstracted by a hospital quality improvement specialist with practical and administrative experience in pediatric sedation. Process variables included notation of nulla per os (NPO) status, performance of a guided risk assessment, assignment of ASA physical status score, obtaining informed consent, generation of a sedation plan, and assessment of sedation level using a quantitative scoring system. Content variables included adherence to AAP NPO guidelines, ASA class, target sedation level, actual sedation level, age, procedure, and drugs used. Complication risk was assessed by logistic regression and Mantel-Haenszel odds ratios (OR). Complications were identified in 40 of 960 records (4.2%). The complication rate was 34 of 895 (3.8%) with planned conscious sedation and 6 of 65 (9.2%) with planned deep sedation ([DS]; OR: 2.6). Complications were reduced by performance of structured risk assessment (OR: 0.10), adherence to all process guidelines (OR: 0), and avoiding actual DS (OR: 0.4). The only drug associated with higher risk was chloral hydrate (OR: 2.1). Failure to adhere to NPO guidelines did not increase risk in this assessment; however, the adverse event rate was 0 if all process guidelines were followed. Presedation assessment reduces complications of DS. Repeated assessment of sedation score reduces the risk of inadvertent DS. The data provide direct evidence that AAP/ASA guidelines can reduce the risk of pediatric procedural sedation.

Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists

PubMed Central

Orel, Rok; Brecelj, Jernej; Dias, Jorge Amil; Romano, Claudio; Barros, Fernanda; Thomson, Mike; Vandenplas, Yvan

2015-01-01

AIM: To present evidence and formulate recommendations for sedation in pediatric gastrointestinal (GI) endoscopy by non-anesthesiologists. METHODS: The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords “endoscopy, GI”, “endoscopy, digestive system” AND “sedation”, “conscious sedation”, “moderate sedation”, “deep sedation” and “hypnotics and sedatives” for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for (upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed. RESULTS: From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented. CONCLUSION: General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations. PMID:26240691

Pressure Injury Progression and Factors Associated With Different End-Points in a Home Palliative Care Setting: A Retrospective Chart Review Study.

PubMed

Artico, Marco; D'Angelo, Daniela; Piredda, Michela; Petitti, Tommasangelo; Lamarca, Luciano; De Marinis, Maria Grazia; Dante, Angelo; Lusignani, Maura; Matarese, Maria

2018-07-01

Patients with advanced illnesses show the highest prevalence for pressure injuries. In the palliative care setting, the ultimate goal is injury healing, but equally important is wound maintenance, wound palliation (wound-related pain and symptom management), and primary and secondary wound prevention. To describe the course of healing for pressure injuries in a home palliative care setting according to different end-points, and to explore patient and caregiver characteristics and specific care activities associated with their achievement. Four-year retrospective chart review of 669 patients cared for in a home palliative care service, of those 124 patients (18.5%) had at least one pressure injury with a survival rate less than or equal to six months. The proportion of healed pressure injuries was 24.4%. Of the injuries not healed, 34.0% were in a maintenance phase, whereas 63.6% were in a process of deterioration. Body mass index (P = 0.0014), artificial nutrition (P = 0.002), and age <70 years (P = 0.022) emerged as predictive factors of pressure injury complete healing. Artificial nutrition, age, male caregiver (P = 0.034), and spouse (P = 0.036) were factors significantly associated with a more rapid pressure injury healing. Continuous deep sedation was a predictive factor for pressure injury deterioration and significantly associated with a more rapid worsening. Pressure injury healing is a realistic aim in home palliative care, particularly for injuries not exceeding Stage II occurring at least two weeks before death. When assessing pressure injuries, our results highlight the need to also pay attention to artificial nutrition, continuous deep sedation, and the caregiver's role and gender. Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Bispectral analysis during deep sedation of pediatric oral surgery patients.

PubMed

Overly, Frank L; Wright, Robert O; Connor, Francis A; Jay, Gregory D; Linakis, James G

2005-02-01

Bispectral (BIS) analysis uses electroencephalogram information from a forehead electrode to calculate an index score (0 to 100; 0 = coma; 90 to 100 = awake). This index score correlates with the level of alertness in anesthetized patients. Classically, sedation has been monitored with clinical sedation scales such as the Observers Assessment of Alertness Sedation Scale (OAA/S), Modified Ramsey Scale, or a Visual Analog Scale (VAS). Our objective was to determine the correlation between clinical sedation scales and BIS index in pediatric patients undergoing sedation in an outpatient oral surgery setting. Prospective cohort study of patients aged 2 to 17 years undergoing sedation in an outpatient oral surgery office. Sedation was performed in the customary manner with the addition of BIS monitoring. Three clinical sedation scores (OAA/S: 5 to 1; 5 = awake, 1 = unresponsive; Modified Ramsey: 1 to 6; 1-2 = awake, 6 = unresponsive; VAS: 0 to 10; 0 = awake, 10 = unresponsive) were assigned every 5 minutes by an investigator blinded to the BIS index. Data were analyzed using a repeated measures linear regression model. Sixteen subjects undergoing oral surgery, ages 4.5 years to 17 years, were enrolled, mean age 12.6 years +/- 4.3 years (standard deviation). Patients received methohexital in addition to 1 or more of the following: nitrous oxide, fentanyl, or midazolam. The results of the longitudinal regression analysis showed a highly significant association between the sedation scales and the BIS index. The BIS monitor may be a useful adjunct in monitoring pediatric patients receiving sedation in the outpatient setting.

Increasing the Capabilities of the Oral Surgery Team With a RN

DTIC Science & Technology

2005-04-01

deep sedation and general anesthesia in dentistry . Retrieved October 10, 2004 from the World Wide Web: http://www.ada.org/prof/resources/positions... General Dentistry , 2005). Increasing the capabilities 7 However, this is only part of the story. Oral surgery procedures range from the relatively...aid in the management of sedation and/or general anesthesia administration in the office. Five modules are covered in the course, each with its own

Haematological effects of 2-phenoxyethanol and etomidate in carp (Cyprinus carpio L.).

PubMed

Witeska, Malgorzata; Dudyk, Joanna; Jarkiewicz, Natalia

2015-09-01

To evaluate the effects of handling alone versus handling under anaesthesia with 2-phenoxyethanol or etomidate on haematological parameters in carp. Prospective, randomized, laboratory experiment. Seventy-two juvenile carp (Cyprinus carpio) weighing 35.9 ± 10.4 g were divided into six groups of 12 fish. Either 2-phenoxyethanol or 2% etomidate were administered to induce deep anaesthesia (0.3 mL L(-1) and 0.6 mL L(-1) , respectively) or deep sedation (0.15 mL L(-1) and 0.3 mL L(-1) , respectively). Fish were handled with and without sedation. Blood was sampled at 1 hour and 1 week post-treatment. Phagocyte oxidative activity [nitrotetrazolium blue reduction test (NBT)] and differential erythrocyte [red blood cell (RBC)] and leukocyte (white blood cell) counts were evaluated. At 1 hour after the induction of anaesthesia, haematocrit (Ht) and haemoglobin (Hb) were increased in fish anaesthetized with 2-phenoxyethanol, and mean corpuscular haemoglobin (MCH) was increased in fish anaesthetized with etomidate. At 1 week, an increase in RBC, erythroblastosis, erythrocyte damage, lymphopenia, neutrophilia, monocytosis and thrombocytosis occurred in both groups. Red blood parameters did not change 1 hour after handling alone, but after 1 week Ht, Hb and mean cell volume decreased, whereas MCH concentration (MCHC) and abnormal erythrocytes increased. Lymphopenia, neutrophilia, monocytosis, thrombocytosis and a decrease in NBT occurred. Fish handled under sedation showed an increase in Hb and MCHC followed by a decrease at 1 week in Ht, Hb and MCH, erythroblastosis and increased abnormal erythrocytes. Lymphopenia and neutrophilia were less pronounced than in fish handled without sedation, but a decrease in NBT was noted at 1 week post-treatment. Deep anaesthesia with 2-phenoxyethanol or etomidate induced significant haematological alterations in juvenile carp. Deep sedation reduced the immediate immunosuppressive effects of handling but did not eliminate longterm effects. These anaesthetics should be avoided during experimental procedures involving haematological measurements. In contexts that require the short-term handling of carp, these drugs should be used with caution in view of their possible side effects. © 2014 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia.

Comparison of intraoperative behavioral and hormonal responses to noxious stimuli between mares sedated with caudal epidural detomidine hydrochloride or a continuous intravenous infusion of detomidine hydrochloride for standing laparoscopic ovariectomy.

PubMed

Virgin, Joanna; Hendrickson, Dean; Wallis, Ty; Rao, Sangeeta

2010-08-01

To compare the presence or absence of pain, pain-related behavioral responses, and hormonal responses to noxious stimuli during standing laparoscopic ovariectomy in mares sedated with continuous intravenous (IV) detomidine infusion and caudal epidural detomidine. A double blind prospective study. Mares (n=12) Mares were divided into 2 treatment groups; 6 were sedated using continuous IV detomidine infusion and 6 were sedated with caudal epidural detomidine. All mares received IV xylazine (0.33 mg/kg) and butorphanol tartrate (5 mg) premedication before detomidine administration. Venous blood samples were taken to assess serum cortisol levels in each mare at 4 time points: a baseline cortisol measurement after the mares' arrival to the clinic, 10 minutes before surgery, at the removal of the 2nd ovary, and 10 minutes postsurgery. Two surgeons performed bilateral ovariectomy and at 8 time points involving surgical manipulations, noted the presence or absence of pain (yes/no) and scored the patient's response on a 10 cm visual analogue scale (VAS) for pain assessment with 0 indicating no pain responses and 10 cm indicating pain so severe that the mare required additional sedation or analgesia to complete the procedure. Each mare was also assigned a VAS score by each surgeon for the overall satisfaction of analgesia during the entire procedure. Serum cortisol levels between the 2 detomidine administration groups differed significantly at the baseline (precortisol) measurement but not at the 3 remaining time points. Seven of the procedures within the surgeries did not differ significantly in VAS scores between the 2 groups. The initial grasp of the left ovary (the 1st ovary) in the continuous infusion group had a significantly higher (P=.05) median VAS score compared with the caudal epidural group. Mares sedated with a continuous IV infusion of detomidine have similar hormonal and behavioral responses to painful stimuli during standing laparoscopic ovariectomy as mares sedated with caudal epidural detomidine. Sedation using a continuous IV infusion of detomidine can be used for laparoscopic ovariectomy in mares.

Clinical characteristics and course of dying in patients with amyotrophic lateral sclerosis withdrawing from long-term ventilation.

PubMed

Kettemann, Dagmar; Funke, Andreas; Maier, André; Rosseau, Simone; Meyer, Robert; Spittel, Susanne; Münch, Christoph; Meyer, Thomas

2017-02-01

Non-invasive ventilation (NIV) or tracheotomy with invasive ventilation (TIV) are treatment options in ALS. However, a proportion of patients receiving long-term ventilation decide to have it withdrawn. The objective of this study was to analyse the clinical characteristics and palliative approaches in ALS patients withdrawing from long-term ventilation (WLTV). In a cohort study, two different palliative concepts in WLTV were studied: (1) augmented symptom control (ASC; sedation not intended) in patients with ventilator-free tolerance; (2) continuous deep sedation (CDS; sedation intended) in patients without ventilator-free tolerance. Results showed that WLTV was realised in 49 ALS patients (NIV = 13; TIV = 36). Mean daily ventilation was 23.4 h. The ALS Functional Rating Scale (ALSFRS-R) was low (5.6 of 48). Forty-one per cent of patients (n = 20) presented with ophthalmoplegia. ASC was performed in 20 patients, CDS in 29 patients. The mean time to death following disconnection was 32 (0.3-164) h during ASC and 0.3 (0.2-0.6) h in CDS. In conclusion, a low ALSFRS-R, high incidence of ophthalmoplegia and extended ventilator dependency were found before WLTV. The presence or absence of ventilator-free tolerance determined the approach to the management of symptoms, the setting for immediate end-of-life care and the course of dying in WLTV.

Dental treatment for handicapped patients; sedation vs general anesthesia and update of dental treatment in patients with different diseases.

PubMed

Corcuera-Flores, J-R; Delgado-Muñoz, J-M; Ruiz-Villandiego, J-C; Maura-Solivellas, I; Machuca-Portillo, G

2014-03-01

Dental treatment on Handicapped Patients is often difficult because many people with a wide range of ages (from children to the elderly) with different pathologies that can affect the oral cavity and differ widely are included in this group. This situation creates some controversy, because according to pathology, each patient will be treated differently depending on collaboration, general health status, age or medication used to treat this pathologies. According to this situation we can opt for an outpatient treatment without any kind of previous medication, a treatment under conscious or deep sedation or a under general anesthesia treatment. With this systematic review is intended to help clarify in which cases patients should be treated under general anesthesia, sedation (conscious or deep) or outpatient clinic without any medication, as well as clarify what kind of treatments can be carried in private dental clinics and which should be carried out in a hospital. It will also discuss the most common diseases among this group of patients and the special care to be taken for their dental treatment.

Balanced propofol sedation administered by nonanesthesiologists: The first Italian experience

PubMed Central

Repici, Alessandro; Pagano, Nico; Hassan, Cesare; Carlino, Alessandra; Rando, Giacomo; Strangio, Giuseppe; Romeo, Fabio; Zullo, Angelo; Ferrara, Elisa; Vitetta, Eva; Ferreira, Daniel de Paula Pessoa; Danese, Silvio; Arosio, Massimo; Malesci, Alberto

2011-01-01

AIM: To assess the efficacy and safety of a balanced approach using midazolam in combination with propofol, administered by non-anesthesiologists, in a large series of diagnostic colonoscopies. METHODS: Consecutive patients undergoing diagnostic colonoscopy were sedated with a single dose of midazolam (0.05 mg/kg) and low-dose propofol (starter bolus of 0.5 mg/kg and repeated boluses of 10 to 20 mg). Induction time and deepest level of sedation, adverse and serious adverse events, as well as recovery times, were prospectively assessed. Cecal intubation and adenoma detection rates were also collected. RESULTS: Overall, 1593 eligible patients were included. The median dose of propofol administered was 70 mg (range: 40-120 mg), and the median dose of midazolam was 2.3 mg (range: 2-4 mg). Median induction time of sedation was 3 min (range: 1-4 min), and median recovery time was 23 min (range: 10-40 min). A moderate level of sedation was achieved in 1561 (98%) patients, whilst a deep sedation occurred in 32 (2%) cases. Transient oxygen desaturation requiring further oxygen supplementation occurred in 8 (0.46%; 95% CI: 0.2%-0.8%) patients. No serious adverse event was observed. Cecal intubation and adenoma detection rates were 93.5% and 23.4% (27.8% for male and 18.5% for female, subjects), respectively. CONCLUSION: A balanced sedation protocol provided a minimalization of the dose of propofol needed to target a moderate sedation for colonoscopy, resulting in a high safety profile for non-anesthesiologist propofol sedation. PMID:21987624

A Survey of Hospice and Palliative Care Physicians Regarding Palliative Sedation Practices.

PubMed

Lux, Michael R; Protus, Bridget McCrate; Kimbrel, Jason; Grauer, Phyllis

2017-04-01

Patients nearing the end of life may experience symptoms that are refractory to standard therapeutic options. Physicians may consider palliative sedation to relieve intolerable suffering. There is limited clinical literature regarding preferred medications for palliative sedation. To determine the preferred medications physicians use when implementing palliative sedation. An Internet-based, cross-sectional survey of hospice and palliative care physicians in the United States. A link to the survey was e-mailed to 3130 physician members of the American Academy of Hospice and Palliative Medicine, of which 381 physicians completed the survey. Physicians were not required to answer all questions. Nearly all (n = 335, 99%) respondents indicated that palliative sedation may be used (acceptable by 73% [n = 248] for refractory symptoms and acceptable by 26% [n = 87] only for imminently dying patients). Seventy-nine percent (n = 252) believed that opioids should not be used to induce palliative sedation but should be continued to provide pain control. Midazolam was the most commonly selected first-line choice for palliative sedation (n = 155, 42%). The most commonly reported second-line agents for the induction of palliative sedation were lorazepam, midazolam (for those who did not select midazolam as first-line agent), and phenobarbital with a reported preference of 20% (n = 49), 19% (n = 46), and 17% (n = 40), respectively. Of the physicians surveyed, 99% (n = 335) felt that palliative sedation is a reasonable treatment modality. Midazolam was considered a drug of choice for inducing and maintaining sedation, and opioids were continued for pain control.

Pressure during decision making of continuous sedation in end-of-life situations in Dutch general practice

PubMed Central

2012-01-01

Background Little is known about pressure from patients or relatives on physician’s decision making of continuous palliative sedation. We aim to describe experienced pressure by general practitioners (GPs) in cases of continuous sedation after the introduction of the Dutch practice guideline, using a questionnaire survey. Methods A sample of 918 Dutch GPs were invited to fill out a questionnaire about their last patient under continuous sedation. Cases in which GPs experienced pressure from the patient, relatives or other persons were compared to those without pressure. Results 399 of 918 invite GPs (43%) returned the questionnaire and 250 provided detailed information about their most recent case of continuous sedation. Forty-one GPs (16%) indicated to have experienced pressure from the patient, relatives or colleagues. In GPs younger than 50, guideline knowledge was not related to experienced pressure, whereas in older GPs, 15% with and 36% without guideline knowledge reported pressure. GPs experienced pressure more often when patients had psychological symptoms (compared to physical symptoms only) and when patients had a longer estimated life expectancy. A euthanasia request of the patient coincided with a higher prevalence of pressure for GPs without, but not for GPs with previous experience with euthanasia. GPs who experienced pressure had consulted a palliative consultation team more often than GPs who did not experience pressure. Conclusion One in six GPs felt pressure from patients or relatives to start sedation. This pressure was related to guideline knowledge, especially in older GPs, longer life expectancy and the presence of a euthanasia request, especially for GPs without previous experience of euthanasia. PMID:22759834

Dexmedetomidine, Ketamine, and Midazolam for Oral Rehabilitation: A Case Report

PubMed Central

Kim, Bill W. S.; Peskin, Robert M.

2015-01-01

Intravenous sedation is frequently provided by anesthesiologists for phobic patients undergoing elective dental treatment in outpatient settings. Propofol is one of the most commonly used anesthetic agents that can result in apnea and respiratory depression, thereby posing potential difficulties with perioperative airway management. Dexmedetomidine has been utilized successfully in intravenous sedation for a wide variety of procedures and holds potential as an alternative to propofol in outpatient dental settings. However, as a single agent, it may not provide adequate depth of sedation and analgesia for oral rehabilitation. In this case report we demonstrate an effective alternative intravenous deep-sedation technique for an adult phobic patient undergoing oral rehabilitation utilizing 3 agents in combination: dexmedetomidine, ketamine, and midazolam. This combination of agents may be especially useful for those patients with a history of substance abuse, where administration of opioids may be undesirable or contraindicated. PMID:25849472

Dexmedetomidine, ketamine, and midazolam for oral rehabilitation: a case report.

PubMed

Kim, Bill W S; Peskin, Robert M

2015-01-01

Intravenous sedation is frequently provided by anesthesiologists for phobic patients undergoing elective dental treatment in outpatient settings. Propofol is one of the most commonly used anesthetic agents that can result in apnea and respiratory depression, thereby posing potential difficulties with perioperative airway management. Dexmedetomidine has been utilized successfully in intravenous sedation for a wide variety of procedures and holds potential as an alternative to propofol in outpatient dental settings. However, as a single agent, it may not provide adequate depth of sedation and analgesia for oral rehabilitation. In this case report we demonstrate an effective alternative intravenous deep-sedation technique for an adult phobic patient undergoing oral rehabilitation utilizing 3 agents in combination: dexmedetomidine, ketamine, and midazolam. This combination of agents may be especially useful for those patients with a history of substance abuse, where administration of opioids may be undesirable or contraindicated.

Comparative antinociceptive and sedative effects of epidural romifidine and detomidine in buffalo (Bubalus bubalis).

PubMed

Marzok, M A; El-Khodery, S A

2017-07-01

In this study, comparative antinociceptive and sedative effects of epidural administration of romifidine and detomidine in buffalo were evaluated. Eighteen healthy adult buffalo, allocated randomly in three groups (two experimental and one control; n=6) received either 50 μg/kg of romifidine or detomidine diluted in sterile saline (0.9 per cent) to a final volume of 20 ml, or an equivalent volume of sterile saline epidurally. Antinociception, sedation and ataxia parameters were recorded immediately after drug administration. Epidural romifidine and detomidine produced mild to deep sedation and complete antinociception of the perineum, inguinal area and flank, and extended distally to the coronary band of the hindlimbs and cranially to the chest area. Times to onset of antinociception and sedation were significantly shorter with romifidine than with detomidine. The antinociceptive and sedative effects were significantly longer with romifidine than with detomidine. Romifidine or detomidine could be used to provide a reliable, long-lasting and cost-effective method for achieving epidural anaesthesia for standing surgical procedures in buffalo. Romifidine induces a longer antinociceptive effect and a more rapid onset than detomidine. Consequently, epidural romifidine may offer better therapeutic benefits in the management of acute postoperative pain. British Veterinary Association.

Continuing Versus New Prescriptions for Sedative-Hypnotic Medications: United States, 2005–2012

PubMed Central

Spira, Adam P.; Depp, Colin A.; Mojtabai, Ramin

2016-01-01

Objectives. To assess trends in continuing and new prescriptions for sedative-hypnotic medications, including benzodiazepines (BZDs) and non-BZD receptor agonists (nBZRAs). Methods. Data came from the National Ambulatory Medical Care Survey and comprised 287 288 randomly sampled patient visits. Physicians reported medications prescribed and whether they were “continuing” or “new” prescriptions. We assessed trends in continuing BZD, new BZD, continuing nBZRA, and new nBZRA prescriptions from 2005 to 2012. Results. Proportions of visits with continuing prescriptions increased from 3.4% in 2005 to 4.7% in 2012 (P < .01) for BZDs, and from 1.0% to 1.7% (P < .01) for nBZRAs. We noted no changes in new prescriptions. We observed the same patterns across patient age and physician specialties, except psychiatry. Despite no growth over time, the prevalence of visits involving continuing and new BZD and nBZRA prescriptions was much higher in psychiatry than in primary care and other specialties. Conclusions. Increased sedative-hypnotic prescribing in recent years may be attributable to long-term growth in continuing prescriptions, rather than new prescriptions. Public Health Implications. Findings call for renewed efforts to limit continuing prescribing of sedative-hypnotics to reduce their use in the population. PMID:27631754

Comparison and usefulness of cardiac magnetic resonance versus computed tomography in infants six months of age or younger with aortic arch anomalies without deep sedation or anesthesia.

PubMed

Fogel, Mark A; Pawlowski, Thomas W; Harris, Matthew A; Whitehead, Kevin K; Keller, Marc S; Wilson, Justine; Tipton, Deanna; Harris, Christine

2011-07-01

The present project investigated whether cardiac magnetic resonance (CMR) of aortic arch anomalies can be performed successfully in infants <6 months of age without the use of cardiac anesthesia or deep sedation. We performed a retrospective review of infants ≤6 months old from 2005 to 2009 who underwent either CMR or computed tomography angiography to investigate aortic arch abnormalities. The CMR procedure used a "feed and swaddle" protocol without deep sedation or cardiac anesthesia. Of the 52 infants referred for CMR, 24 underwent the feed and swaddle protocol (aged 2.6 ± 1.4 months). One patient awoke during the study, and examination of the remaining 23 yielded a definitive diagnosis (success rate 96%). The scanning time was 6.2 ± 3.1 minutes, with the large airways evaluation accounting for 1/2 the time. Single-shot axial steady-state free precession, in which the definitive diagnosis was made, accounted for 0.59 ± 0.3 minutes. Fifteen infants were diagnosed with a vascular ring. Of the 8 infants who underwent surgery, the diagnostic accuracy was 100%. During the same period, 19 patients, who had undergone computed tomography angiography (aged 1.67 ± 1.20 months), were referred for aortic arch evaluation. Of these 19 patients, 6 (32%) underwent sedation or anesthesia. The imaging time was 0.08 ± 0.06 minutes, significantly different from the CMR times (p <0.01). However, the overall room times (31.3 ± 22.3 and 35.8 ± 3.86 minutes, respectively) were not different between the CMR and angiographic groups. The radiation dose was 1.41 ± 1.03 mSv. In conclusion, CMR evaluation of aortic arch anomalies in children <6 months old can be successfully completed quickly using a feed and swaddle approach with high diagnostic accuracy. This protocol avoids the risks of sedation, as well as the radiation associated with computed tomography angiography. Copyright © 2011 Elsevier Inc. All rights reserved.

Bispectral Index Monitoring: validity and utility in pediatric dentistry.

PubMed

Goyal, Ashima; Mittal, Neeti; Mittal, Parteek; Gauba, K

2014-01-01

Reliable and safe provision of sedation and general anesthesia is dependent on continuous vigilance of patient's sedation depth. Failure to do so may result in unintended oversedation or undersedation. It is a common practice to observe sedation depth by applying subjective sedation scales and in case of general anesthesia, practitioner is dependent on vital sign assessment. The Bispectral Index System (BIS) is a recently introduced objective, quantitative, easy to use, and free from observer bias, and clinically useful tool to assess sedation depth and it precludes the need to stimulate the patient to assess his sedation level. The present article is an attempt to orient the readers towards utility and validity of BIS for sedation and general anesthesia in pediatric dentistry. In this article, we attempt to make the readers understand the principle of BIS, its variation across sedation continuum, its validity across different age groups and for a variety of sedative drugs.

Propofol and non-propofol based sedation for outpatient colonoscopy-prospective comparison of depth of sedation using an EEG based SEDLine monitor.

PubMed

Goudra, Basavana; Singh, Preet Mohinder; Gouda, Gowri; Borle, Anuradha; Carlin, Augustus; Yadwad, Avantika

2016-10-01

Propofol is a popular anesthetic sedative employed in colonoscopy. It is known to increase the patient satisfaction and improve throughput. However, there are concerns among the clinicians with regard to the depth of sedation, as a deeper degree of sedation is known to increase the incidence of aspiration and other adverse events. So we planned to compare the depth of sedation between propofol and non-propofol based sedation in patients undergoing outpatient colonoscopy, as measured by an electroencephalogram (EEG) based monitor SEDLine monitor (SedlineInc., San Diego, CA). The non-randomized prospective observational study was performed in the outpatient gastroenterology suite of the Hospital of the University of Pennsylvania, Philadelphia. Patients included ASA class I-III aged more than 18 years scheduled for colonoscopy under Propofol or non-propofol based sedation. After an institutional review board approval, a written consent was obtained from prospective patients. Sedation (propofol or non-propofol based) was administered by either a certified nurse anesthetist under the supervision of an anesthesiologist (propofol) or a registered endoscopy nurse under the guidance of the endoscopist performing the procedure (non-propofol sedation). Depth of sedation was measured with an EEG based SEDLine monitor. The sedation providers were blinded to the patient state index-the indicator of depth of sedation. PSI (patient state index-SEDLine reading) was documented at colonoscope insertion, removal and at the return of verbal responsiveness after colonoscope withdrawal. Sedation spectrum was retrieved from the data stored on the SEDLine monitor. Patients sedated with propofol experience significantly deeper degrees of sedation at all times during the procedure. Additionally, during significant part of the procedure, they are at PSI levels associated with deep general anesthesia. The group that received propofol was more deeply sedated and had lower PSI values. Lighter propofol titration protocols may lead to improved patient care such as lowering risk of aspiration and hypotension. The role of processed EEG monitors such as the SEDLine monitor to improve sedation protocols remains to be determined. Trial registration We obtained an ethical clearance from the Institute. No trial registration was mandated, as no interventional drug or investigational device were used during the study.

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

PubMed

Ozkalayci, Ozlem; Araz, Coskun; Cehreli, Sevi Burcak; Tirali, Resmiye Ebru; Kayhan, Zeynep

2016-11-01

The 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. Prospective, randomized, and controlled study. Tertiary, university hospital. In 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. Patients 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. Bispectral 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). Listening 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. Copyright © 2016 Elsevier Inc. All rights reserved.

Effects of medetomidine on serum glucose in cattle calves.

PubMed

Tariq, Muhammad; Kalhoro, Amir Bukhsh; Sarwar, Mian Saeed; Khan, Hamayun; Ahmad, Shakoor; Hassan, Sayed Mubashir; Zahoor, Arshad

2016-05-01

An experimental study was carried out to compare physiological effects (serum glucose level) of medetomidine in Red Sindhi cattle calves at three different doses i.e. 8, 10 and 12µg/kg body weight intravenously. Medetomidine produced a dose dependent significant (P<0.01) increase in serum glucose level with a maximum increase observed at 30 minutes with 8µg/kg, 10μg/kg and 12μg/kg body weight respectively. Start of sedation, degree of sedation and total duration of sedation were all dose dependent and the values obtained were significantly (P<0.01) different from each other. It was observed that the sedation was rapid, deep and longer with the higher doses of medetomidine i.e. 12μg/kg. The results of the present study shows that medetomidine is a very effective and safest drug use as sedative for calves which in lower doses (8μg/kg) can be used as a pre-anesthetic and for restraining of the animal, while higher calculated doses (10μg/kg, 12μg/kg) can be used to execute the minor surgical procedures.

Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children.

PubMed

Kennedy, Robert M; Luhmann, Jan D; Luhmann, Scott J

2004-01-01

Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.

A retrospective study of deep sedation with concomitant administration of sedative agents in children undergoing surgical removal of a mesiodens.

PubMed

Lee, Soo Jeong; Baek, Kwangwoo

2015-12-01

Pediatric dentists face challenges when young patients require a mesiodens extraction. General anesthesia may be a burden to the child as well as the parent due to dental fears and costs. The aim of this study was to evaluate oral and intravenous sedation in the outpatient setting as a safe and effective means of managing patients who require a mesiodens extraction. Records were reviewed retrospectively to find patients who underwent a mesiodens removal procedure from January 2013 to September 2014 in the Department of Pediatric Dentistry at Ajou University Hospital (Suwon, Gyeonggi-do, Republic of Korea). A total of 81 patients (62 male and 19 female) between 4 and 11 years of age (mean [± SD] 81.6 ± 14.1 months) were studied, with a mean weight of 22.9 ± 3.3 kg (16 kg to 30 kg). Vital signs, sedation drug dosage, and sedation time were studied. Mean doses of 63.7 ± 2.5 mg/kg chloral hydrate and 1.36 ± 0.22 mg/kg hydroxyzine were used for oral sedation. Nitrous oxide/oxygen was administrated for 40.0 ± 2.1 min. The mean dose of midazolam administered intravenously was 0.14 ± 0.06 mg/kg (2.38 ± 0.97 times). In all cases, the mesiodens was removed successfully. Intravenous sedation combined with oral sedation and nitrous oxide/oxygen inhalation can be an alternative to general anesthesia when administrated and monitored properly.

Dental treatment for handicapped patients; sedation vs general anesthesia and update of dental treatment in patients with different diseases

PubMed Central

Corcuera-Flores, José R.; Delgado-Muñoz, José M.; Ruiz-Villandiego, José C.; Maura-Solivellas, Isabel

2014-01-01

Dental treatment on Handicapped Patients is often difficult because many people with a wide range of ages (from children to the elderly) with different pathologies that can affect the oral cavity and differ widely are included in this group. This situation creates some controversy, because according to pathology, each patient will be treated differently depending on collaboration, general health status, age or medication used to treat this pathologies. According to this situation we can opt for an outpatient treatment without any kind of previous medication, a treatment under conscious or deep sedation or a under general anesthesia treatment. With this systematic review is intended to help clarify in which cases patients should be treated under general anesthesia, sedation (conscious or deep) or outpatient clinic without any medication, as well as clarify what kind of treatments can be carried in private dental clinics and which should be carried out in a hospital. It will also discuss the most common diseases among this group of patients and the special care to be taken for their dental treatment. Key words:Hospital dentistry, handicapped patient. PMID:24121922

Paediatric dental chair sedation: An audit of current practice in Gauteng, South Africa.

PubMed

Bham, F; Perrie, H; Scribante, J; Lee, C-A

2015-06-01

Procedural sedation and analgesia (PSA) is often required to perform dental procedures in children. Serious adverse outcomes, while rare, are usually preventable. To determine the proportion of dental practitioners making use of paediatric dental chair PSA in Gauteng Province, South Africa, describe their PSA practice, and determine compliance with recommended safety standards. A prospective, contextual, descriptive study design was used, with 222 randomly selected dental practitioners contacted to determine whether they offered paediatric dental chair PSA. Practitioners offering PSA were then asked to complete a web-based questionnaire assessing their practice. Of the 213 dental practitioners contacted, 94 (44.1%; 95% confidence interval 37 - 51) provided PSA to children. Most patients were 1 - 5 years old, although there were practices that offered PSA to infants. While most procedures were performed under minimal to moderate sedation, deep sedation and general anaesthesia were also administered in dental rooms. Midazolam was the most frequently used sedative agent, often in conjunction with inhaled nitrous oxide; 28.1% of PSA providers administered a combination of three or more agents. Presedation patient assessment was documented in 83.0% of cases, and informed consent for sedation was obtained in 75.6%. The survey raised several areas of concern regarding patient safety: 41.3% of dental practices did not use any monitoring equipment during sedation; the operator was responsible for the sedation and monitoring of the patient in 41.3%; 43.2% did not keep any recommended emergency drugs; and 19.6% did not have any emergency or resuscitation equipment available. Most respondents (81.8%) indicated an interest in sedation training. Paediatric dental chair PSA was offered by 44.1% of dental practitioners interviewed in Gauteng. Modalities of PSA provided varied between practices, with a number of safety concerns being raised.

Moderate-dose sedation and analgesia during targeted temperature management after cardiac arrest.

PubMed

May, Teresa L; Seder, David B; Fraser, Gilles L; Stone, Philip; McCrum, Barbara; Riker, Richard R

2015-02-01

Sedation and analgesia regimens during targeted temperature management (TTM), after cardiac arrest varies widely, are poorly described in the literature and may have a negative impact on outcome. Since implementing TTM in 2005, we have used moderate-dose sedation and describe our experience with this approach. In this retrospective review, we included patients treated with TTM for cardiac arrest at our institution for 2008-2012. Patients received TTM if they did not follow verbal commands following cardiac arrest, regardless of place of arrest or rhythm. Utstein-compatible data were prospectively entered into the International Cardiac Arrest Registry, supplemented by review of nursing, pharmacy, and physical therapy records. We report analgesic and sedative medications and doses during the 24 h of active TTM at 33 °C, resource utilization, and important clinical events. 166 patients treated with TTM after in- and out-of-hospital cardiac arrest with complete data were included. Overall survival was 42 %, median time to following commands was 3 h after rewarming (-6, 14), time to spontaneous breathing trial was 19 h (5-35), time to extubation was 28 h (9-60), and 59 % of survivors were discharged directly home at 13 (10-20) days. The incidence of seizure was 6 %, septic shock 4 %, and pneumonia 32 %. Four survivors required tracheostomy at 8, 8, 12, and 16 days. A moderate-dose sedation and analgesia regimen was well tolerated and effective during therapeutic hypothermia after cardiac arrest and is an effective alternative to very deep sedation. We recommend more complete description of sedation and analgesia protocols in future studies, including expanded outcome reporting to include variables affected by sedation therapy. Further study is required to define which sedation approach for TTM may be best.

Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study).

PubMed

Walsh, Timothy S; Kydonaki, Kalliopi; Antonelli, Jean; Stephen, Jacqueline; Lee, Robert J; Everingham, Kirsty; Hanley, Janet; Uutelo, Kimmo; Peltola, Petra; Weir, Christopher J

2016-03-04

To describe the rationale, design and methodology for a trial of three novel interventions developed to improve sedation-analgesia quality in adult intensive care units (ICUs). 8 clusters, each a Scottish ICU. All mechanically ventilated sedated patients were potentially eligible for inclusion in data analysis. Cluster randomised design in 8 ICUs, with ICUs randomised after 45 weeks baseline data collection to implement one of four intervention combinations: a web-based educational programme (2 ICUs); education plus regular sedation quality feedback using process control charts (2 ICUs); education plus a novel sedation monitoring technology (2 ICUs); or all three interventions. ICUs measured sedation-analgesia quality, relevant drug use and clinical outcomes, during a 45-week preintervention and 45-week postintervention period separated by an 8-week implementation period. The intended sample size was >100 patients per site per study period. The primary outcome was the proportion of 12 h care periods with optimum sedation-analgesia, defined as the absence of agitation, unnecessary deep sedation, poor relaxation and poor ventilator synchronisation. Secondary outcomes were proportions of care periods with each of these four components of optimum sedation and rates of sedation-related adverse events. Sedative and analgesic drug use, and ICU and hospital outcomes were also measured. Multilevel generalised linear regression mixed models will explore the effects of each intervention taking clustering into account, and adjusting for age, gender and APACHE II score. Sedation-analgesia quality outcomes will be explored at ICU level and individual patient level. A process evaluation using mixed methods including quantitative description of intervention implementation, focus groups and direct observation will provide explanatory information regarding any effects observed. The DESIST study uses a novel design to provide system-level evaluation of three contrasting complex interventions on sedation-analgesia quality. Recruitment is complete and analysis ongoing. NCT01634451. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A retrospective study of deep sedation with concomitant administration of sedative agents in children undergoing surgical removal of a mesiodens

PubMed Central

Lee, Soo Jeong

2015-01-01

Background Pediatric dentists face challenges when young patients require a mesiodens extraction. General anesthesia may be a burden to the child as well as the parent due to dental fears and costs. The aim of this study was to evaluate oral and intravenous sedation in the outpatient setting as a safe and effective means of managing patients who require a mesiodens extraction. Methods Records were reviewed retrospectively to find patients who underwent a mesiodens removal procedure from January 2013 to September 2014 in the Department of Pediatric Dentistry at Ajou University Hospital (Suwon, Gyeonggi-do, Republic of Korea). A total of 81 patients (62 male and 19 female) between 4 and 11 years of age (mean [± SD] 81.6 ± 14.1 months) were studied, with a mean weight of 22.9 ± 3.3 kg (16 kg to 30 kg). Vital signs, sedation drug dosage, and sedation time were studied. Results Mean doses of 63.7 ± 2.5 mg/kg chloral hydrate and 1.36 ± 0.22 mg/kg hydroxyzine were used for oral sedation. Nitrous oxide/oxygen was administrated for 40.0 ± 2.1 min. The mean dose of midazolam administered intravenously was 0.14 ± 0.06 mg/kg (2.38 ± 0.97 times). In all cases, the mesiodens was removed successfully. Conclusions Intravenous sedation combined with oral sedation and nitrous oxide/oxygen inhalation can be an alternative to general anesthesia when administrated and monitored properly. PMID:28879282

Bispectral Index monitoring in cancer patients undergoing palliative sedation: a preliminary report.

PubMed

Monreal-Carrillo, Edith; Allende-Pérez, Silvia; Hui, David; García-Salamanca, Maria-Fernanda; Bruera, Eduardo; Verástegui, Emma

2017-10-01

Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) monitoring. We enrolled consecutive patients with refractory symptoms requiring PS. We documented the level of sedation using Ramsay Sedation Scale (RSS) and BIS at 0, 2, 4, 6, 12, and 24 h during the first day of PS and examined their degree of association. Intravenous midazolam or propofol was titrated according to the sedation level. Twenty patients on PS were recruited and had BIS continuous monitoring. Delirium was the most frequent reason for PS (n = 15, 75%). The median time of sedation was 24.5 h (interquartile range 6-46). The average time to achieve the desired sedation level was 6 h, and dose titration was required in 80% of the cases. At baseline, 14 (70%) patients were considered to be awake according to RSS (i.e., 1-3) and 19 (95%) were awake according to BIS (i.e., >60%). This proportion decreased to 31 and 56% at 4 h, 27% and 53 at 6 h, and 22 and 33% at 24 h. RS and BIS had moderate correlation (rho = -0.58 to -0.65); however, a small proportion of patients were found to be awake by BIS (i.e., ≥60%) despite clinical observation (i.e., RSS 4-6) indicating otherwise. The BIS is a noninvasive, bedside, real-time continuous monitoring method that may facilitate the objective assessment of level of consciousness and dose titration in patients undergoing PS.

Risk and safety of pediatric sedation/anesthesia for procedures outside the operating room.

PubMed

Cravero, Joseph P

2009-08-01

Sedation and anesthesia outside the operating room represents a rapidly growing field of practice that involves a number of different specialty providers including anesthesiology. The literature surrounding this work is found in a variety of journals - many outside anesthesiology. This review is intended to inform readers about the current status of risk and safety involving sedation/anesthesia for tests and minor procedures utilizing a wide range of sources. Two large database studies have helped to define the frequency and nature of adverse events in pediatric sedation/anesthesia practice from a multispecialty perspective. A number of papers describing respiratory and hemodynamic aspects of dexmedetomidine sedation have also been published. Finally, a number of studies relating to training sedation providers, reporting of sedation adverse events, sedation for vulnerable populations, and (in particular) ketamine sedation adverse respiratory events have also come to light. The latest publications continue to document a relatively low risk to pediatric sedation yet also warn us about the potential adverse events in this field. The results help to define competencies required to deliver pediatric sedation and make this practice even safer. Particularly interesting are new jargon and methodologies for defining adverse events and the use of new methods for training sedation providers.

A systematic literature review on the ethics of palliative sedation: an update (2016).

PubMed

Henry, Blair

2016-09-01

Palliative sedation has been the subject of intensive debate since its first appearance in 1990. In a 2010 review of palliative sedation, the following areas were identified as lacking in consensus: inconsistent terminology, its use in nonphysical suffering, the ongoing experience of distress, and concern that the practice of palliative sedation may hasten death. This review looks at the literature over the past 6 years and provides an update on these outstanding concerns. Good clinical guidelines and policies are still required to address issues of emotional distress and waylay concerns that palliative sedation hastens death. The empirical evidence suggests some movement toward consensus on the practice of palliative sedation. However, a continued need exists for evidence-informed practice guidelines, education, and research to support the ethical practice of palliative sedation at the end of life. Until that time, clinicians are advised to adopt a framework or guideline that has been expert driven to ensure consistent and ethical use of palliative sedation at the end of life.

Management of exaggerated gag reflex in dental patients using intravenous sedation with dexmedetomidine.

PubMed

Reshetnikov, Aleksei P; Kasatkin, Anton A; Urakov, Aleksandr L; Baimurzin, Dmitrii Y

2017-01-01

Pharmacological sedation is one of the effective ways of prevention of gag reflex development in patients experiencing anxiety and fright before dental treatment. We are reporting a case where we could successfully eliminate exaggerated gag reflex (intravenous [IV] Gagging Severity Index) in a dental patient using IV sedation with dexmedetomidine. IV administration of dexmedetomidine provided elimination of gag reflex at a depth of sedation for the patient with the Richmond Agitation-Sedation Scale score of -2 and -1. The patient received dexmedetomidine 1.0 μg/kg for 10 min and then a continuous infusion of dexmedetomidine 0.4 μg/kg/h. The use of dexmedetomidine for sedation may be an alternative to other pharmacological agents in patients with dental anxiety accompanied by exaggerated gag reflex.

Continuous sedation-analgesia delays diagnosis of compartment syndrome in a patient with intra-aortic balloon pump.

PubMed

Barkhordari, Khosro; Yousefshahi, Fardin; Khajavi, Mohammad Reza; Karimi, Abbasali

2012-06-01

Compartment syndrome is a rare, devastating complication of coronary artery bypass grafting (CABG) and intra-aortic balloon pump (IABP). Prompt diagnosis is based on symptoms and signs and is paramount for limb rescue. This report describes a CABG patient with IABP in whom receiving continuous analgesia-sedation obscured the symptoms of compartment syndrome.

Intravenous labetolol in treating hypertensive crisis following dexmedetomidine infusion for procedural sedation.

PubMed

Muthiah, Thilaka; Moni, Amarnath; Mathews, Lailu; Balaji, Sudarshan

2016-03-01

Dexmedetomidine is widely used for procedural sedation because of its unique combination of sedation, analgesia, and anxiolysis with minimal respiratory depression. Transient hypertension has been reported during the use of dexmedetomidine which is usually benign and is taken over by the hypotensive response on continuing the infusion. We report a case of hypertensive crisis following dexmedetomidine infusion used for procedural sedation, necessitating discontinuation of the infusion and treatment of hypertension. The dilemmas involved in treating hypertension caused by dexmedetomidine are discussed. Copyright © 2016 Elsevier Inc. All rights reserved.

Review of palliative sedation and its distinction from euthanasia and lethal injection.

PubMed

Hahn, Michael P

2012-01-01

Palliative sedation evolved from within the practice of palliative medicine and has become adopted by other areas of medicine, such as within intensive care practice. Clinician's usually come across this practice for dying patients who are foregoing or having life support terminated. A number of intolerable and intractable symptom burdens can occur during the end of life period that may require the use of palliative sedation. Furthermore, when patients receive palliative sedation, the continued use of hydration and nutrition becomes an issue of consideration and there are contentious bioethical issues involved in using or withholding these life-sustaining provisions. A general understanding of biomedical ethics helps prevent abuse in the practice of palliative sedation. Various sedative drugs can be employed in the provision of palliative sedation that can produce any desired effect, from light sedation to complete unconsciousness. Although there are some similarities in the pharmacotherapy of palliative sedation, euthanasia, physician-assisted suicide, and lethal injection, there is a difference in how the drugs are administered with each practice. There are some published guidelines about how palliative sedation should be practiced, but currently there is not any universally accepted standard of practice.

Altered cerebral protein synthesis in fragile X syndrome: studies in human subjects and knockout mice

PubMed Central

Qin, Mei; Schmidt, Kathleen C; Zametkin, Alan J; Bishu, Shrinivas; Horowitz, Lisa M; Burlin, Thomas V; Xia, Zengyan; Huang, Tianjiang; Quezado, Zenaide M; Smith, Carolyn Beebe

2013-01-01

Dysregulated protein synthesis is thought to be a core phenotype of fragile X syndrome (FXS). In a mouse model (Fmr1 knockout (KO)) of FXS, rates of cerebral protein synthesis (rCPS) are increased in selective brain regions. We hypothesized that rCPS are also increased in FXS subjects. We measured rCPS with the ℒ-[1-11C]leucine positron emission tomography (PET) method in whole brain and 10 regions in 15 FXS subjects who, because of their impairments, were studied under deep sedation with propofol. We compared results with those of 12 age-matched controls studied both awake and sedated. In controls, we found no differences in rCPS between awake and propofol sedation. Contrary to our hypothesis, FXS subjects under propofol sedation had reduced rCPS in whole brain, cerebellum, and cortex compared with sedated controls. To investigate whether propofol could have a disparate effect in FXS subjects masking usually elevated rCPS, we measured rCPS in C57Bl/6 wild-type (WT) and KO mice awake or under propofol sedation. Propofol decreased rCPS substantially in most regions examined in KO mice, but in WT mice caused few discrete changes. Propofol acts by decreasing neuronal activity either directly or by increasing inhibitory synaptic activity. Our results suggest that changes in synaptic signaling can correct increased rCPS in FXS. PMID:23299245

Minimum number of spermatozoa required for normal fertility after deep intrauterine insemination in non-sedated sows.

PubMed

Martinez, E A; Vazquez, J M; Roca, J; Lucas, X; Gil, M A; Parrilla, I; Vazquez, J L; Day, B N

2002-01-01

A fibreoptic endoscope procedure for non-surgical deep intrauterine insemination in non-sedated sows has been reported. However, the endoscope is an expensive and fragile instrument, and is unsuitable for use under field conditions. The aim of this study was to determine the minimum number of spermatozoa required to maintain optimal fertility using a flexible catheter (1.8 m in length, 4 mm in diameter) for deep intrauterine insemination in 2-6 parity non-sedated sows. Crossbred sows were treated with eCG 24 h after weaning and with hCG 72 h later to induce oestrus. Deep intrauterine insemination was performed 36 h after hCG treatment in 117, 126, 60 and 69 sows with 15.0, 5.0, 2.5 or 1.0 x 10(7) spermatozoa in 10 ml, respectively. Weaned sows (n = 147) not treated with hormones and used for standard artificial insemination (AI) (two inseminations per oestrus with 3 x 10(9) spermatozoa in 100 ml) served as controls. The flexible catheter was passed successfully through the cervix into one uterine horn in 95.4% of the sows in an average of 3.7 +/- 0.09 min. Farrowing rates after deep intrauterine insemination with 15 or 5 x 10(7) spermatozoa did not differ from those of the control group (82.9, 76.2 and 83.0%, respectively), but a significant decrease (P < 0.001) was observed in sows inseminated with 2.5 or 1.0 x 10(7) spermatozoa (46.7 and 39.1%, respectively). In contrast, the number of spermatozoa inseminated did not affect prolificacy. Laparotomy revealed that the tip of the flexible catheter reached approximately the anterior third of the uterine horn. Although deep intrauterine insemination was performed in only one uterine horn, the percentages of embryos collected from the tip of both uterine horns 2 days after deep insemination were not significantly different. The results show that in comparison with standard AI, a 20-60-fold reduction in the number of spermatozoa inseminated and an 8-10-fold reduction in the dose volume can be achieved without decreasing fertility when semen is deposited non-surgically into the upper first third of one uterine horn.

[A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient].

PubMed

Frade-Mera, M J; Regueiro-Díaz, N; Díaz-Castellano, L; Torres-Valverde, L; Alonso-Pérez, L; Landívar-Redondo, M M; Muñoz-Pasín, R; Terceros-Almanza, L J; Temprano-Vázquez, S; Sánchez-Izquierdo-Riera, J Á

Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi 2 , and a significance of p<.05 were used. The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes. Copyright © 2015 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

Society of Family Planning clinical guidelines pain control in surgical abortion part 1 - local anesthesia and minimal sedation.

PubMed

Allen, Rebecca H; Singh, Rameet

2018-06-01

Satisfactory pain control for women undergoing surgical abortion is important for patient comfort and satisfaction. Clinicians ought to be aware of the safety and efficacy of different pain control regimens. This document will focus on nonpharmacologic modalities to reduce pain and pharmacologic interventions up to the level of minimal sedation. For surgical abortion without intravenous medications, a multimodal approach to pain control may combine a dedicated emotional-support person, visual or auditory distraction, administration of local anesthesia to the cervix with buffered lidocaine and a preoperative nonsteroidal anti-inflammatory drug. Oral opioids do not decrease procedural pain. Oral anxiolytics decrease anxiety but not the experience of pain. Further research is needed on alternative options to control pain short of moderate or deep sedation. Copyright © 2018 Elsevier Inc. All rights reserved.

Sedation Intensity in the First 48 Hours of Mechanical Ventilation and 180-Day Mortality: A Multinational Prospective Longitudinal Cohort Study.

PubMed

Shehabi, Yahya; Bellomo, Rinaldo; Kadiman, Suhaini; Ti, Lian Kah; Howe, Belinda; Reade, Michael C; Khoo, Tien Meng; Alias, Anita; Wong, Yu-Lin; Mukhopadhyay, Amartya; McArthur, Colin; Seppelt, Ian; Webb, Steven A; Green, Maja; Bailey, Michael J

2018-06-01

In the absence of a universal definition of light or deep sedation, the level of sedation that conveys favorable outcomes is unknown. We quantified the relationship between escalating intensity of sedation in the first 48 hours of mechanical ventilation and 180-day survival, time to extubation, and delirium. Harmonized data from prospective multicenter international longitudinal cohort studies SETTING:: Diverse mix of ICUs. Critically ill patients expected to be ventilated for longer than 24 hours. Richmond Agitation Sedation Scale and pain were assessed every 4 hours. Delirium and mobilization were assessed daily using the Confusion Assessment Method of ICU and a standardized mobility assessment, respectively. Sedation intensity was assessed using a Sedation Index, calculated as the sum of negative Richmond Agitation Sedation Scale measurements divided by the total number of assessments. We used multivariable Cox proportional hazard models to adjust for relevant covariates. We performed subgroup and sensitivity analysis accounting for immortal time bias using the same variables within 120 and 168 hours. The main outcome was 180-day survival. We assessed 703 patients in 42 ICUs with a mean (SD) Acute Physiology and Chronic Health Evaluation II score of 22.2 (8.5) with 180-day mortality of 32.3% (227). The median (interquartile range) ventilation time was 4.54 days (2.47-8.43 d). Delirium occurred in 273 (38.8%) of patients. Sedation intensity, in an escalating dose-dependent relationship, independently predicted increased risk of death (hazard ratio [95% CI], 1.29 [1.15-1.46]; p < 0.001, delirium hazard ratio [95% CI], 1.25 [1.10-1.43]), p value equals to 0.001 and reduced chance of early extubation hazard ratio (95% CI) 0.80 (0.73-0.87), p value of less than 0.001. Agitation level independently predicted subsequent delirium hazard ratio [95% CI], of 1.25 (1.04-1.49), p value equals to 0.02. Delirium or mobilization episodes within 168 hours, adjusted for sedation intensity, were not associated with survival. Sedation intensity independently, in an ascending relationship, predicted increased risk of death, delirium, and delayed time to extubation. These observations suggest that keeping sedation level equivalent to a Richmond Agitation Sedation Scale 0 is a clinically desirable goal.

Palliative sedation at home in the Netherlands: a nationwide survey among nurses.

PubMed

Brinkkemper, Tijn; Klinkenberg, Marianne; Deliens, Luc; Eliel, Miriam; Rietjens, Judith A C; Zuurmond, Wouter W A; Perez, Roberto S G M

2011-08-01

This paper is a report of a nationwide study conducted to assess experiences of nurses involved in palliative sedation at home after introduction of a physicians' guideline for palliative sedation. Most studies investigating the practice of palliative sedation focus on physicians' practices and attitudes. However, little is known about experiences and attitudes of nurses. A web-based structured questionnaire was offered to 387 nurses providing medical technical care in 2007, assessing their experiences concerning decision-making, treatment policy and communication, focussing on the last patient receiving palliative sedation. The questionnaire was filled out by 201 nurses (response rate 52%). The majority of respondents agreed with the indication for palliative sedation. However, 21% reported to have refused carrying out a palliative sedation in the preceding year. The general practitioner was not present at the start of palliative sedation in a third of the cases, but was available when needed. The sedation was considered insufficiently effective by 42% of the respondents. According to a third of the respondents, the level of sedation was not related to the required level of symptom relief nor were changes in dosage based on the severity of symptoms. Although the guideline for palliative sedation appears to be followed adequately in the majority of cases with respect to indication for palliative sedation and reportage. The survey findings revealed shortcomings in medication policy, communication, medical control over the start and continued monitoring of palliative sedation. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

Nurses' Sedation Practices During Weaning of Adults From Mechanical Ventilation in an Intensive Care Unit.

PubMed

Borkowska, Marta; Labeau, Sonia; Schepens, Tom; Vandijck, Dominique; Van de Vyver, Katrien; Christiaens, Daphné; Lizy, Christelle; Blackwood, Bronagh; Blot, Stijn I

2018-01-01

Sedation and analgesia have an important impact on the outcome of patients treated with mechanical ventilation. International guidelines recommend use of sedation protocols to ensure best patient care. To determine the sedation practice of intensive care nurses weaning adults from mechanical ventilation. A cross-sectional survey with a self-administered questionnaire was used to determine sedation practices of Flemish critical care nurses during weaning. Consensus on content validity was achieved through a Delphi procedure among experts. Data were collected during the 32nd Annual Congress of the Flemish Society of Critical Care Nurses in Ghent, Belgium, December 2014. A total of 342 nurses were included in the study. Of these, 43.7% had a sedation protocol in their unit that was used by 61.8% of the respondents. Sedation protocols were more often available ( P < .001) in academic hospitals (72%) than in general hospitals (41.5%). Sedatives were administered via continuous infusion with bolus doses if needed (81%). Level of sedation was assessed every 2 hours (56%), mostly via the Richmond Agitation-Sedation Scale (59.1%). Daily interruption of sedation was used by 16.5% of respondents. The biggest barriers to daily interruption were patient comfort (49.4%) and fear of respiratory worsening (46.6%). A considerable discrepancy exists between international recommendations and actual sedation practices. Standardization of sedation practices across different institutions on a regional and national level may improve the quality of care. ©2018 American Association of Critical-Care Nurses.

Airway Management During Upper GI Endoscopic Procedures: State of the Art Review.

PubMed

Goudra, Basavana; Singh, Preet Mohinder

2017-01-01

With the growing popularity of propofol mediated deep sedation for upper gastrointestinal (GI) endoscopic procedures, challenges are being felt and appreciated. Research suggests that management of the airway is anything but routine in this setting. Although many studies and meta-analyses have demonstrated the safety of propofol sedation administered by registered nurses under the supervision of gastroenterologists (likely related to the lighter degrees of sedation than those provided by anesthesia providers and is under medicolegal controversy in the United States), there is no agreement on the optimum airway management for procedures such as endoscopic retrograde cholangiopancreatography. Failure to rescue an airway at an appropriate time has led to disastrous consequences. Inability to evaluate and appreciate the risk factors for aspiration can ruin the day for both the patient and the health care providers. This review apprises the reader of various aspects of airway management relevant to the practice of sedation during upper GI endoscopy. New devices and modification of existing devices are discussed in detail. Recognizing the fact that appropriate monitoring is important for timely recognition and management of potential airway disasters, these issues are explored thoroughly.

Neural correlates of successful semantic processing during propofol sedation.

PubMed

Adapa, Ram M; Davis, Matthew H; Stamatakis, Emmanuel A; Absalom, Anthony R; Menon, David K

2014-07-01

Sedation has a graded effect on brain responses to auditory stimuli: perceptual processing persists at sedation levels that attenuate more complex processing. We used fMRI in healthy volunteers sedated with propofol to assess changes in neural responses to spoken stimuli. Volunteers were scanned awake, sedated, and during recovery, while making perceptual or semantic decisions about nonspeech sounds or spoken words respectively. Sedation caused increased error rates and response times, and differentially affected responses to words in the left inferior frontal gyrus (LIFG) and the left inferior temporal gyrus (LITG). Activity in LIFG regions putatively associated with semantic processing, was significantly reduced by sedation despite sedated volunteers continuing to make accurate semantic decisions. Instead, LITG activity was preserved for words greater than nonspeech sounds and may therefore be associated with persistent semantic processing during the deepest levels of sedation. These results suggest functionally distinct contributions of frontal and temporal regions to semantic decision making. These results have implications for functional imaging studies of language, for understanding mechanisms of impaired speech comprehension in postoperative patients with residual levels of anesthetic, and may contribute to the development of frameworks against which EEG based monitors could be calibrated to detect awareness under anesthesia. Copyright © 2013 Wiley Periodicals, Inc.

Brainstem response patterns in deeply-sedated critically-ill patients predict 28-day mortality.

PubMed

Rohaut, Benjamin; Porcher, Raphael; Hissem, Tarik; Heming, Nicholas; Chillet, Patrick; Djedaini, Kamel; Moneger, Guy; Kandelman, Stanislas; Allary, Jeremy; Cariou, Alain; Sonneville, Romain; Polito, Andréa; Antona, Marion; Azabou, Eric; Annane, Djillali; Siami, Shidasp; Chrétien, Fabrice; Mantz, Jean; Sharshar, Tarek

2017-01-01

Deep sedation is associated with acute brain dysfunction and increased mortality. We had previously shown that early-assessed brainstem reflexes may predict outcome in deeply sedated patients. The primary objective was to determine whether patterns of brainstem reflexes might predict mortality in deeply sedated patients. The secondary objective was to generate a score predicting mortality in these patients. Observational prospective multicenter cohort study of 148 non-brain injured deeply sedated patients, defined by a Richmond Assessment sedation Scale (RASS) <-3. Brainstem reflexes and Glasgow Coma Scale were assessed within 24 hours of sedation and categorized using latent class analysis. The Full Outline Of Unresponsiveness score (FOUR) was also assessed. Primary outcome measure was 28-day mortality. A "Brainstem Responses Assessment Sedation Score" (BRASS) was generated. Two distinct sub-phenotypes referred as homogeneous and heterogeneous brainstem reactivity were identified (accounting for respectively 54.6% and 45.4% of patients). Homogeneous brainstem reactivity was characterized by preserved reactivity to nociceptive stimuli and a partial and topographically homogenous depression of brainstem reflexes. Heterogeneous brainstem reactivity was characterized by a loss of reactivity to nociceptive stimuli associated with heterogeneous brainstem reflexes depression. Heterogeneous sub-phenotype was a predictor of increased risk of 28-day mortality after adjustment to Simplified Acute Physiology Score-II (SAPS-II) and RASS (Odds Ratio [95% confidence interval] = 6.44 [2.63-15.8]; p<0.0001) or Sequential Organ Failure Assessment (SOFA) and RASS (OR [95%CI] = 5.02 [2.01-12.5]; p = 0.0005). The BRASS (and marginally the FOUR) predicted 28-day mortality (c-index [95%CI] = 0.69 [0.54-0.84] and 0.65 [0.49-0.80] respectively). In this prospective cohort study, around half of all deeply sedated critically ill patients displayed an early particular neurological sub-phenotype predicting 28-day mortality, which may reflect a dysfunction of the brainstem.

Computerized tests to evaluate recovery of cognitive function after deep sedation with propofol and remifentanil for colonoscopy.

PubMed

Borrat, Xavier; Ubre, Marta; Risco, Raquel; Gambús, Pedro L; Pedroso, Angela; Iglesias, Aina; Fernandez-Esparrach, Gloria; Ginés, Àngels; Balust, Jaume; Martínez-Palli, Graciela

2018-03-27

The use of sedation for diagnostic procedures including gastrointestinal endoscopy is rapidly growing. Recovery of cognitive function after sedation is important because it would be important for most patients to resume safe, normal life soon after the procedure. Computerized tests have shown being accurate descriptors of cognitive function. The purpose of the present study was to evaluate the time course of cognitive function recovery after sedation with propofol and remifentanil. A prospective observational double blind clinical study conducted in 34 young healthy adults undergoing elective outpatient colonoscopy under sedation with the combination of propofol and remifentanil using a target controlled infusion system. Cognitive function was measured using a validated battery of computerized cognitive tests (Cogstate™, Melbourne, Australia) at different predefined times: prior to starting sedation (Tbaseline), and then 10 min (T10), 40 min (T40) and 120 min (T120) after the end of colonoscopy. Tests included the assessment of psychomotor function, attention, visual memory and working memory. All colonoscopies were completed (median time: 26 min) without significant adverse events. Patients received a median total dose of propofol and remifentanil of 149 mg and 98 µg, respectively. Psychomotor function and attention declined at T10 but were back to baseline values at T40 for all patients. The magnitude of psychomotor task reduction was large (d = 0.81) however 100% of patients were recovered at T40. Memory related tasks were not affected 10 min after ending sedation. Cognitive impairment in attention and psychomotor function after propofol and remifentanil sedation was significant and large and could be easily detected by computerized cognitive tests. Even though, patients were fully recovered 40 min after ending the procedure. From a cognitive recovery point of view, larger studies should be undertaken to propose adequate criteria for discharge after sedation.

Factors Associated with Tremor Changes during Sedation with Dexmedetomidine in Parkinson's Disease Surgery.

PubMed

Honorato-Cia, Cristina; Martínez-Simón, Antonio; Alegre, Manuel; Guridi, Jorge; Cacho-Asenjo, Elena; Panadero, Alfredo; Núñez-Córdoba, Jorge M

2015-01-01

Dexmedetomidine is an α2-agonist recently proposed as a potentially ideal drug for sedation during the surgical treatment of Parkinson's disease (PD). This report documents the incidence of changes in motor symptoms (especially tremor) in PD patients sedated with dexmedetomidine for deep brain stimulation or ablation procedures. We reviewed a retrospective cohort of 22 patients who underwent surgery for PD with dexmedetomidine sedation at a single institution from 2010 to 2014. A logistic regression analysis was performed to analyze possible confounding factors. 14 cases of tremor reduction or suppression were recorded (cumulative incidence: 63.6%; 95% CI: 40.7-82.8). No association could be identified between loading dose, β-blocker use and preoperative total Unified Parkinson's Disease Rating Scale III, with tremor changes. The maintenance dose of dexmedetomidine was higher in patients who did not experience changes [median and range for patients with and without tremor alteration 0.75 (0.2-1.0) and 1.0 µg × kg(-1) × h(-1) (0.7-1.4), respectively; p = 0.021]. Dexmedetomidine provides adequate sedation during surgery for PD, but it might affect motor signs making intraoperative testing difficult or even impossible. Dosage appears not to be the determining factor in motor changes, whose cause remains unclear. © 2015 S. Karger AG, Basel.

Sedation during mechanical ventilation: a trial of benzodiazepine and opiate in combination.

PubMed

Richman, Paul S; Baram, Daniel; Varela, Marie; Glass, Peter S

2006-05-01

To compare the efficacy of continuous intravenous sedation with midazolam alone vs. midazolam plus fentanyl ("co-sedation") during mechanical ventilation. A randomized, prospective, controlled trial. A ten-bed medical intensive care unit at a university hospital. Thirty patients with respiratory failure who were expected to require >48 hrs of mechanical ventilation and who were receiving a sedative regimen that did not include opiate pain control. An intravenous infusion of either midazolam alone or co-sedation was administered by a nurse-implemented protocol to achieve a target Ramsay Sedation Score set by the patient's physician. Study duration was 3 days, with a brief daily "wake-up." We recorded the number of hours/day that patients were "off-target" with their Ramsay Sedation Scores, the number of dose titrations per day, the incidence of patient-ventilator asynchrony, and the time required to achieve adequate sedation as measures of sedative efficacy. We also recorded sedative cost in U.S. dollars and adverse events including hypotension, hypoventilation, ileus, and coma. Compared with the midazolam-only group, the co-sedation group had fewer hours per day with an "off-target" Ramsay Score (4.2 +/- 2.4 and 9.1 +/- 4.9, respectively, p < .002). Fewer episodes per day of patient-ventilator asynchrony were noted in the co-sedation group compared with midazolam-only (0.4 +/- 0.1 and 1.0 +/- 0.2, respectively, p < .05). Co-sedation also showed nonsignificant trends toward a shorter time to achieve sedation, a need for fewer dose titrations per day, and a lower total sedative drug cost. There was a trend toward more episodes of ileus with co-sedation compared with midazolam-only (2 vs. 0). In mechanically ventilated patients, co-sedation with midazolam and fentanyl by constant infusion provides more reliable sedation and is easier to titrate than midazolam alone, without significant difference in the rate of adverse events.

Computer-assisted propofol administration.

PubMed

O'Connor, J P A; O'Moráin, C A; Vargo, J J

2010-01-01

The use of propofol for sedation in endoscopy may allow for better quality of sedation, quicker recovery and facilitate greater throughput in endoscopy units. The cost-effectiveness and utility of propofol sedation for endoscopic procedures is contingent on the personnel and resources required to carry out the procedure. Computer-based platforms are based on the patients response to stimulation and physiologic parameters. They offer an appealing means of delivering safe and effective doses of propofol. One such means is the bispectral index where continuous EEG recordings are used to assess the degree of sedation. Another is the closed-loop target-controlled system where a set of physical parameters, such as muscle relaxation and auditory-evoked potential, determine a level of medication appropriate to achieve sedation. Patient-controlled platforms may also be used. These electronic adjuncts may help endoscopists who wish to adopt propofol sedation to change current practices with greater confidence. Copyright 2010 S. Karger AG, Basel.

[Non-invasive mechanical ventilation with a facial interface during sedation for a percutaneous endoscopic gastrostomy in a patient with amyotrophic lateral sclerosis].

PubMed

González-Frasquet, M C; García-Covisa, N; Vidagany-Espert, L; Herranz-Gordo, A; Llopis-Calatayud, J E

2015-11-01

Amyotrophic lateral sclerosis is a chronic neurodegenerative disease of the central nervous system which affects the motor neurons and produces a progressive muscle weakness, leading to atrophy and muscle paralysis, and ultimately death. Performing a percutaneous endoscopic gastrostomy with sedation in patients with amyotrophic lateral sclerosis can be a challenge for the anesthesiologist. The case is presented of a 76-year-old patient who suffered from advanced stage amyotrophic lateral sclerosis, ASA III, in which a percutaneous endoscopic gastrostomy was performed with deep sedation, for which non-invasive ventilation was used as a respiratory support to prevent hypoventilation and postoperative respiratory complications. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Sedation in gastrointestinal endoscopy: current issues.

PubMed

Triantafillidis, John K; Merikas, Emmanuel; Nikolakis, Dimitrios; Papalois, Apostolos E

2013-01-28

Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate (conscious) sedation. Moderate sedation, using midazolam and an opioid, is the standard method of sedation, although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation. Moreover, the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and, consequently, its low risk of inducing hepatic encephalopathy. In the future, propofol could become the preferred sedation agent, especially for routine colonoscopy. Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. Among opioids, pethidine and fentanyl are the most popular. A number of other substances have been tested in several clinical trials with promising results. Among them, newer opioids, such as remifentanil, enable a faster recovery. The controversy regarding the administration of sedation by an endoscopist or an experienced nurse, as well as the optimal staffing of endoscopy units, continues to be a matter of discussion. Safe sedation in special clinical circumstances, such as in the cases of obese, pregnant, and elderly individuals, as well as patients with chronic lung, renal or liver disease, requires modification of the dose of the drugs used for sedation. In the great majority of patients, sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide. In this review, an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature.

Sedation in gastrointestinal endoscopy: Current issues

PubMed Central

Triantafillidis, John K; Merikas, Emmanuel; Nikolakis, Dimitrios; Papalois, Apostolos E

2013-01-01

Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate (conscious) sedation. Moderate sedation, using midazolam and an opioid, is the standard method of sedation, although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation. Moreover, the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and, consequently, its low risk of inducing hepatic encephalopathy. In the future, propofol could become the preferred sedation agent, especially for routine colonoscopy. Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. Among opioids, pethidine and fentanyl are the most popular. A number of other substances have been tested in several clinical trials with promising results. Among them, newer opioids, such as remifentanil, enable a faster recovery. The controversy regarding the administration of sedation by an endoscopist or an experienced nurse, as well as the optimal staffing of endoscopy units, continues to be a matter of discussion. Safe sedation in special clinical circumstances, such as in the cases of obese, pregnant, and elderly individuals, as well as patients with chronic lung, renal or liver disease, requires modification of the dose of the drugs used for sedation. In the great majority of patients, sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide. In this review, an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature. PMID:23382625

Sedation and Anesthesia in Pediatric and Congenital Cardiac Catheterization: A Prospective Multicenter Experience.

PubMed

Lin, C Huie; Desai, Sanyukta; Nicolas, Ramzi; Gauvreau, Kimberlee; Foerster, Susan; Sharma, Anshuman; Armsby, Laurie; Marshall, Audrey C; Odegard, Kirsten; DiNardo, James; Vincent, Julie; El-Said, Howaida; Spaeth, James; Goldstein, Bryan; Holzer, Ralf; Kreutzer, Jackie; Balzer, David; Bergersen, Lisa

2015-10-01

Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart patient. We sought to identify current sedation/anesthesia practices, the serious adverse event rate related to airway, sedation, or anesthesia, and the rate of intra-procedural conversion from procedural sedation to the use of assisted ventilation or an artificial airway. Data from 13,611 patients who underwent catheterization at eight institutions were prospectively collected from 2007 to 2010. Ninety-four (0.69 %) serious sedation/airway-related adverse events occurred; events were more likely to occur in smaller patients (<4 kg, OR 4.4, 95 % CI 2.3-8.2, p < 0.001), patients with non-cardiac comorbidities (OR 1.7, 95 % CI 1.1-26, p < 0.01), and patients with low mixed venous oxygen saturation (OR 2.3, 95 % CI 1.4-3.6, p < 0.001). Nine thousand three hundred and seventy-nine (69 %) patients were initially managed with general endotracheal anesthesia, LMA, or tracheostomy, whereas 4232 (31 %) were managed with procedural sedation without an artificial airway, of which 75 (1.77 %) patients were converted to assisted ventilation/general anesthesia. Young age (<12 months, OR 5.2, 95 % CI 2.3-11.4, p < 0.001), higher-risk procedure (category 4, OR 10.1, 95 % CI 6.5-15.6, p < 0.001), and continuous pressor/inotrope requirement (OR 11.0, 95 % CI 8.6-14.0, p < 0.001) were independently associated with conversion. Cardiac catheterization in pediatric/congenital patients was associated with a low rate of serious sedation/airway-related adverse events. Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk. Patients under 1 year of age, undergoing high-risk procedures, or requiring continuous pressor/inotrope support may be at higher risk of requiring conversion from procedural sedation to assisted ventilation/general anesthesia.

Survey on sedation in paediatric dentistry: a global perspective.

PubMed

Wilson, Stephen; Alcaino, Eduardo A

2011-09-01

Paediatric dentists receive training in sedation during their advanced education training, but evidence suggests that this training varies widely. The purpose of this study was to survey members of the International Association of Paediatric Dentistry (IAPD) and the European Academy of Paediatric Dentistry (EAPD) on their opinion on pharmacological and other behavioural management techniques and their training related to provision of oral health care of paediatric patients in the dental setting. A request was made for access to the IAPD and EAPD membership email addresses. The responses were recorded anonymously and data uploaded into spss (version 9) and analysed using descriptive analysis and chi-square with and without tabulation processes. A total of 311 respondents of 1973 targeted individuals answered the survey. The response rate was 16%. The majority of the respondents came from the continent of Europe, Asia, and the Americas. The most frequent type of sedation was general anaesthesia (52% of the respondents), followed by nitrous oxide (46%) and then oral sedation (44%). At least 91% of the respondents indicated that they were interested in the development of continuing education on the topic of sedation. Paediatric dentists around the world use relatively few behaviour management techniques, including pharmacological management. There is a definite interest in continuing education in the area of sedation. The Authors. International Journal of Paediatric Dentistry © 2011 BSPD, IAPD and Blackwell Publishing Ltd.

Intravenous Sedation with Low-Dose Dexmedetomidine: Its Potential for Use in Dentistry

PubMed Central

Ogawa, Sachie; Seino, Hiroaki; Ito, Hiroshi; Yamazaki, Shinya; Ganzberg, Steven; Kawaai, Hiroyoshi

2008-01-01

This study investigated the physiologic and sedative parameters associated with a low-dose infusion of dexmedetomidine (Dex). Thirteen healthy volunteers were sedated with Dex at a loading dose of 6 mcg/kg/h for 5 minutes and a continuous infusion dose of 0.2 mcg/kg/h for 25 minutes. The recovery process was observed for 60 minutes post infusion. The tidal volume decreased significantly despite nonsignificant changes in respiratory rate, minute ventilation, oxygen saturation, and end-tidal carbon dioxide. The mean arterial pressure and heart rate also decreased significantly but within clinically acceptable levels. Amnesia to pin prick was present in 69% of subjects. A Trieger dot test plot error ratio did not show a significant change at 30 minutes post infusion despite a continued significant decrease in bispectral index. We conclude that sedation with a low dose of Dex appears to be safe and potentially efficacious for young healthy patients undergoing dental procedures. PMID:18788843

Actigraphy in the critically ill: correlation with activity, agitation, and sedation.

PubMed

Grap, Mary Jo; Borchers, C Todd; Munro, Cindy L; Elswick, R K; Sessler, Curtis N

2005-01-01

To determine the feasibility of continuous measurement of limb movement via wrist and ankle actigraphy (an activity measure) in critically ill patients and to compare actigraphy measurements with observed activity, subjective scores on sedation-agitation scales, and heart rate and blood pressure of patients. In a prospective, descriptive, correlational study, all activity of 20 adult patients in medical and coronary care units in a university medical center were observed for 2 hours and documented. Wrist and ankle actigraphy, heart rate, and systolic and diastolic blood pressure data were collected every minute. The Comfort Scale and the Richmond Agitation-Sedation Scale were completed at the beginning of the observation period and 1 and 2 hours later. Wrist actigraphy data correlated with scores on the Richmond Agitation-Sedation Scale (r = 0.58) and the Comfort Scale (r = 0.62) and with observed stimulation and activity events of patients (r = 0.45). Correlations with systolic, diastolic, and mean arterial pressures were weaker. Wrist and ankle actigraphy data were significantly correlated (r = 0.69; P < .001); however, their mean values (wrist, 418; ankle, 147) were significantly different (t = 5.77; P < .001). Actigraphy provides a continuous recording of patients' limb movement. Actigraphy measurements correlate well with patients' observed activity and with subjective scores on agitation and sedation scales. Actigraphy may become particularly important as a continuous measurement of activity for use in behavioral research and may enhance early recognition and management of the excessive activity that characterizes agitation.

Evidence-based clinical improvement for mechanically ventilated patients.

PubMed

Hampton, Debra C; Griffith, Deborah; Howard, Alan

2005-01-01

Bundling or grouping together evidence-based interventions to improve care for the mechanically ventilated patient was piloted by a 10-bed medical-surgical critical care unit of a hospital. The bundled care interventions included: (a) keeping the head of bed elevated at 30 degrees, (b) instituting daily interruption of continuous sedative infusion, (c) assessing readiness to wean using a rapid-wean assessment guide, (d) initiating deep venous thrombosis prophylaxis, and (e) implementing peptic ulcer disease prophylaxis. The interventions were implemented using a plan-do-check-act quality-improvement methodology. Results indicated that the use of bundled interventions for mechanically ventilated patients could decrease average ventilator times and average length of stay with no concomitant increase in reintubations. Average mortality rates and the number of adverse events per 100 patient days also were reduced.

Chloral hydrate sedation for magnetic resonance imaging in newborn infants.

PubMed

Finnemore, Anna; Toulmin, Hilary; Merchant, Naz; Arichi, Tom; Tusor, Nora; Cox, David; Ederies, Ash; Nongena, Phumza; Ko, Christopher; Dias, Ryan; Edwards, Anthony D; Groves, Alan M

2014-02-01

The aim of this study was to look for clinically significant adverse effects of chloral hydrate used in a large cohort of infants sedated for magnetic resonance imaging. Case notes of infants who underwent magnetic resonance imaging (MRI) scanning from 2008 to 2010 were reviewed, with patient demographics, sedation dose, comorbidities, time to discharge, and side effects of sedation noted. Four hundred and eleven infants (median [range] postmenstrual age per weight at scan 42 [31(+4) -60] weeks per 3500 g [1060-9900 g]) were sedated with chloral hydrate (median [range] dose 50 [20-80] mg·kg(-1)). In three cases (0.7%), desaturations occurred which prompted termination of the scan. One infant (0.2%) was admitted for additional observation following sedation but had no prolonged effects. In 17 (3.1%) cases, infants had desaturations which were self-limiting or responded to additional inspired oxygen such that scanning was allowed to continue. When adhering to strict protocols, MRI scanning in newborn infants in this cohort was performed using chloral hydrate sedation with a relatively low risk of significant adverse effects. © 2013 John Wiley & Sons Ltd.

Moderate-to-deep sedation technique, using propofol and ketamine, allowing synchronised breathing for magnetic resonance high-intensity focused ultrasound (MR-HIFU) treatment for uterine fibroids: a pilot study.

PubMed

Vaessen, Hermanus H B; Knuttel, F M; van Breugel, J M M; Ikink, M E; Dieleman, J M; van den Bosch, M A A J; Knape, J T A

2017-01-01

Magnetic resonance high-intensity focused ultrasound (MR-HIFU) treatment for uterine fibroids is rapidly gaining popularity as a treatment modality. This procedure is generally uncomfortable, painful, and requires minimal or absence of movement and an MR-HIFU synchronised breathing pattern of the patient. Procedural sedation and analgesia protocols have become the standard practice in interventional radiology departments worldwide. The aim of this study was to explore if a sedation regimen with low-dose propofol and ketamine performed by trained non-medical sedation practitioners could result in relief of discomfort for the patient and in adequate working conditions for MR-HIFU treatment for uterine fibroids. In this study, conducted from August 2013 until November 2014, 20 patients were subjected to MR-HIFU treatment of uterine fibroids. Patients were deeply sedated using intravenous propofol and esketamine according to a standardised hospital protocol to allow synchronisation of the breathing pattern to the MR-HIFU. The quality of sedation for MR-HIFU and complications were recorded and analysed. The side effects of the sedation technique, the propofol and esketamine consumption rate, the duration of recovery, and patient satisfaction after 24 h were examined. A total of 20 female patients (mean age 42.4 [range 32-53] years) were enrolled. Mean propofol/esketamine dose was 1309 mg/39.5 mg (range 692-1970 mg/ 23.6-87.9 mg). Mean procedure time was 269 min (range 140-295 min). Application of the sedation protocol resulted in a regular breathing pattern, which could be synchronised with the MR-HIFU procedures without delay. The required treatment was completed in all cases. There were no major adverse events. Hypoxemia (oxygen desaturation <92%) and hallucinations were not observed. The use of a specific combination of IV propofol and esketamine for procedural sedation and analgesia reduced the discomfort and pain during MR-guided HIFU treatments of uterine fibroids. The resulting regular breathing pattern allowed for easy synchronisation of the MR-HIFU procedure. Based on our results, esketamine and propofol sedation performed by trained non-medical sedation practitioners is feasible and safe, has a low risk of major adverse events, and has a short recovery time, avoiding a session of general anaesthesia.

Anesthesia Practice and Clinical Trends in Interventional Radiology: A European Survey

DOE Office of Scientific and Technical Information (OSTI.GOV)

Haslam, Philip J.; Yap, Bernard; Mueller, Peter R.

Purpose: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends.Methods: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived frommore » a similar survey of interventional practice in the United States.Results: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds.Conclusion: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.« less

Severe cardiorespiratory complications derived from propofol sedation monitored by an endoscopist.

PubMed

Maestro Antolín, Sergio; Moreira Da Silva, Bruno Antonio; Santos Santamarta, Fernando; Germade, Arantza; Pérez Citores, Laura; Santamaría, Ana; Bonoso Criado, Rocío; Madrigal, Rosa Eva; Saracibar, Esther; Barcenilla Laguna, Javier; Igea Arisqueta, Francisco; Pérez-Millán, Antonio Germán

2018-04-01

deep sedation with propofol monitored by an endoscopist in different endoscopy units is a controversial subject and the source of conflicts of interest between the various scientific societies of Anesthesiology and Gastroenterology. Many studies have already demonstrated the efficacy, efficiency and low incidence of complications associated with sedation when under the control of a trained endoscopist vs an anesthesiologist. the rate of severe cardiorespiratory complications during various endoscopic examinations (gastroscopy, colonoscopy, endoscopic retrograde cholangiopancreatography [ERCP] and endoscopic ultrasound [EUS]) where sedation was controlled by an endoscopist within our unit, from 2011 to 2016, was reviewed. during the study period, 33,195 examinations were analyzed. The rate of cardiorespiratory complications was 0.13% and the majority were severe desaturations. Most cases responded to an opening in the airway associated with the interruption of drug infusion and an ambu bag was required in a few cases. There were no statistically significant differences between the different groups, except for mean age, risk by type of examination and ASA risk, where the difference between ERCP and the rest of examinations was statistically significant. there is a high level of evidence in the scientific literature suggesting that sedation controlled by a trained endoscopist is safe, effective and efficient. However, further prospective studies are required in order to confirm this conclusion due to the fact that the majority of studies to date are retrospective.

"Sedation is tricky": A qualitative content analysis of nurses' perceptions of sedation administration in mechanically ventilated intensive care unit patients.

PubMed

Hetland, Breanna; Guttormson, Jill; Tracy, Mary Fran; Chlan, Linda

2018-05-01

Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses' comments regarding sedation administration practices with mechanically ventilated patients. This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses' perceptions of current sedation administration practices. Multiple factors guided sedation administration practices, including individual patient needs, nurses' synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing. Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients. Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

[Determining factors in the sedation of geriatric and oncology patients treated at home].

PubMed

Zamora-Mur, A; García-Foncillas, R; Zamora-Catevilla, A; Nabal-Vicuña, M; Calderero-Aragón, V; Lostalé-Latorre, F

2017-04-01

Sedation, used as a therapeutic measure in the field of Palliative Care, continues to present difficulties for many professionals in its management and indications. Is varied existing literature in this regard, often exclusive cancer patients. Our objective is to analyse the characteristics of patients attended by a Home Care Support Team who required sedation compared to non-sedated patients, for possible determining factors for its use that could help in decision-making. A prospective analytical study conducted in Barbastro (Huesca) from September 2007 to February 2011. The study population are patients referred to the Home Care Support Team of Barbastro. Age, sex, medical history, symptoms, previous and current Barthel, Karnofsky, primary caregiver, previous drugs, drugs after intervention, sedation yes/no. Required sedation 16.6% (n=106) of the cases (N=638). Sedated patients were younger, with no differences in sex, and the large majority (83%) were oncology patients. The presence of metastases showed no differences in need for sedation. Sedated patients have an increased functional impairment, determined by Barthel index decreased and a worse Karnofsky. Sedated patients showed increased frequency of uncontrolled symptoms, except psychomotor agitation, a fact determined by the medications used pre- and post-intervention. The presence of neoplastic disease, marked with existence of functional decline, and uncontrolled clinical need for certain medications to control symptoms may determine the need for sedation at the end of the process, above other factors such as patient comorbidity. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

Use of electricity to sedate Lake Trout for intracoelomic implantation of electronic transmitters

USGS Publications Warehouse

Faust, Matthew D.; Vandergoot, Christopher; Hostnik, Eric T.; Binder, Thomas R.; Mida Hinderer, Julia L.; Ives, Jessica T.; Krueger, Charles C.

2017-01-01

Use of telemetry data to inform fisheries conservation and management is becoming increasingly common; as such, fish typically must be sedated before surgical implantation of transmitters into the coelom. Given that no widely available, immediate-release chemical sedative currently exists in North America, we investigated the feasibility of using electricity to sedate Lake Trout Salvelinus namaycush long enough for an experienced surgeon to implant an electronic transmitter (i.e., 180 s). Specifically, our study objectives were to determine (1) whether some combination of electrical waveform characteristics (i.e., duty cycle, frequency, voltage, and pulse type) could sedate Lake Trout for at least 180 s; and (2) whether Lake Trout that were sequentially exposed to continuous DC and pulsed DC had greater rates of spinal injury and short-term mortality than control fish. A Portable Electrosedation System unit was used to sedate hatchery and wild Lake Trout. Dual-frequency pulsed-DC and two-stage approaches successfully sedated Lake Trout and had similar induction and recovery times. Lake Trout sedated using the two-stage approach did not have survival rates or spinal abnormalities that were significantly different from those of control fish. We concluded that electricity was a viable alternative to chemical sedatives for sedating Lake Trout before surgical implantation of an electronic transmitter, but we suggest that Lake Trout and other closely related species (e.g., Arctic Char Salvelinus alpinus) may require morphotype-specific electrical waveforms due to their morphological diversity.

An international survey of management of pain and sedation after paediatric cardiac surgery.

PubMed

Zeilmaker-Roest, Gerdien A; Wildschut, Enno D; van Dijk, Monique; Anderson, Brian J; Breatnach, Cormac; Bogers, Ad J J C; Tibboel, Dick

2017-01-01

The mainstay of pain treatment after paediatric cardiac surgery is the use of opioids. Current guidelines for its optimal use are based on small, non-randomised clinical trials, and data on the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids are lacking. This study aims at providing an overview of international hospital practices on the treatment of pain and sedation after paediatric cardiac surgery. A multicentre survey study assessed the management of pain and sedation in children aged 0-18 years after cardiac surgery. Pediatric intensive care units (PICU)of 19 tertiary children's hospitals worldwide were invited to participate. The focus of the survey was on type and dose of analgesic and sedative drugs and the tools used for their pharmacodynamic assessment. Fifteen hospitals (response rate 79%) filled out the survey. Morphine was the primary analgesic in most hospitals, and its doses for continuous infusion ranged from 10 to 60 mcg kg -1 h -1 in children aged 0-36 months. Benzodiazepines were the first choice for sedation, with midazolam used in all study hospitals. Eight hospitals (53%) reported routine use of sedatives with pain treatment. Overall, type and dosing of analgesic and sedative drugs differed substantially between hospitals. All participating hospitals used validated pain and sedation assessment tools. There was a large variation in the type and dosing of drugs employed in the treatment of pain and sedation after paediatric cardiac surgery. As a consequence, there is a need to rationalise pain and sedation management for this vulnerable patient group.

Palliative sedation: reliability and validity of sedation scales.

PubMed

Arevalo, Jimmy J; Brinkkemper, Tijn; van der Heide, Agnes; Rietjens, Judith A; Ribbe, Miel; Deliens, Luc; Loer, Stephan A; Zuurmond, Wouter W A; Perez, Roberto S G M

2012-11-01

Observer-based sedation scales have been used to provide a measurable estimate of the comfort of nonalert patients in palliative sedation. However, their usefulness and appropriateness in this setting has not been demonstrated. To study the reliability and validity of observer-based sedation scales in palliative sedation. A prospective evaluation of 54 patients under intermittent or continuous sedation with four sedation scales was performed by 52 nurses. Included scales were the Minnesota Sedation Assessment Tool (MSAT), Richmond Agitation-Sedation Scale (RASS), Vancouver Interaction and Calmness Scale (VICS), and a sedation score proposed in the Guideline for Palliative Sedation of the Royal Dutch Medical Association (KNMG). Inter-rater reliability was tested with the intraclass correlation coefficient (ICC) and Cohen's kappa coefficient. Correlations between the scales using Spearman's rho tested concurrent validity. We also examined construct, discriminative, and evaluative validity. In addition, nurses completed a user-friendliness survey. Overall moderate to high inter-rater reliability was found for the VICS interaction subscale (ICC = 0.85), RASS (ICC = 0.73), and KNMG (ICC = 0.71). The largest correlation between scales was found for the RASS and KNMG (rho = 0.836). All scales showed discriminative and evaluative validity, except for the MSAT motor subscale and VICS calmness subscale. Finally, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. The RASS and KNMG scales stand as the most reliable and valid among the evaluated scales. In addition, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. Further research is needed to evaluate the impact of the scales on better symptom control and patient comfort. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Noise level measurement, a new method to evaluate effectiveness of sedation in pediatric dentistry.

PubMed

Sabouri, A Sassan; Firoozabadi, Farshid; Carlin, Drew; Creighton, Paul; Raczka, Michelle; Joshi, Prashant; Heard, Christopher

2014-12-01

Pediatric dentists perform moderate sedation frequently to facilitate dental treatment in uncooperative children. Assessing the depth and quality of sedation is an important factor in the clinical utilization of moderate sedation. We aimed to determine if the level of noise, created by the children who are undergoing moderate sedation during dental procedures, could be used as a nonsubjective measurement of the depth of sedation and compare it to the Ohio State Behavior Rating Score (OSBRS). Following Institutional Review Board approval and after receiving informed consent, we studied 51 children with a mean age of 4.2 years and average weight of 18.5 kg, who were undergoing restorative or extractive dental procedures, requiring moderate sedation. Sedation efficacy was assessed using OSBRS at several stages of the procedure. The noise level was measured by using a NoisePRO logging device to record the noise level at a rate of every second throughout the procedure. The depth of sedation assessed by OSBRS during the operative procedure was significantly correlated with noise level. The act of administering the local anesthesia and the operative procedure itself were two phases of the encounter that were significantly associated with higher OSBRS as well as noise levels. Measurement of noise level can be used as an effective guide to quantify the depth of sedation at different stages of the dental procedure. It is a nonsubjective and continuous measurement, which could be useful in clinical practice for the administration of moderate sedation during dental procedures. By using noise level analysis we are able to determine successful, poor, and failed sedation outcome. Copyright © 2014. Published by Elsevier B.V.

Accounting for the sedative and analgesic effects of medication changes during patient participation in clinical research studies: measurement development and application to a sample of institutionalized geriatric patients.

PubMed

Sloane, Philip; Ivey, Jena; Roth, Mary; Roederer, Mary; Williams, Christianna S

2008-03-01

To date, no system has been published that allows investigators to adjust for the overall sedative and/or analgesic effects of medications, or changes in medications, in clinical trial participants for whom medication use cannot be controlled. This is common in clinical trials of behavioral and complementary/alternative therapies, and in research involving elderly or chronically ill patients for whom ongoing medical care continues during the trial. This paper describes the development, and illustrates the use, of a method we developed to address this issue, in which we generate single continuous variables to represent the daily sedative and analgesic loads of multiple medications. Medications for 90 study participants in a clinical trial of a nonpharmacological intervention were abstracted from medication administration records across multiple treatment periods. An expert panel of three academic clinical pharmacists and a geriatrician met to develop a system by which each study medication could be assigned a sedative and analgesic effect rating. The two measures, when applied to data on 90 institutionalized persons with Alzheimer's disease, resulted in variables with moderately skewed distributions that are consistent with the clinical profile of analgesia and sedation use in long-term care populations. The average study participant received 1.89 analgesic medications per day and had a daily analgesic load of 2.96; the corresponding figures for sedation were 2.07 daily medications and an average daily load of 11.41. A system of classifying the sedative and analgesic effects of non-study medications was created that divides drugs into categories based on the strength of their effects and assigns a rating to express overall sedative and analgesic effects. These variables may be useful in comparing patients and populations, and to control for drug effects in future studies.

Sedation at the end of life - a nation-wide study in palliative care units in Austria.

PubMed

Schur, Sophie; Weixler, Dietmar; Gabl, Christoph; Kreye, Gudrun; Likar, Rudolf; Masel, Eva Katharina; Mayrhofer, Michael; Reiner, Franz; Schmidmayr, Barbara; Kirchheiner, Kathrin; Watzke, Herbert Hans

2016-05-14

Sedation is used to an increasing extent in end-of-life care. Definitions and indications in this field are based on expert opinions and case series. Little is known about this practice at palliative care units in Austria. Patients who died in Austrian palliative care units between June 2012 and June 2013 were identified. A predefined set of baseline characteristics and information on sedation during the last two weeks before death were obtained by reviewing the patients' charts. The data of 2414 patients from 23 palliative care units were available for analysis. Five hundred two (21 %) patients received sedation in the last two weeks preceding their death, 356 (71 %) received continuous sedation until death, and 119 (24 %) received intermittent sedation. The median duration of sedation was 48 h (IQR 10-72 h); 168 patients (34 %) were sedated for less than 24 h. Indications for sedation were delirium (51 %), existential distress (32 %), dyspnea (30 %), and pain (20 %). Midazolam was the most frequently used drug (79 %), followed by lorazepam (13 %), and haloperidol (10 %). Sedated patients were significantly younger (median age 67 years vs. 74 years, p ≤ 0.001, r = 0.22), suffered more often from an oncological disease (92 % vs. 82 %, p ≤ 0.001, φ = 0.107), and were hospitalized more frequently (94 % vs. 76 %, p ≤ 0.001, φ = 0.175). The median number of days between admission to a palliative care ward/mobile palliative care team and death did not differ significantly in sedated versus non-sedated patients (10 vs. 9 days; p = 0.491). This study provides insights into the practice of end-of-life sedation in Austria. Critical appraisal of these data will serve as a starting point for the development of nation-wide guidelines for palliative sedation in Austria.

Level of Discomfort Decreases After the Administration of Continuous Palliative Sedation: A Prospective Multicenter Study in Hospices and Palliative Care Units.

PubMed

van Deijck, Rogier H P D; Hasselaar, Jeroen G J; Verhagen, Stans C A H H V M; Vissers, Kris C P; Koopmans, Raymond T C M

2016-09-01

A gold standard or validated tool for monitoring the level of discomfort during continuous palliative sedation (CPS) is lacking. Therefore, little is known about the course of discomfort in sedated patients, the efficacy of CPS, and the determinants of discomfort during CPS. To identify the course of discomfort in patients receiving CPS. A prospective observational multicenter study in nine hospices and palliative care units was performed. The Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) was independently assessed for monitoring of patient discomfort during CPS. The DS-DAT scores range from 0 (no observed discomfort) to a maximum of 27 (high level of observed discomfort). Using a mixed model, the mean group score of discomfort between four predefined time frames of CPS was compared, correcting for confounding patient characteristics. A total of 130 patients were sedated, and the DS-DAT was completed in 106 patients at least once. The median duration of the sedation in these 106 patients was 25.5 hours (range 2-161). The mean score of the DS-DAT in the phase before sedation was 12.16 (95% CI 9.83-14.50) and decreased significantly to 8.06 (95% CI 5.53-10.58) in the titration phase of sedation. The mean score of the DS-DAT in the final phase of sedation was 7.42 (95% CI 4.90-9.94). This study shows that CPS is associated with a decrease in the level of discomfort within an acceptable time frame, although in some sedated patients higher levels of discomfort in the last hours of life occurred. Although the DS-DAT seems to be of value for monitoring the level of discomfort during CPS, the results of this study should be interpreted within the constraints of the limitations, and further research on the psychometric properties of this tool is needed before the DS-DAT can be used in clinical practice. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Staff education, regular sedation and analgesia quality feedback, and a sedation monitoring technology for improving sedation and analgesia quality for critically ill, mechanically ventilated patients: a cluster randomised trial.

PubMed

Walsh, Timothy S; Kydonaki, Kalliopi; Antonelli, Jean; Stephen, Jacqueline; Lee, Robert J; Everingham, Kirsty; Hanley, Janet; Phillips, Emma C; Uutela, Kimmo; Peltola, Petra; Cole, Stephen; Quasim, Tara; Ruddy, James; McDougall, Marcia; Davidson, Alan; Rutherford, John; Richards, Jonathan; Weir, Christopher J

2016-10-01

Optimal sedation of patients in intensive care units (ICUs) requires the avoidance of pain, agitation, and unnecessary deep sedation, but these outcomes are challenging to achieve. Excessive sedation can prolong ICU stay, whereas light sedation can increase pain and frightening memories, which are commonly recalled by ICU survivors. We aimed to assess the effectiveness of three interventions to improve sedation and analgesia quality: an online education programme; regular feedback of sedation-analgesia quality data; and use of a novel sedation-monitoring technology (the Responsiveness Index [RI]). We did a cluster randomised trial in eight ICUs, which were randomly allocated to receive education alone (two ICUs), education plus sedation-analgesia quality feedback (two ICUs), education plus RI monitoring technology (two ICUs), or all three interventions (two ICUs). Randomisation was done with computer-generated random permuted blocks, stratified according to recruitment start date. A 45 week baseline period was followed by a 45 week intervention period, separated by an 8 week implementation period in which the interventions were introduced. ICU and research staff were not masked to study group assignment during the intervention period. All mechanically ventilated patients were potentially eligible. We assessed patients' sedation-analgesia quality for each 12 h period of nursing care, and sedation-related adverse events daily. Our primary outcome was the proportion of care periods with optimal sedation-analgesia, defined as being free from excessive sedation, agitation, poor limb relaxation, and poor ventilator synchronisation. Analysis used multilevel generalised linear mixed modelling to explore intervention effects in a single model taking clustering and patient-level factors into account. A concurrent mixed-methods process evaluation was undertaken to help understand the trial findings. The trial is registered with ClinicalTrials.gov, number NCT01634451. Between June 1, 2012, and Dec 31, 2014, we included 881 patients (9187 care periods) during the baseline period and 591 patients (6947 care periods) during the intervention period. During the baseline period, optimal sedation-analgesia was present for 5150 (56%) care periods. We found a significant improvement in optimal sedation-analgesia with RI monitoring (odds ratio [OR] 1·44 [95% CI 1·07-1·95]; p=0·017), which was mainly due to increased periods free from excessive sedation (OR 1·59 [1·09-2·31]) and poor ventilator synchronisation (OR 1·55 [1·05-2·30]). However, more patients experienced sedation-related adverse events (OR 1·91 [1·02-3·58]). We found no improvement in overall optimal sedation-analgesia with education (OR 1·13 [95% CI 0·86-1·48]), but fewer patients experienced sedation-related adverse events (OR 0·56 [0·32-0·99]). The sedation-analgesia quality data feedback did not improve quality (OR 0·74 [95% CI 0·54-1·00]) or sedation-related adverse events (OR 1·15 [0·61-2·15]). The process evaluation suggested many clinicians found the RI monitoring useful, but it was often not used for decision making as intended. Education was valued and considered useful by staff. By contrast, sedation-analgesia quality feedback was poorly understood and thought to lack relevance to bedside nursing practice. Combination of RI monitoring and online education has the potential to improve sedation-analgesia quality and patient safety in mechanically ventilated ICU patients. The RI monitoring seemed to improve sedation-analgesia quality, but inconsistent adoption by bedside nurses limited its impact. The online education programme resulted in a clinically relevant improvement in patient safety and was valued by nurses, but any changes to behaviours did not seem to alter other measures of sedation-analgesia quality. Providing sedation-analgesia quality feedback to ICUs did not appear to improve any quality metrics, probably because staff did not think it relevant to bedside practice. Chief Scientist Office, Scotland; GE Healthcare. Copyright © 2016 Elsevier Ltd. All rights reserved.

Does dental undergraduate education and postgraduate training enable intention to provide inhalation sedation in primary dental care? A path analytical exploration.

PubMed

Yuan, S; J Carson, S; Rooksby, M; McKerrow, J; Lush, C; Humphris, G; Freeman, R

2017-08-01

To examine how quality standards of dental undergraduate education, postgraduate training and qualifications together with confidence and barriers could be utilised to predict intention to provide inhalation sedation. All 202 dentists working within primary dental care in NHS Highland were invited to participate. The measures in the questionnaire survey included demographic information, undergraduate education and postgraduate qualifications, current provision and access to sedation service, attitudes towards confidence, barriers and intention to provide inhalation sedation. A path analytical approach was employed to investigate the fit of collected data to the proposed mediational model. One hundred and nine dentists who completed the entire questionnaire participated (response rate of 54%). Seventy-six per cent of dentists reported receiving lectures in conscious sedation during their undergraduate education. Statistically significantly more Public Dental Service dentists compared with General Dental Service (GDS) dentists had postgraduate qualification and Continuing Professional Development training experience in conscious sedation. Only twenty-four per cent of the participants stated that they provided inhalation sedation to their patients. The findings indicated that PDS dentists had higher attitudinal scores towards inhalation sedation than GDS practitioners. The proposed model showed an excellent level of fit. A multigroup comparison test confirmed that the level of association between confidence in providing inhalation sedation and intention varied by group (GDS vs. PDS respondents). Public Dental Service respondents who showed extensive postgraduate training experience in inhalation sedation were more confident and likely to provide this service. The quality standards of dental undergraduate education, postgraduate qualifications and training together with improved confidence predicted primary care dentists' intention to provide inhalation sedation. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Sedation in palliative care – a critical analysis of 7 years experience

PubMed Central

Muller-Busch, H Christof; Andres, Inge; Jehser, Thomas

2003-01-01

Background The administration of sedatives in terminally ill patients becomes an increasingly feasible medical option in end-of-life care. However, sedation for intractable distress has raised considerable medical and ethical concerns. In our study we provide a critical analysis of seven years experience with the application of sedation in the final phase of life in our palliative care unit. Methods Medical records of 548 patients, who died in the Palliative Care Unit of GK Havelhoehe between 1995–2002, were retrospectively analysed with regard to sedation in the last 48 hrs of life. The parameters of investigation included indication, choice and kind of sedation, prevalence of intolerable symptoms, patients' requests for sedation, state of consciousness and communication abilities during sedation. Critical evaluation included a comparison of the period between 1995–1999 and 2000–2002. Results 14.6% (n = 80) of the patients in palliative care had sedation given by the intravenous route in the last 48 hrs of their life according to internal guidelines. The annual frequency to apply sedation increased continuously from 7% in 1995 to 19% in 2002. Main indications shifted from refractory control of physical symptoms (dyspnoea, gastrointestinal, pain, bleeding and agitated delirium) to more psychological distress (panic-stricken fear, severe depression, refractory insomnia and other forms of affective decompensation). Patients' and relatives' requests for sedation in the final phase were significantly more frequent during the period 2000–2002. Conclusion Sedation in the terminal or final phase of life plays an increasing role in the management of intractable physical and psychological distress. Ethical concerns are raised by patients' requests and needs on the one hand, and the physicians' self-understanding on the other hand. Hence, ethically acceptable criteria and guidelines for the decision making are needed with special regard to the nature of refractory and intolerable symptoms, patients' informed consent and personal needs, the goals and aims of medical sedation in end-of-life care. PMID:12744722

Experiences of Family Members of Dying Patients Receiving Palliative Sedation.

PubMed

Tursunov, Olga; Cherny, Nathan I; Ganz, Freda DeKeyser

2016-11-01

To describe the experience of family members of patients receiving palliative sedation at the initiation of treatment and after the patient has died and to compare these experiences over time.
. Descriptive comparative study.
. Oncology ward at Shaare Zedek Medical Center in Jerusalem, Israel.
. A convenience sample of 34 family members of dying patients receiving palliative sedation. 
. A modified version of a questionnaire describing experiences of family members with palliative sedation was administered during palliative sedation and one to four months after the patient died. Descriptive statistics were used to describe the results of the questionnaire, and appropriate statistical analyses were conducted for comparisons over time.
. Experiences of family members and time.
. Most relatives were satisfied with the sedation and staff support. Palliative sedation was experienced as an ethical way to relieve suffering. However, one-third felt that it shortened the patient's life. An explanation of the treatment was given less than half of the time and was usually given on the same day treatment was started. This explanation was given by physicians and nurses. Many felt that they were not ready for changes in the patient's condition and wanted increased opportunities to discuss the treatment with oncology care providers. No statistically significant differences in experiences were found over time. 
. Relatives' experiences of palliative sedation were generally positive and stable over time. Important experiences included timing of the initiation of sedation, timing and quality of explanations, and communication.
. Nurses should attempt to initiate discussions of the possible role of sedation in the event of refractory symptoms and follow through with continued discussions. The management of refractory symptoms at the end of life, the role of sedation, and communication skills associated with decision making related to palliative sedation should be a part of the core nursing curriculum. Nursing administrators in areas that use palliative sedation should enforce good nursing clinical practice as recommended by international practice guidelines, such as those of the European Association for Palliative Care.

Prospective Observational Evaluation of Sedation and Pain Management Guideline Adherence Across New Jersey Intensive Care Units.

PubMed

Brophy, Alison; Cardinale, Maria; Andrews, Liza B; Kaplan, Justin B; Adams, Christopher; Opsha, Yekaterina; Brandt, Kimberly A; Dixit, Deepali; Nerenberg, Steven F; Saleh, Julie A

2018-01-01

The practice guidelines for the management of pain, agitation, and delirium (PAD) from the Society of Critical Care Medicine shifted from primarily focusing on the treatment of anxiety in 2002 to the treatment of pain in 2013. This prospective, observational, multicenter study aimed to assess the degree of practice adherence to the PAD guidelines for ventilated patients in New Jersey intensive care units (ICUs). Pharmacist investigators at 8 centers designated 4 days at least 10 days apart to evaluate all patients on mechanical ventilation. The primary outcomes included adherence to 4 guideline recommendations: treatment of pain before sedation, use of nonnarcotic analgesic medications, use of nonbenzodiazepine sedative medications, and use of goal-directed sedation. Of 138 patients evaluated, 50% had a primary medical diagnosis (as opposed to surgical, cardiac, or neurological diagnosis), and the median Sequential Organ Failure Assessment (SOFA) score was 7. Pain was treated prior to administration of sedatives in 55.4% of subjects, with fentanyl being the primary analgesic used. In addition, 19% received no analgesia, and 11.5% received nonopioid analgesia. Sedative agents were administered to 87 subjects (48 nonbenzodiazepine and 39 benzodiazepine). Of those receiving benzodiazepines, 22 received intermittent bolus regimens and 16 received continuous infusions, of which 5 were for another indication besides sedation. Validated scales measuring the degree of sedation were completed at least once in 56 (81.6%) patients receiving sedatives. Current sedation practices suggest that integration of evidence-based PAD guidelines across New Jersey adult ICUs is inconsistent despite pharmacist involvement.

Adverse events related to gastrointestinal endoscopic procedures in pediatric patients under anesthesia care and a predictive risk model (AEGEP Study).

PubMed

Ariza, F; Montilla-Coral, D; Franco, O; González, L F; Lozano, L C; Torres, A M; Jordán, J; Blanco, L F; Suárez, L; Cruz, G; Cepeda, M

2014-01-01

Multiple studies have analyzed perioperative factors related to adverse events (AEs) in children who require gastrointestinal endoscopic procedures (GEP) in settings where deep sedation is the preferred anesthetic technique over general anesthesia (GA) but not for the opposite case. We reviewed our anesthesia institutional database, seeking children less than 12 years who underwent GEP over a 5-year period. A logistic regression was used to determine significant associations between preoperative conditions, characteristics of the procedure, airway management, anesthetic approaches and the presence of serious and non-serious AEs. GA was preferred over deep sedation [77.8% vs. 22.2% in 2178 GEP under anesthesia care (n=1742)]. We found 96 AEs reported in 77 patients, including hypoxemia (1.82%), bronchospasm (1.14%) and laryngospasm (0.91%) as the most frequent. There were 2 cases of severe bradycardia related to laryngospasm/hypoxemia and a case of aspiration resulting in unplanned hospitalization, but there were no cases of intra- or postoperative deaths. Final predictive model for perioperative AEs included age <1 year, upper respiratory tract infections (URTI) <1 week prior to the procedure and low weight for the age (LWA) as independent risk factors and ventilation by facial mask as a protector against these events (p<0.05). AEs are infrequent and severe ones are remote in a setting where AG is preferred over deep sedation. Ventilatory AEs are the most frequent and depend on biometrical and comorbid conditions more than anesthetic drugs chosen. Age <1 year, history of URTI in the week prior to the procedure and LWA work as independent risk factors for AEs in these patients. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

Cyanide Suicide After Deep Web Shopping: A Case Report.

PubMed

Le Garff, Erwan; Delannoy, Yann; Mesli, Vadim; Allorge, Delphine; Hédouin, Valéry; Tournel, Gilles

2016-09-01

Cyanide is a product that is known for its use in industrial or laboratory processes, as well as for intentional intoxication. The toxicity of cyanide is well described in humans with rapid inhibition of cellular aerobic metabolism after ingestion or inhalation, leading to severe clinical effects that are frequently lethal. We report the case of a young white man found dead in a hotel room after self-poisoning with cyanide ordered in the deep Web. This case shows a probable complex suicide kit use including cyanide, as a lethal tool, and dextromethorphan, as a sedative and anxiolytic substance. This case is an original example of the emerging deep Web shopping in illegal drug procurement.

Bridging the gap between continuous sedation until death and physician-assisted death: a focus group study in nursing homes in Flanders, Belgium.

PubMed

Rys, Sam; Deschepper, Reginald; Mortier, Freddy; Deliens, Luc; Bilsen, Johan

2015-06-01

The distinction between continuous sedation until death (CSD) and physician-assisted death (PAD) has become a topic of medical ethical debate. We conducted 6 focus groups to examine how nursing home clinicians perceive this distinction. For some, the difference is clear whereas others consider CSD a form of euthanasia. Another group situates CSD between pain relief and ending life. Arguments for these perspectives refer to the following themes: intention, dosage of sedative drugs, unconsciousness, and the pace of the dying process. Generally, CSD is considered emotionally easier to deal with since it entails a gradual dying process. Nursing home clinicians have diverging perceptions of the relation between CSD and PAD; some consider CSD to be more than a purely palliative measure, that is, also as a means to hasten death. © The Author(s) 2014.

Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views.

PubMed

Voeuk, Anna; Nekolaichuk, Cheryl; Fainsinger, Robin; Huot, Ann

2017-01-01

Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory. The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress. A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians. Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone. Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.

Nitrous Oxide and the Inhalation Anesthetics

PubMed Central

Becker, Daniel E; Rosenberg, Morton

2008-01-01

Nitrous oxide is the most commonly used inhalation anesthetic in dentistry and is commonly used in emergency centers and ambulatory surgery centers as well. When used alone, it is incapable of producing general anesthesia reliably, but it may be combined with other inhalation and/or intravenous agents in deep sedative/general anesthestic techniques. However, as a single agent, it has impressive safety and is excellent for providing minimal and moderate sedation for apprehensive dental patients. To gain a full appreciation of the pharmacology, physiologic influences, and proper use of nitrous oxide, one must compare it with other inhalation anesthetics. The purpose of this CE article is to provide an overview of inhalation anesthetics in general and to address nitrous oxide more specifically in comparison. PMID:19108597

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

PubMed

Flint, Robert B; Brouwer, Carole N M; Kränzlin, Anne S C; Lie-A-Huen, Loraine; Bos, Albert P; Mathôt, Ron A A

2017-11-01

S-ketamine is the S(+)-enantiomer of the racemic mixture ketamine, an anesthetic drug providing both sedation and analgesia. In clinical practice, significant interpatient variability in drug effect of S-ketamine is observed during long-term sedation. The aim of this study was to evaluate the pharmacokinetic variability of S-ketamine in children aged 0-18 years during long-term sedation. Twenty-five children (median age: 0.42 years, range: 0.02-12.5) received continuous intravenous administrations of 0.3-3.6 mg/kg/h S-ketamine for sedation during mechanical ventilation. Infusion rates were adjusted to the desired level of sedation and analgesia based on the COMFORT-B score and Visual Analog Scale. Blood samples were drawn once daily at random time-points, and at 1 and 4 hours after discontinuation of S-ketamine infusion. Time profiles of plasma concentrations of S-ketamine and active metabolite S-norketamine were analyzed using nonlinear mixed-effects modeling software. Clearance and volume of distribution were allometrically scaled using the ¾ power model. A total of 86 blood samples were collected. A 2-compartment and 1-compartment model adequately described the PK of S-ketamine and S-norketamine, respectively. The typical parameter estimates for clearance and central and peripheral volumes of distribution were: CL S - KETAMINE =112 L/h/70 kg, V1 S- KETAMINE =7.7 L/70 kg, V2 S- KETAMINE =545L/70 kg, Q S - kETAMINE =196 L/h/70 kg, and CL S - NORKETAMINE =53 L/h/70 kg. Interpatient variability of CL S - KETAMINE and CL S - NORKETAMINE was considerable with values of 40% and 104%, respectively, leading to marked variability in steady-state plasma concentrations. Substantial interpatient variability in pharmacokinetics in children complicates the development of adequate dosage regimen for continuous sedation. © 2017 John Wiley & Sons Ltd.

A dose-response study of dexmedetomidine administered as the primary sedative in infants following open heart surgery.

PubMed

Su, Felice; Nicolson, Susan C; Zuppa, Athena F

2013-06-01

To evaluate the dose-response relationship of dexmedetomidine in infants with congenital heart disease postoperative from open heart surgery. Prospective open-label dose-escalation pharmacokinetic-pharmacodynamic study. Tertiary pediatric cardiac ICU. Thirty-six evaluable infants, 1-24 months old, postoperative from open heart surgery requiring mechanical ventilation. Cohorts of 12 infants were enrolled sequentially to one of the three IV loading doses of dexmedetomidine (0.35, 0.7, and 1 mcg/kg) over 10 minutes followed by respective continuous infusions (0.25, 0.5, and 0.75 mcg/kg/hr) for up to 24 hours. Dexmedetomidine plasma concentrations were obtained at timed intervals during and following discontinuation of infusion. Pharmacodynamic variables evaluated included sedation scores, supplemental sedation and analgesia medication administration, time to tracheal extubation, respiratory function, and hemodynamic parameters. Infants achieved a deeper sedation measured by the University of Michigan Sedation Scale score (2.6 vs 1) despite requiring minimal supplemental sedation (0 unit doses/hr) and fewer analgesic medications (0.07 vs 0.15 unit doses/hr) while receiving dexmedetomidine compared with the 12-hour follow-up period. Thirty-one patients were successfully extubated while receiving the dexmedetomidine infusion. Only one patient remained intubated due to oversedation during the infusion. While receiving dexmedetomidine, there was a decrease in heart rate compared with baseline, 132 versus 161 bpm, but there was an increase in heart rate compared with postinfusion values, 132 versus 128 bpm. There was no statistically or clinically significant change in mean arterial blood pressure. Dexmedetomidine administration in infants following open heart surgery can provide improved sedation with reduction in supplemental medication requirements, leading to successful extubation while receiving a continuous infusion. The postoperative hemodynamic changes that occur in infants postoperative from open heart surgery are multifactorial. Although dexmedetomidine may play a role in decreasing heart rate immediately postoperative, the changes were not clinically significant and did not fall below postinfusion heart rates.

Impact of Rocuronium and Succinylcholine on Sedation Initiation After Rapid Sequence Intubation.

PubMed

Johnson, Eric G; Meier, Alex; Shirakbari, Alicia; Weant, Kyle; Baker Justice, Stephanie

2015-07-01

Rapid sequence intubation (RSI) involves a rapidly acting sedative plus a neuromuscular blocking agent (NMBA) to facilitate endotracheal intubation. Rocuronium and succinylcholine are NMBAs commonly used in RSI with drastically different durations of action. Evaluate whether patients receiving RSI with a longer-acting NMBA had a greater delay in sedation or analgesia than patients that received a short-acting NMBA. This was a retrospective review of patients presenting to the emergency department requiring endotracheal intubation. Exclusions included age < 18 years, pregnancy, prior intubation, and contraindication to sedation and analgesia. Primary endpoint was time to continuous sedation or analgesia after RSI in patients receiving rocuronium or succinylcholine. Secondary endpoints included hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), and impact of an emergency medicine pharmacist (EPh). A total 106 patients met inclusion criteria, 76 patients receiving rocuronium and 30 receiving succinylcholine. Mean time to sedation or analgesia was longer in the rocuronium group when compared to the succinylcholine group at 34 ± 36 min vs. 16 ± 21 min (p = 0.002). In the presence of an EPh, the mean time to sedation or analgesia was 20 ± 21 min, vs. 49 ± 45 min (p < 0.001). Time spent on ventilator, HLOS, and ICU LOS were not significantly different between groups. Patients receiving rocuronium in RSI had a significantly longer time to sedation or analgesia when compared to patients receiving succinylcholine. The presence of an EPh significantly decreased the time to administration of sedation or analgesia after RSI. Copyright © 2015 Elsevier Inc. All rights reserved.

Effect of ketamine pretreatment for anaesthesia in patients undergoing percutaneous transluminal balloon angioplasty with continuous remifentanil infusion

PubMed Central

Jun, Na Hyung; Shim, Jae Kwang; Choi, Yong Sun; An, Seung Ho

2011-01-01

Background An appropriate level of sedation and pharmacological assist are essential during percutaneous transluminal balloon angioplasty (PTA). Ketamine provides good analgesia while preserving airway patency, ventilation, and cardiovascular stability with an opioid sparing effect suggesting that it would be ideal in combination with remifentanil and midazolam in spontaneously breathing patients. We evaluated the effect of a small dose of ketamine added to midazolam and remifentanil on analgesia/sedation for PTA procedures. Methods Sixty-four patients receiving PTA were enrolled. The Control group received midazolam 1.0 mg i.v. and continuous infusion of remifentanil 0.05 µg/kg/min. The Ketamine group received, in addition, an intravenous bolus of 0.5 mg/kg ketamine. Patients' haemodynamic data were monitored before remifentanil infusion, 5 min after remifentanil infusion, at 1, 3, 5, 30 min after incision, and at admission to the recovery room. Verbal numerical rating scales (VNRS) and sedation [OAA/S (Observer's Assessment of Alertness/Sedation)] scores were also recorded. Results The VNRS values at 1, 3, and 5 min after incision and OAA/S scores at 5 min after remifentanil infusion, and 1, 3, and 5 min after incision were lower in the Ketamine group than in the Control group. In the Control group, the VNRS value at 1 min after incision significantly increased and OAA/S values at 3, 5, and 30 min after incision significantly decreased compared to baseline values, while there were no significant changes in the ketamine group. Conclusions A small dose of ketamine as an adjunct sedative to the combination of midazolam and remifentanil produced a better quality of sedation and analgesia than without ketamine and provided stable respiration without cardiopulmonary deterioration. PMID:22110884

Detection of Respiratory Adverse Events in Pediatric Dental Patients Sedated With 0.75mg/Kg of Midazolam and Oxygen by Continuous Pretracheal Auscultation: A Prospective Randomized Controlled Trial.

PubMed

Somri, Mostafa; Matter, Ibrahim; Hadjittofi, Christopher; Hoash, Naser; Moaddi, Bian; Kharouba, Johnny; Parisinos, Constantinos A; Peretz, Benjamin

Sedation is becoming more commonplace for pediatric patients undergoing minor procedures. Fortunately, electronic monitors have contributed to a reduction in the associated respiratory adverse events (RAEs). To test the hypothesis that adding the pretracheal stethoscope (PTS) to standard monitoring methods (SMMs) may improve RAE detection in sedated pediatric dental patients, the frequency of RAEs detected by SMMs (i.e. visual observation, capnography, and pulse oximetry) was compared to that detected by SMMs alongside continuous PTS auscultation. A prospective, randomised, controlled trial was performed with 100 pediatric patient participants of ASA≤2, who were scheduled to receive dental treatment under 0.75 mg/kg and oxygen. Patients were randomised into Groups A (n=50; SMMs) and B (n=50; SMMs+PTS). Inclusion criteria were behavioral management problems and intolerance to dental treatment despite behavioral management techniques or nitrous oxide administration. Exclusion criteria were high-risk conditions for RAEs, altered mental status, gastrointestinal disorders, parental refusal of conscious sedation and failure of previous conscious sedation. An anesthesist was present throughout the dental treatments. RAEs were detected in 10 (20%) and 22(44%) Group A and B patients respectively (p=0.01). The majority of RAEs within Group B were detected by PTS auscultation (n=19). Capnography produced 13 and 15 false-positive results in Groups A and B respectively, whereas the PTS produced 4(8%) false-positive results in Group B (p=0.009). PTS was found to be useful for detecting RAEs during pediatric dental sedation with 0.75mg/kg midazolam and oxygen, in the presence of an anesthesist.

Palliative Sedation: An Analysis of International Guidelines and Position Statements.

PubMed

Gurschick, Lauren; Mayer, Deborah K; Hanson, Laura C

2015-09-01

To describe the suggested clinical practice of palliative sedation as it is presented in the literature and discuss available guidelines for its use. CINAHL, PubMed, and Web of Science were searched for publications since 1997 for recommended guidelines and position statements on palliative sedation as well as data on its provision. Keywords included palliative sedation, terminal sedation, guidelines, United States, and end of life. Inclusion criteria were palliative sedation policies, frameworks, guidelines, or discussion of its practice, general or oncology patient population, performance of the intervention in an inpatient unit, for humans, and in English. Exclusion criteria were palliative sedation in children, acute illness, procedural, or burns, and predominantly ethical discussions. Guidelines were published by American College of Physicians-American Society of Internal Medicine (2000), Hospice and Palliative Nurses Association (2003), American Academy of Hospice and Palliative Medicine (2006), American Medical Association (2008), Royal Dutch Medical Association (2009), European Association for Palliative Care (2009), National Hospice and Palliative Care Organization (2010), and National Comprehensive Cancer Network (2012). Variances throughout guidelines include definitions of the practice, indications for its use, continuation of life-prolonging therapies, medications used, and timing/prognosis. The development and implementation of institutional-based guidelines with clear stance on the discussed variances is necessary for consistency in practice. Data on provision of palliative sedation after implementation of guidelines needs to be collected and disseminated for a better understanding of the current practice in the United States. © The Author(s) 2014.

Medicine, Morality, and Mortality: The Challenges of Moral Diversity.

PubMed

Cherry, Mark J

2015-10-01

This issue of The Journal of Medicine and Philosophy assesses the deep and abiding tensions that exist among the competing epistemic perspectives that bear on medicine and morality. Concepts of health and disease, as well as the theoretical framing of medical ethics and health care policy, intersect with an overlapping set of culturally situated communities (scientific, political, moral, and religious), striving to understand and manipulate the world in ways that each finds explanatory, appropriate, or otherwise befitting. The articles explore the complexities of framing public health care policy to guide bioethical decision making in the face of the plurality of ethical viewpoints and moral rationalities--including health enhancing supplements, continuous sedation until death, medical futility, the protection of vulnerable populations, and competing professional obligations. © The Author 2015. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Medical Services: Patient Administration

DTIC Science & Technology

2001-03-12

5–16, page 41 Final disposition procedures for military patients • 5–17, page 42 Military patients requiring continued hospitalization or nursing ...general anesthetic, intravenous sedation , or nitrous oxide sedation . (3) All nonoperative procedures that involve more than a slight risk of harm to the...aid or palliative treatment, (b) Is likely to result in any disability for work beyond the day or occurrence, (c) Appears to require prolonged

The evolution of invasive cerebral vasospasm treatment in patients with spontaneous subarachnoid hemorrhage and delayed cerebral ischemia-continuous selective intracarotid nimodipine therapy in awake patients without sedation.

PubMed

Paľa, Andrej; Schneider, Max; Brand, Christine; Pedro, Maria Teresa; Özpeynirci, Yigit; Schmitz, Bernd; Wirtz, Christian Rainer; Kapapa, Thomas; König, Ralph; Braun, Michael

2018-05-26

Cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) are major factors that limit good outcome in patients with spontaneous subarachnoid hemorrhage (SAH). Continuous therapy with intra-arterial calcium channel blockers has been introduced as a new step in the invasive treatment cascade of CV and DCI. Sedation is routinely necessary for this procedure. We report about the feasibility to apply this therapy in awake compliant patients without intubation and sedation. Out of 67 patients with invasive endovascular treatment of cerebral vasospasm due to spontaneous SAH, 5 patients underwent continuous superselective intracarotid nimodipine therapy without intubation and sedation. Complications, neurological improvement, and outcome at discharge were summarized. Very good outcome was achieved in all 5 patients. The Barthel scale was 100 and the modified Rankin scale 0-1 in all cases at discharge. We found no severe complications and excellent neurological monitoring was possible in all cases due to patients' alert status. Symptoms of DCI resolved within 24 h in all 5 cases. We could demonstrate the feasibility and safety of selective intracarotid arterial nimodipine treatment in awake, compliant patients with spontaneous SAH and symptomatic CV and DCI. Using this method, an excellent monitoring of neurological function as well as early detection of other complications is possible. It might be an important step in the risk reduction of invasive CV therapy to improve the outcome with CV and DCI after SAH in selected patients.

Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community*.

PubMed

Kudchadkar, Sapna R; Yaster, Myron; Punjabi, Naresh M

2014-07-01

To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children. An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment. Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013. Pediatric critical care providers. Survey. The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in PICUs with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%) and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent's PICUs, and only 2% reported routine screening at least twice a day. The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.

Closed-Loop Strategies for Patient Care Systems

DTIC Science & Technology

2008-04-01

Department of Anesthesiology and Critical Care Medicine (R.P.), Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Im- pact Instrumentation ...ogy to general anesthesia, it is important to understand that different medications target different components of the anes- thetic such as hypnosis ...sedation, respectively, and values less than 40 suggesting deep to excessive hypnosis .37 BIS is sensitive to multiple artifacts including muscle movement

Use of analgesic and sedative drugs in the NICU: integrating clinical trials and laboratory data.

PubMed

Durrmeyer, Xavier; Vutskits, Laszlo; Anand, Kanwaljeet J S; Rimensberger, Peter C

2010-02-01

Recent advances in neonatal intensive care include and are partly attributable to growing attention for comfort and pain control in the term and preterm infant requiring intensive care.Limitation of painful procedures is certainly possible, but most critically ill infants require unavoidable painful or stressful procedures such as intubation, mechanical ventilation, or catheterization.Many analgesics (opioids and nonsteroidal anti-inflammatory drugs)and sedatives (benzodiazepines and other anesthetic agents) are available but their use varies considerably among units. This review summarizes current experimental knowledge on the effects of sedative and analgesic drugs on brain development and reviews clinical evidence that speaks for or against the use of common analgesic and sedative drugs in the NICU but avoids any discussion of anesthesia during surgery. Risk/benefit ratios of intermittent boluses or continuous infusions for the commonly used sedative and analgesic agents are discussed in the light of clinical and experimental studies. The limitations of extrapolating experimental results from animals to humans must be considered while making practical recommendations based on the currently available evidence.

Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk.

PubMed

Havidich, Jeana E; Beach, Michael; Dierdorf, Stephen F; Onega, Tracy; Suresh, Gautham; Cravero, Joseph P

2016-03-01

Preterm and former preterm children frequently require sedation/anesthesia for diagnostic and therapeutic procedures. Our objective was to determine the age at which children who are born <37 weeks gestational age are no longer at increased risk for sedation/anesthesia adverse events. Our secondary objective was to describe the nature and incidence of adverse events. This is a prospective observational study of children receiving sedation/anesthesia for diagnostic and/or therapeutic procedures outside of the operating room by the Pediatric Sedation Research Consortium. A total of 57,227 patients 0 to 22 years of age were eligible for this study. All adverse events and descriptive terms were predefined. Logistic regression and locally weighted scatterplot regression were used for analysis. Preterm and former preterm children had higher adverse event rates (14.7% vs 8.5%) compared with children born at term. Our analysis revealed a biphasic pattern for the development of adverse sedation/anesthesia events. Airway and respiratory adverse events were most commonly reported. MRI scans were the most commonly performed procedures in both categories of patients. Patients born preterm are nearly twice as likely to develop sedation/anesthesia adverse events, and this risk continues up to 23 years of age. We recommend obtaining birth history during the formulation of an anesthetic/sedation plan, with heightened awareness that preterm and former preterm children may be at increased risk. Further prospective studies focusing on the etiology and prevention of adverse events in former preterm patients are warranted. Copyright © 2016 by the American Academy of Pediatrics.

Phases-of-illness paradigm: better communication, better outcomes

DTIC Science & Technology

2011-11-28

ILP) 2. Hold continuous sedation at 0600 ( nurse ) 3. Notify RT when the patient is ‘awake’ ( nurse ) 4. Perform breathing trial (RT) CVP, central...recovery phases. Patients transitioned to palliative care would exit this model into a palliative care ‘phase’ that is distinct because it is blind...patient-driven standardization of supportive care elements, such as types of monitoring, frequency and type of laboratory assessment, sedation

The impact of Narcotrend™ EEG-guided propofol administration on the speed of recovery from pediatric procedural sedation-A randomized controlled trial.

PubMed

Weber, Frank; Walhout, Laurence C; Escher, Johanna C

2018-05-01

Propofol is often used for procedural sedation in children undergoing gastrointestinal endoscopy. Reliable assessment of the depth of hypnosis during the endoscopic procedure is challenging. Processed electroencephalography using the Narcotrend Index can help titrating propofol to a predefined sedation level. The aim of this trial was to investigate the impact of Narcotrend Index-guided titration of propofol delivery on the speed of recovery. Children, aged 12-17 years, undergoing gastrointestinal endoscopy under procedural sedation, had propofol delivered via target controlled infusion either based on Narcotrend Index guidance (group NI) or standard clinical parameters (group C). Sedation was augmented with remifentanil in both study groups. The primary endpoint of this study was to compare the speed of fulfilling discharge criteria from the operating room between study groups. Major secondary endpoints were propofol consumption, discharge readiness from the recovery room, hypnotic depth as measured by the Narcotrend Index, and adverse events. Of the 40 children included, data were obtainable from 37. The time until discharge readiness from the operating room was shorter in group NI than in group C, with a difference between medians of 4.76 minutes [95%CI 2.6 to 7.4 minutes]. The same accounts for recovery room discharge times; difference between medians 4.03 minutes [95%CI 0.81 to 7.61 minutes]. Propofol consumption and the percentage of EEG traces indicating oversedation were higher in group C than in group NI. There were no significant adverse events in either study group. Narcotrend Index guidance of propofol delivery for deep sedation in children aged 12-17 years, underdoing gastrointestinal endoscopy results in faster recovery, less drug consumption, and fewer episodes of oversedation than dosing propofol according to clinical surrogate parameters of depth of hypnosis. The results of this study provide additional evidence in favor of the safety profile of propofol/remifentanil for procedural sedation in adequately selected pediatric patients. © 2018 The Authors. Pediatric Anesthesia Published by John Wiley & Sons Ltd.

Intratesticular and incisional line infiltration with ropivacaine for castration in medetomidine-butorphanol-midazolam sedated dogs.

PubMed

Kushnir, Yishai; Toledano, Noa; Cohen, Liat; Bdolah-Abram, Tali; Shilo-Benjamini, Yael

2017-03-01

To evaluate whether intratesticular and incisional ropivacaine infiltration produces sufficient intra- and postoperative analgesia for castrating dogs under sedation. Randomized, blinded, controlled clinical study. Twenty-three healthy dogs weighing 5.8-35.6 kg admitted for castration. Dogs were sedated with medetomidine (0.01 mg kg -1 ), butorphanol (0.2 mg kg -1 ) and midazolam (0.2 mg kg -1 ) intramuscularly, and were randomly assigned to group R, 0.2-0.4 mL kg -1 of ropivacaine 0.5%, or group S, an equivalent volume of saline injected intratesticularly and along the incision line. If persistent motion was observed during surgery, sedation was considered to be insufficient and general anaesthesia was induced. Carprofen 2.2 mg kg -1 was administered postoperatively. Pain was evaluated in all dogs before sedation and postoperatively following atipamezole administration at 1, 2, 4, 8 and 24 hours using an interactive visual analogue scale (IVAS; 0-100), the Glasgow composite pain scale-short form (CMPS-SF; 0-24), and a mechanical algometer. Methadone 0.3 mg kg -1 was administered intravenously to dogs if IVAS >30 or CMPS-SF >4. There was no significant difference between groups for the number of dogs administered general anaesthesia. The time from the beginning of surgery to induction of general anaesthesia was significantly shorter [median (range)] in group S [6 (3-25) minutes] than in group R [56 (36-76) minutes]. At 8 hours IVAS was significantly higher in group S (14 ± 10) than in group R (6 ± 4). Intratesticular and incisional ropivacaine infiltration delayed the time to anaesthesia induction, and provided analgesia after castration performed under deep sedation in dogs. Intratesticular local anaesthesia can be an important part of the anaesthetic plan for castration. Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

Temporal Disorganization of Circadian Rhythmicity and Sleep-Wake Regulation in Mechanically Ventilated Patients Receiving Continuous Intravenous Sedation

PubMed Central

Gehlbach, Brian K.; Chapotot, Florian; Leproult, Rachel; Whitmore, Harry; Poston, Jason; Pohlman, Mark; Miller, Annette; Pohlman, Anne S.; Nedeltcheva, Arlet; Jacobsen, John H.; Hall, Jesse B.; Van Cauter, Eve

2012-01-01

Objectives: Sleep is regulated by circadian and homeostatic processes and is highly organized temporally. Our study was designed to determine whether this organization is preserved in patients receiving mechanical ventilation (MV) and intravenous sedation. Design: Observational study. Setting: Academic medical intensive care unit. Patients: Critically ill patients receiving MV and intravenous sedation. Methods: Continuous polysomnography (PSG) was initiated an average of 2.0 (1.0, 3.0) days after ICU admission and continued ≥ 36 h or until the patient was extubated. Sleep staging and power spectral analysis were performed using standard approaches. We also calculated the electroencephalography spectral edge frequency 95% (SEF95), a parameter that is normally higher during wakefulness than during sleep. Circadian rhythmicity was assessed in 16 subjects through the measurement of aMT6s in urine samples collected hourly for 24-48 hours. Light intensity at the head of the bed was measured continuously. Measurements and Results: We analyzed 819.7 h of PSG recordings from 21 subjects. REM sleep was identified in only 2/21 subjects. Slow wave activity lacked the normal diurnal and ultradian periodicity and homeostatic decline found in healthy adults. In nearly all patients, SEF95 was consistently low without evidence of diurnal rhythmicity (median 6.3 [5.3, 7.8] Hz, n = 18). A circadian rhythm of aMT6s excretion was present in most (13/16, 81.3%) patients, but only 4 subjects had normal timing. Comparison of the SEF95 during the melatonin-based biological night and day revealed no difference between the 2 periods (P = 0.64). Conclusions: The circadian rhythms and PSG of patients receiving mechanical ventilation and intravenous sedation exhibit pronounced temporal disorganization. The finding that most subjects exhibited preserved, but phase delayed, excretion of aMT6s suggests that the circadian pacemaker of such patients may be free-running. Clinical Trial Information: Clinicaltrials.gov NCT01276652. Citation: Gehlbach BK; Chapotot F; Leproult R; Whitmore H; Poston J; Pohlman M; Miller A; Pohlman AS; Nedeltcheva A; Jacobsen JH; Hall JB; Van Cauter E. Temporal disorganization of circadian rhythmicity and sleep-wake regulation in mechanically ventilated patients receiving continuous intravenous sedation. SLEEP 2012;35(8):1105-1114. PMID:22851806

Influence of general anaesthesia on slow waves of intracranial pressure.

PubMed

Lalou, Despina A; Czosnyka, Marek; Donnelly, Joseph; Lavinio, Andrea; Pickard, John D; Garnett, Matthew; Czosnyka, Zofia

2016-07-01

Slow vasogenic intracranial pressure (ICP) waves are spontaneous ICP oscillations with a low frequency bandwidth of 0.3-4 cycles/min (B-waves). B-waves reflect dynamic oscillations in cerebral blood volume associated with autoregulatory cerebral vasodilation and vasoconstriction. This study quantifies the effects of general anaesthesia (GA) on the magnitude of B-waves compared to natural sleep and conscious state. The magnitude of B-waves was assessed in 4 groups of 30 patients each with clinical indications for ICP monitoring. Normal pressure hydrocephalus patients undergoing Cerebrospinal Fluid (CSF) infusion studies in the conscious state (GROUP A) and under GA (GROUP B), and hydrocephalus patients undergoing overnight ICP monitoring during physiological sleep (GROUP C) were compared to deeply sedated traumatic brain injury (TBI) patients with well-controlled ICP during the first night of Intensive Care Unit (ICU) stay (GROUP D). A total of 120 patients were included. During CSF infusion studies, the magnitude of slow waves was higher in conscious patients ( 0.23+/-0.10 mm Hg) when compared to anaesthetised patients ( 0.15+/-0.10 mm Hg; p = 0.011). Overnight magnitude of slow waves was higher in patients during natural sleep (GROUP C: 0.20+/-0.13 mm Hg) when compared to TBI patients under deep sedation (GROUP D: 0.11+/- 0.09 mm Hg; p = 0.002). GA and deep sedation are associated with a reduced magnitude of B-waves. ICP monitoring carried out under GA is affected by iatrogenic suppression of slow vasogenic waves of ICP. Accounting for the effects of anaesthesia on vasogenic waves may prevent the misidentification of potential shunt-responders as non-responders.

Comparison of the analgesic effects of robenacoxib, buprenorphine and their combination in cats after ovariohysterectomy.

PubMed

Staffieri, F; Centonze, P; Gigante, G; De Pietro, L; Crovace, A

2013-08-01

The aim of this study was to compare the postoperative analgesic effects of robenacoxib and buprenorphine alone or in combination, in cats after ovariohysterectomy. Thirty healthy cats were randomly assigned to receive buprenorphine (0.02 mg/kg, n=10; GB), robenacoxib (2mg/kg, n=10; GR) or their combination at the same dosages (n=10; GBR) SC. After 30 min cats were sedated with an IM administration of medetomidine (0.02 mg/kg) and ketamine (5mg/kg). General anaesthesia was induced with propofol and after intubation was maintained with isoflurane. Before premedication and at 1, 2, 3, 4, 6, 8, 12 and 24h after extubation, pain and sedation were assessed using a simple descriptive pain scale, ranging from 0 (no pain/no sedation) to 4 (intense pain/ deep sedation). If the pain score was ≥ 3, rescue analgesia was provided using buprenorphine (0.02 mg/kg) administered IM. Pain score was higher in GB at 2, 3, 4, 6 and 8h compared to baseline and compared to GBR at the same study times. Moreover, the pain score was also higher in GB compared to GR at 2, 3, 4 and 6h. Pain score was similar at all study times between GR and GBR. Sedation at 1 and 2h was higher than baseline values in all groups. Cats in GB received rescue analgesia more often than cats assigned to GR or GBR. Robenacoxib was an effective analgesic drug in cats up to 24h after ovariohysterectomy. The addition of buprenorphine did not provide any additional analgesic effects compared to robenacoxib alone. Copyright © 2013 Elsevier Ltd. All rights reserved.

Comparison of the effects of intravenous premedication: Midazolam, Ketamine, and combination of both on reducing anxiety in pediatric patients before general anesthesia

PubMed Central

Sajedi, Parvin; Habibi, Bashir

2015-01-01

Objective: In some medical circumstances, pediatric patients may need premedication for transferring to the operating room. In these situations, using intravenous premedication is preferred. We assessed the efficacy and safety of intravenous midazolam, intravenous ketamine, and combination of both to reduce the anxiety and improve behavior in children undergoing general anesthesia. Methods: In a double-blind randomized clinical trial, 90 pediatric patients aged 6 months to 6 years with American Society of Anesthesiologist grade I or II were enrolled. Before anesthesia, children were randomly divided into three groups to receive intravenous midazolam 0.1 mg/kg, or intravenous ketamine 1 mg/kg, or combination of half doses of both. Behavior types and sedation scores were recorded before premedication, after premedication, before anesthesia, and after anesthesia in the postanesthesia care unit. Anesthesia time, recovery duration, blood pressure, and heart rate were also recorded. For comparing distribution of behavior types and sedation scores among three groups, we used Kruskal–Wallis test, and for comparing mean and standard deviation of blood pressure and heart rates, we used analysis of variance. Findings: After premedication, children's behavior was significantly better in the combination group (P < 0.001). After anesthesia, behavior type was same among three groups (P = 0.421). Sedation scores among three groups were also different after premedication and the combination group was significantly more sedated than the other two groups (P < 0.001). Conclusion: Combination of 0.05 mg/kg of intravenous midazolam and 0.5 mg/kg of intravenous ketamine as premedication produced more deep sedation and more desirable behavior in children compared with each midazolam 0.1 mg/kg or ketamine 1 mg/kg. PMID:26645024

A survey of the intravenous sedation status in one provincial dental clinic center for the disabled in Korea

PubMed Central

Seok, Ujeong; Ji, Sangeun; Yoo, Seunghoon; Kim, Jongsoo; Kim, Seungoh

2016-01-01

Background The objective of the present study was to examine the status of patients who had received dental treatment under intravenous (IV) sedation at Chungnam Dental Clinic for the Disabled in Korea from its inception to the present time, and to review the analysis results. Methods Retrospective analysis was performed on 305 cases of patients who had received dental treatments under IV sedation between January 2011 and May 2016. The analysis examined the patient's sex, age, primary reason for IV sedation, duration of anesthesia and dental treatment, type of dental treatment performed, number of clinical departments involved in the dental treatment and level of multidisciplinary cooperation, and annual trends. Results Most dental treatments using intravenous sedation were performed on medically disabled patients or dentally disabled patients with an extreme gag reflex or dental phobia. The mean duration of IV sedation was 72.5 min, while the mean duration of treatment was 58.0 min. The types of dental treatments included surgical treatment (n = 209), periodontal treatment (n = 28), prosthodontic treatment (n = 28), restorative treatment (n = 23), implant surgery (n = 22), endodontic treatment (n = 9), reduction of temporomandibular joint dislocation (n = 1), and treatment of traumatic injuries (n = 1), with treatments mostly performed on adult patients. Conclusions With increasing demand for minimally painful treatment, cases using IV sedation are on an upward trend and are expected to continue to increase. PMID:28879305

Preliminary investigation comparing a detomidine continuous rate infusion combined with either morphine or buprenorphine for standing sedation in horses.

PubMed

Potter, Joanna J; MacFarlane, Paul D; Love, Emma J; Tremaine, Henry; Taylor, Polly M; Murrell, Joanna C

2016-03-01

To compare sedative and analgesic properties of buprenorphine or morphine for standing procedures combined with a detomidine continuous rate infusion (CRI). Blinded, prospective, randomized clinical pilot study. Ten horses presented for dental or sinus procedures. Horses received 0.02 mg kg(-1) acepromazine intravenously (IV), followed 30 minutes later by detomidine 10 μg kg(-1) IV. Five minutes later, buprenorphine 0.01 mg kg(-1) (n = 6) or morphine 0.1 mg kg(-1) (n = 4) was administered IV. Detomidine was administered by CRI (0.2 μg kg(-1) minute(-1)) and adjusted to maintain appropriate sedation. Heart rate, respiratory frequency, gastrointestinal motility and rectal temperature were measured; pain, ataxia and sedation were scored. Sedation, pain scores and ataxia scores were analysed using a mixed linear model. Detomidine dose and procedure success scores were compared using Wilcoxon's rank sum test. Complications between groups were analysed using Fisher's exact test. Two horses had incomplete data. Weights and ages were not different between groups (p = 0.15 and p = 0.42, respectively). The dose rate for detomidine was not different between groups (0.33 ± 0.02 μg kg(-1) minute(-1) in the buprenorphine group and 0.33 ± 0.05 μg kg(-1) minute(-1), in the morphine group p = 0.89). Intraoperative visual analogue scale scores were greater after buprenorphine than morphine (mean ± SD, buprenorphine 48 ± 4, morphine 40 ± 5, p = 0.0497). Procedure duration was not different between groups (buprenorphine 142 ± 33, morphine 140 ± 12 minutes). All horses treated with buprenorphine experienced complications compared with none in the morphine group (p = 0.0286). At the doses used, buprenorphine produced greater sedation but more post-operative complications than morphine. However, Type I or Type II errors cannot be excluded and larger studies are required to confirm these findings. © 2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia.

Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children: A Wake-up Call for the Pediatric Critical Care Community

PubMed Central

Yaster, Myron; Punjabi, Naresh M.

2014-01-01

Objective To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children. Design An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment. Setting Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013. Interventions Survey Measurements and Main Results The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in pediatric intensive care units (PICUs) with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%), and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day. Conclusions The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children, as well as a paucity of sleep promotion and delirium screening in PICUs worldwide. PMID:24717461

Myths, fallacies and practical pearls in GI lab

PubMed Central

Kumar, Pradeep

2014-01-01

Many prevalent practices and guidelines related to Gastrointestinal endoscopy and procedural sedation are at odds with the widely available scientific-physiological and clinical outcome data. In many institutions, strict policy of pre-procedural extended fasting is still rigorously enforced, despite no evidence of increased incidence of aspiration after recent oral intake prior to sedation. Supplemental oxygen administration in the setting of GI procedural sedation has been increasingly adopted as reported in the medical journals, despite clear evidence that supplemental oxygen blunts the usefulness of pulse oximetry in timely detection of sedation induced hypoventilation, leading to increased number of adverse cardiopulmonary outcomes. Use of Propofol by Gastroenterologist-Nurse team is erroneously considered dangerous and often prohibited in various institutions, at the same time worldwide reports of remarkable safety and patient satisfaction continue to be published, dating back more than a decade. Of patient monitoring practices that have been advocated to be standard, many merely add cost, not value. Advances in the technology often are not incorporated in a timely manner in guidelines or clinical practices, e.g., Capsule endoscopy or electrocautery during GI procedures do not interfere with proper functioning of the current pacemakers or defibrillators. Orthopedic surgeons have continued to recommend prophylactic antibiotics for joint replacement patients prior to GI procedures, without any evidence of need. These myths are explored for a succint review to prompt a change in clinical practices and institutional policies. PMID:25512767

Effectiveness and acceptability of intravenous sedation in child and adolescent dental patients: report of a case series at King's College Hospital, London.

PubMed

Lourenço-Matharu, L; Roberts, G J

2011-06-24

Conscious sedation for young patients continues to be challenging. Few studies have shown positive results using intravenous midazolam when sedating young patients. This case series reports an investigation of conscious sedation using intravenous midazolam for young patients receiving dental treatment. To determine acceptance, safety and efficacy of intravenous midazolam for conscious sedation in children and adolescent patients undergoing dental treatment.Patients and methods Patients from seven to 16 years of age, ASA I, II and III, opted to have extractions, minor oral surgery and/or conservative treatment with IV midazolam and local anaesthesia. A pulse oximeter was used to monitor vital signs and the Houpt scale to assess overall behaviour. A total of 552 patients, 234 boys and 318 girls with mean ages of 13.3 years and 13.5 years respectively, were included. Three hundred and sixty-five patients (66%) claimed to be anxious or very anxious before treatment. The average dose given was 5.7 mg and dosage ranged from 2 to 10 mg. Four hundred and fifty-seven patients (83%) scored 'very good' and 'excellent' for overall behaviour. Side-effects included crying, drowsiness and amnesia. Intravenous midazolam is accepted by patients and is a safe and effective method of sedation for use in children and adolescents, producing some level of tearfulness.

The effect of dexmedetomidine sedation on patient and surgeon satisfaction during retinal surgery under sub-tenon's anesthesia: a randomized controlled trial.

PubMed

Yoo, Jae-Hwa; Kim, Soon Im; Cho, Ana; Lee, Sung Jin; Sun, Hae Jung; Cho, Ho Bum; Lee, Dong Ryun

2015-10-01

The purpose of this study was to evaluate the effect of intraoperative dexmedetomidine sedation on patient's and surgeon's satisfaction during retinal surgery under sub-tenon's anesthesia. Forty-four patients scheduled for elective retinal surgery under sub-tenon's anesthesia were enrolled in this randomized controlled trial. The patients were divided into Dexmedetomidine (n = 22) and Control (n = 22) groups. Intravenous dexmedetomidine or 0.9% saline via infusion pump were administered continuously to the dexmedetomidine or control group, respectively. Ramsay sedation scale with a target level of 3-4 was used to assess adequacy of sedation. Perioperative pain, hemodynamic and respiratory data were collected, while satisfaction from patients and surgeon were assessed post-surgery using a 5-point satisfaction scale. Patient and surgeon satisfaction was higher in the dexmedetomidine group (P < 0.001, P = 0.002, respectively). The pain associated with sub-tenon's anesthesia and peripheral vitrectomy was lesser in the dexmedetomidine group than in the control group (P = 0.020). There was significant reduction of heart rate in the dexmedetomidine group (P = 0.001), but only one patient needed treatment with atropine. There was no respiratory effect on both groups. Dexmedetomidine sedation during retinal surgery improved satisfaction from both patient and surgeon without respiratory complication. It is a safe and preferable choice of sedation for retinal surgery.

Successful implementation of a neonatal pain and sedation protocol at 2 NICUs.

PubMed

Deindl, Philipp; Unterasinger, Lukas; Kappler, Gregor; Werther, Tobias; Czaba, Christine; Giordano, Vito; Frantal, Sophie; Berger, Angelika; Pollak, Arnold; Olischar, Monika

2013-07-01

To evaluate the implementation of a neonatal pain and sedation protocol at 2 ICUs. The intervention started with the evaluation of local practice, problems, and staff satisfaction. We then developed and implemented the Vienna Protocol for Neonatal Pain and Sedation. The protocol included well-defined strategies for both nonpharmacologic and pharmacologic interventions based on regular assessment of a translated version of the Neonatal Pain Agitation and Sedation Scale and titration of analgesic and sedative therapy according to aim scores. Health care staff was trained in the assessment by using a video-based tutorial and bedside teaching. In addition, we performed reevaluation, retraining, and random quality checks. Frequency and quality of assessments, pharmacologic therapy, duration of mechanical ventilation, and outcome were compared between baseline (12 months before implementation) and 12 months after implementation. Cumulative median (interquartile range) opiate dose (baseline dose of 1.4 [0.5-5.9] mg/kg versus intervention group dose of 2.7 [0.4-57] mg/kg morphine equivalents; P = .002), pharmacologic interventions per episode of continuous sedation/analgesia (4 [2-10] vs 6 [2-13]; P = .005), and overall staff satisfaction (physicians: 31% vs 89%; P < .001; nurses: 17% vs 55%; P < .001) increased after implementation. Time on mechanical ventilation, length of stay at the ICU, and adverse outcomes were similar before and after implementation. Implementation of a neonatal pain and sedation protocol at 2 ICUs resulted in an increase in opiate prescription, pharmacologic interventions, and staff satisfaction without affecting time on mechanical ventilation, length of intensive care stay, and adverse outcomes.

[Palliative sedation at a university palliative care unit--a descriptive analysis].

PubMed

Hopprich, A; Günther, L D; Laufenberg-Feldmann, R; Reinholz, U; Weber, M

2016-04-01

Palliative sedation (pS) is indicated in the presence of end-stage disease with treatment-refractory symptoms not tolerable for the patient. We investigated the practice of pS at a university palliative care unit. Before starting pS the following data were documented: indication and decision making, type of sedation, life expectancy evaluated by the physician using the palliative prognostic index. Over the time of pS communication skills, depth of sedation, relief in symptoms, substitution of fluid and nutrition and used medications were collected. During evaluation time 99 patients died. 34 patients received pS (34 %). All patients suffered from cancer. Indications for palliative sedation were: terminal restlessness (56 %), dyspnea (39 %), pain (32 %), psychological distress (15 %), agitated delir (9 %), vomiting (3 %) and bleeding (3 %) (multiple nominations possible). In 31 cases (91 %) nurses were included for decision making. In 33 cases continuous sedation were initiated immediately (median duration 27.5 hours). The most applied medication was midazolam (94 %), sometimes combined with neuroleptics (44 %) and propofol (15 %). 91 % of the patients additionally received opioids. Artificial fluid was substituted in two cases. Palliative sedation started in the median 27.5 hours before death. The final physician assessment revealed complete symptom relief in 12 patients (35 %), very strong symptom relief in 20 patients (59 %) and moderate symptom relief in 2 patients (6 %). pS was successfully used as last resort for relief of treatment-refractory symptoms in one third of decedents at the investigated palliative care unit. © Georg Thieme Verlag KG Stuttgart · New York.

A randomized, double-blind pilot study of dexmedetomidine versus midazolam for intensive care unit sedation: patient recall of their experiences and short-term psychological outcomes.

PubMed

MacLaren, Robert; Preslaski, Candice R; Mueller, Scott W; Kiser, Tyree H; Fish, Douglas N; Lavelle, James C; Malkoski, Stephen P

2015-03-01

Sedation with dexmedetomidine may facilitate ventilator liberation and limit the occurrence of delirium. No trial has assessed patient recall or the development of psychological outcomes after dexmedetomidine sedation. This pilot study evaluated whether transitioning benzodiazepine sedation to dexmedetomidine alters patient recall and the incidence of anxiety, depression, or acute stress disorder (ASD). This investigation was a randomized, double-blind, single-center study. Existing continuous benzodiazepine sedation was converted to dexmedetomidine or midazolam when patients qualified for daily awakenings. Sedation was titrated to achieve Riker sedation agitation scores of 3 to 4. The intensive care unit (ICU) Stressful Experiences Questionnaire, hospital anxiety and depression scale, and the impact of event scale-revised were administered before hospital discharge to assess recall, anxiety, depression, and manifestations of ASD. A total of 11 patients received dexmedetomidine, and 12 patients received midazolam. Median dosing was 0.61 µg/kg/h for 3.5 days for dexmedetomidine and 3.7 mg/h for 3 days for midazolam. Attainment of goal sedation and analgesia was similar; however, more dexmedetomidine patients experienced agitation and pain. The median duration of mechanical ventilation from study drug initiation to extubation was 3.4 days in dexmedetomidine patients and 2.9 days in midazolam patients. Dexmedetomidine patients remembered 18.5 experiences compared with 8.5 in midazolam patients (P = .015). Rates of anxiety and depression were similar. In all, 5 (62.5%) dexmedetomidine patients and 1 (12.5%) midazolam patient manifested ASD (P = .063), and 1 dexmedetomidine patient and 5 midazolam patients developed new-onset delirium (P = .07). Hypotension occurred in 10 (90.9%) dexmedotomidine patients and 6 (50%) midazolam patients (P = .069). Transitioning benzodiazepine sedation to dexmedetomidine when patients qualify for daily awakenings may reduce the development of delirium and facilitate remembrance of ICU experiences but may lead to manifestations of ASD. Monitoring hypotension is required for both the sedatives. Additional comparative studies focusing on the long-term impact of ICU recall and psychological outcomes are needed. © The Author(s) 2013.

Palliative sedation challenging the professional competency of health care providers and staff: a qualitative focus group and personal written narrative study.

PubMed

Leboul, Danièle; Aubry, Régis; Peter, Jean-Michel; Royer, Victor; Richard, Jean-François; Guirimand, Frédéric

2017-04-11

Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation. Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives. Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients. The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it.

Effect of warm compress application on tissue temperature in healthy dogs.

PubMed

Millard, Ralph P; Towle-Millard, Heather A; Rankin, David C; Roush, James K

2013-03-01

To measure the effect of warm compress application on tissue temperature in healthy dogs. 10 healthy mixed-breed dogs. Dogs were sedated with hydromorphone (0.1 mg/kg, IV) and diazepam (0.25 mg/kg, IV). Three 24-gauge thermocouple needles were inserted to a depth of 0.5 cm (superficial), 1.0 cm (middle), and 1.5 cm (deep) into a shaved, lumbar, epaxial region to measure tissue temperature. Warm (47°C) compresses were applied with gravity dependence for periods of 5, 10, and 20 minutes. Tissue temperature was recorded before compress application and at intervals for up to 80 minutes after application. Control data were collected while dogs received identical sedation but with no warm compress. Mean temperature associated with 5 minutes of heat application at the superficial, middle, and deep depths was significantly increased, compared with the control temperature. Application for 10 minutes significantly increased the temperature at all depths, compared with 5 minutes of application. Mean temperature associated with 20 minutes of application was not different at the superficial or middle depths, compared with 10 minutes of application. Temperature at the deep depth associated with 10 minutes of application was significantly higher, compared with 20 minutes of application, but all temperature increases at this depth were minimal. Results suggested that application of a warm compress should be performed for 10 minutes. Changes in temperature at a tissue depth of 1.5 cm were minimal or not detected. The optimal compress temperature to achieve therapeutic benefits was not determined.

Nurses' attitudes towards end-of-life decisions in medical practice: a nationwide study in Flanders, Belgium.

PubMed

Inghelbrecht, E; Bilsen, J; Mortier, F; Deliens, L

2009-10-01

We investigated on a nationwide level the attitudes of nurses towards end-of-life decisions (ELDs) that may hasten death and towards their role in those decisions. We took a representative random sample of 6000 nurses in Flanders, Belgium. Response rate was 62.5%. Most nurses agreed with the practice of withholding/withdrawing potentially life-prolonging treatments (93%), with decisions to alleviate symptoms with possible life-shortening side effects (96%) and with the practice of euthanasia (92%). Their support for the different decisions existed regardless of whether they had cared for terminally ill patients or not. Most nurses also thought that they have an important role to play especially in the ELD-making process. Nurses' views on their proper role in the administration of drugs in euthanasia and continuous deep sedation showed a large dispersal. Overall, nurses' work setting determines their opinions on nurses' role in ELDs. In conclusion, nurses accept a wide variety of ELDs being practiced with terminally ill patients.

The patient experience of intensive care: a meta-synthesis of Nordic studies.

PubMed

Egerod, Ingrid; Bergbom, Ingegerd; Lindahl, Berit; Henricson, Maria; Granberg-Axell, Anetth; Storli, Sissel Lisa

2015-08-01

Sedation practices in the intensive care unit have evolved from deep sedation and paralysis toward lighter sedation and better pain management. The new paradigm of sedation has enabled early mobilization and optimized mechanical ventilator weaning. Intensive care units in the Nordic countries have been particularly close to goals of lighter or no sedation and a more humane approach to intensive care. The aim of our study was to systematically review and reinterpret newer Nordic studies of the patient experience of intensive care to obtain a contemporary description of human suffering during life-threatening illness. We conducted a meta-synthesis in which we collected, assessed, and analyzed published qualitative studies with the goal of synthesizing these findings into a new whole. Analysis was based on the scientific approach of Gadamerian hermeneutics. Nordic intensive care units. Patients in Nordic intensive care units. We performed a literature search of qualitative studies of the patient experience of intensive care based on Nordic publications in 2000-2013. We searched the following databases: PubMed, CINAHL, Scopus, and PsycINFO. Each original paper was assessed by all authors using the Critical Appraisal Skills Program instrument for qualitative research. We included 22 studies, all of which provided direct patient quotes. The overarching theme was identified as: The patient experience when existence itself is at stake. We constructed an organizing framework for analysis using the main perspectives represented in the included studies: body, mind, relationships, and ICU-environment. Final analysis and interpretation resulted in the unfolding of four themes: existing in liminality, existing in unboundedness, existing in mystery, and existing on the threshold. Our main finding was that human suffering during intensive care is still evident although sedation is lighter and the environment is more humane. Our interpretation suggested that patients with life-threatening illness descend into a liminal state, where they face the choice of life or death. Caring nurses and family members play an important role in assisting the patient to transition back to life. Copyright © 2015 Elsevier Ltd. All rights reserved.

Hormonal, metabolic and physiological effects of laparoscopic surgery using a detomidine-buprenorphine combination in standing horses.

PubMed

van Dijk, P; Lankveld, D P K; Rijkenhuizen, A B M; Jonker, F H

2003-04-01

To assess the hormonal, metabolic and physiological effects of laparascopic surgery performed under a sedative analgesic combination of detomidine and buprenorphine in standing horses. Prospective study. Eight healthy adult Dutch Warmblood horses and five healthy adult ponies undergoing laparoscopy were studied. Five healthy adult horses not undergoing laparoscopy were used as a control group. The sedative effect of an initial detomidine and buprenorphine injection was maintained using a continuous infusion of detomidine alone. The heart and respiratory rate, arterial blood pH and arterial oxygen and carbon dioxide tensions were monitored, while blood samples were taken for the measurement of glucose, lactate, cortisol, insulin and nonesterified fatty acids (NEFA). The same variables were monitored in a control group of horses which were sedated, but which did not undergo surgery. At the end of the sedation period the effects of detomidine were antagonized using atipamezole. The protocol provided suitable conditions for standing laparoscopy in horses. Laparoscopy induced obvious metabolic and endocrine responses which, with the exception of NEFA values, were not significantly different from changes found in the control group. While atipamezole did not produce detectable adverse effects, it is possible that anatagonism may not be essential. The technique described reliably produces adequate sedation and analgesia for laparoscopic procedures. The level of sedation/analgesia was controlled by decreasing or increasing the infusion rate. Antagonism of the effects of detomidine may not be necessary in all cases.

How Do Observational Scales Correlate the Ratings of Children's Behavior during Pediatric Procedural Sedation?

PubMed Central

Moura, Larissa da Silva

2016-01-01

Background. There is little information regarding the ability of observational scales to properly assess children's behavior during procedural sedation. Aim. To evaluate the characteristics of the Houpt scales, the Ohio State University Behavioral Rating Scale (OSUBRS) and the Venham Behavior Rating Scale when applied to preschool children undergoing conscious dental sedation. Design. This study included 27 children, 4–6 years old with early childhood caries that participated in a clinical trial (NCT02284204) that investigated two sedative regimes using oral midazolam/ketamine. Dental appointments were video-recorded; five calibrated observers assessed 1,209 minutes of video recording to score the children's behavior, following the instructions of the investigated scales. Data were analyzed by descriptive analysis and Spearman correlation tests (P < 0.05). Results. The Houpt overall behavior and the Venham scale were highly correlated (rho = −0.87; P < 0.001). OSUBRS scores were better correlated with Houpt overall behavior and Venham ratings, when compared to Houpt scores in the categories for movement and crying. Conclusions. The Houpt overall behavior and the Venham scores are global scales that properly measure children's behavior during dental sedation. Continuous assessment with OSUBRS through videos has a chance to give more precise data, while the Houpt categories can easily demonstrate children's behavior during procedures. PMID:28116299

Framework for continuous palliative sedation therapy in Canada.

PubMed

Dean, Mervyn M; Cellarius, Victor; Henry, Blair; Oneschuk, Doreen; Librach Canadian Society Of Palliative Care Physicians Taskforce, S Lawrence

2012-08-01

Canada does not have a standardized ethical and practice framework for continuous palliative sedation therapy (CPST). Although a number of institutional and regional guidelines exist, Canadian practice varies. Given the lack of international and national consensus on CPST, the Canadian Society for Palliative Care Physicians (CSPCP) formed a special task force to develop a consensus-based framework for CPST. Through a preliminary review of sedation practices nationally and internationally, it was determined that although considerable consensus was emerging on this topic, there remained both areas of contention and a lack of credible scientific evidence to support a definitive clinical practice guideline. This led to the creation of a framework to help guide policy, practice, and research. This framework was developed through the following steps: 1) literature review; 2) identification of issues; 3) preparation of a draft framework; 4) expert consultation and revision; 5) presentation at conferences and further revision; and 6) further revision and national consensus building. A thorough literature review, including gray literature, of sedation therapy at the end of life was conducted from which an initial framework was drafted. This document was reviewed by 30 multidisciplinary experts in Canada and internationally, revised several times, and then submitted to CSPCP members for review. Consensus was high on most parts of the framework. The framework for CPST will provide a basis for the development of safe, effective, and ethical use of CPST for patients in palliative care and at the end of life.

Partial Nephrogenic Diabetes Insipidus in a Burned Patient Receiving Sevoflurane Sedation With an Anesthetic Conserving Device-A Case Report.

PubMed

Muyldermans, Marie; Jennes, Serge; Morrison, Stuart; Soete, Olivier; François, Pierre-Michel; Keersebilck, Elkana; Rose, Thomas; Pantet, Olivier

2016-12-01

To describe a case of partial nephrogenic diabetes insipidus in a burned patient after prolonged delivery of low inspired concentrations of sevoflurane via an Anesthetic Conserving Device. Clinical observation. Case report. Relevant clinical information. A 34-year-old man was admitted with burns covering 52% of his total body surface area. Mechanical ventilation was provided during sedation with continuous infusions of sufentanil and midazolam. Sedation became increasingly difficult, and in order to limit administration of IV agents, sevoflurane was added to the inspiratory gas flow. This was provided using an Anesthetic Conserving Device and continued for 8 days. The patient rapidly developed polyuria and hypernatremia with an inappropriate decrease in urinary osmolality. Administration of desmopressin resulted in only a modest effect on renal concentrating ability. After cessation of sevoflurane, all variables returned to normal within 5 days. The results of further investigations (cerebral computed tomographic scan, cerebral magnetic resonance imaging, and serum arginine vasopressin concentration) were compatible with a diagnosis of partial nephrogenic diabetes insipidus. The temporal sequence of clinical findings in relation to sevoflurane administration suggests that the sevoflurane was the probable underlying cause. Clinicians should be aware of the possibility of sevoflurane-induced diabetes insipidus not only during general anesthesia but also in the intensive care setting of sedation in critically ill patients. This is especially important in patients, such as those with severe burns, in whom preserved renal concentrating ability is important to ensure compensation for extrarenal fluid losses.

A review of the safety and efficacy of inhaled methoxyflurane as an analgesic for outpatient procedures.

PubMed

Jephcott, C; Grummet, J; Nguyen, N; Spruyt, O

2018-05-01

Methoxyflurane delivered via a hand-held inhaler is a proven analgesic which has been used in Australasia for emergency relief of trauma associated pain since the 1970s. The agent is self-administered by the patient under the supervision of trained personnel. More than 5 million patients have received inhaled methoxyflurane without significant side effects. Methoxyflurane is also licensed in Australasia for the relief of pain in monitored conscious patients requiring analgesia for minor surgical procedures. Recent clinical studies undertaken in a variety of outpatient settings, including colonoscopy, prostate biopsy, dental procedures, bone marrow biopsy, and the management of burns dressings, indicate that inhaled methoxyflurane has significant analgesic activity, without producing deep sedation or respiratory depression. Return to full psychomotor activity is rapid. Thus, methoxyflurane may be a suitable and well-tolerated alternative to traditional i.v. sedative agents for outpatient medical and surgical procedures. There are direct advantages to the patient in terms of rapid recovery and an early return to normal activities, and significant benefits for outpatient departments in terms of cost saving and rate of throughput. Further randomised controlled trials comparing the efficacy, safety, and cost-effectiveness of inhaled methoxyflurane against traditional i.v. sedative techniques are currently in progress. Copyright © 2018 British Journal of Anaesthesia. All rights reserved.

Pain control in patients with hepatocellular carcinoma treated by percutaneous radiofrequency ablation: comparison of the efficacy of one-shot and continuous intravenous fentanyl delivery.

PubMed

Yokoyama, Koichi; Ikeda, Osamu; Kawanaka, Koichi; Nakasone, Yutaka; Inoue, Seijiro; Tamura, Yoshitaka; Yamashita, Yasuyuki

2014-12-01

Hepatic percutaneous radiofrequency ablation (RFA) is usually performed with the patient under deep intravenous (i.v.) sedation or general anesthesia. Nonetheless, many patients report pain during and/or after the procedure. To perform a prospective study of pain control obtained by the i.v. one-shot delivery and the continuous i.v. infusion of fentanyl in patients with hepatocellular carcinoma (HCC) treated by RFA. Between April 2007 and March 2010, 83 patients with 106 HCCs underwent percutaneous RFA. All HCCs were addressed by computed tomography (CT)-guided percutaneous RFA performed within 5 h of embolization of the tumor vessels with iodized oil and gelatin sponges. Standard anesthesia consisted of 10 mL of 1% lidocaine injected locally. For conscious sedation, group one patients (n = 41) were injected i.v. with 100 µg of fentanyl before and 100 µg of fentanyl 30 min after percutaneous RFA. In group two (n = 42) we delivered fentanyl by continuous i.v. infusion at 100 µg/h during RFA. Upon request, patients in both groups also received 5 mg of diazepam i.v. for pain during the RFA procedure. The severity of pain experienced by all patients was evaluated on a visual analogue scale (VAS) and complications elicited by the anesthesia regimens were recorded. We also assessed the effectiveness of the treatment on sequential follow-up CT and/or magnetic resonance imaging (MRI) at 3-month intervals. Percutaneous RFA was technically successful in all 83 patients. Two patients in group one (4.8%) and one patient in group two (2.4%) manifested residual enhancement 3 months post RFA. There was no significant difference in the local recurrence rate between the two groups. At 4.0 ± 1.8 for group one and 3.4 ± 1.9 for group two, the VAS score was not significantly different. Major fentanyl or diazepam toxicity was recorded in 11 patients (24.4%) in group one and two patients (4.8%) in group two; the difference was statistically significant (P < 0.01). The continuous infusion of fentanyl provided effective and safe analgesia in HCC patients undergoing percutaneous RFA. © The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Developing policy, standard orders, and quality-assurance monitoring for palliative sedation therapy.

PubMed

Ghafoor, Virginia L; Silus, Lauren S

2011-03-15

The development of a policy, evidence-based standard orders, and monitoring for palliative sedation therapy (PST) is described. Concerns regarding PST at the University of Minnesota Medical Center (UMMC) arose and needed to be addressed in a formal process. A multidisciplinary group consisting of palliative care physicians, nurse practitioners, clinical nurse specialists, and clinical pharmacy specialists reached consensus on the practice model and medications to be used for PST. Major elements of the plan included the development and implementation of an institutional policy for palliative sedation; standard orders for patient care, sedation, and monitoring; education for staff, patients, and patients' family members; and quality-assurance monitoring. A literature review was performed to identify research and guidelines defining the practice of PST. Policy content includes the use of a standard order set linking patient care, medication administration, the monitoring of sedation, and symptom management. Approval of the policy involved several UMMC committees. An evaluation matrix was used to determine critical areas for PST monitoring and to guide development of a form to monitor quality. A retrospective chart audit using the quality-assurance monitoring form assessed baseline sedation medication and patient outcomes. Assessment of compliance began in the fall of 2008, after the policy and standard orders were approved by the UMMC medical executive committee. In 2008, two cases of PST were monitored using the standardized form. PST cases will be continually monitored and analyzed. Development of policy, standard orders, and quality-assurance monitoring for PST required a formal multidisciplinary process. A process-improvement process is critical to defining institutional policy, educational goals, and outcome metrics for PST.

Brain measures of nociception using near-infrared spectroscopy in patients undergoing routine screening colonoscopy.

PubMed

Becerra, Lino; Aasted, Christopher M; Boas, David A; George, Edward; Yücel, Meryem A; Kussman, Barry D; Kelsey, Peter; Borsook, David

2016-04-01

Colonoscopy is an invaluable tool for the screening and diagnosis of many colonic diseases. For most colonoscopies, moderate sedation is used during the procedure. However, insufflation of the colon produces a nociceptive stimulus that is usually accompanied by facial grimacing/groaning while under sedation. The objective of this study was to evaluate whether a nociceptive signal elicited by colonic insufflation could be measured from the brain. Seventeen otherwise healthy patients (age 54.8 ± 9.1; 6 female) undergoing routine colonoscopy (ie, no history of significant medical conditions) were monitored using near-infrared spectroscopy (NIRS). Moderate sedation was produced using standard clinical protocols for midazolam and meperidine, titrated to effect. Near-infrared spectroscopy data captured during the procedure was analyzed offline to evaluate the brains' responses to nociceptive stimuli evoked by the insufflation events (defined by physician or observing patients' facial responses). Analysis of NIRS data revealed a specific, reproducible prefrontal cortex activity corresponding to times when patients grimaced. The pattern of the activation is similar to that previously observed during nociceptive stimuli in awake healthy individuals, suggesting that this approach may be used to evaluate brain activity evoked by nociceptive stimuli under sedation, when there is incomplete analgesia. Although some patients report recollection of procedural pain after the procedure, the effects of repeated nociceptive stimuli in surgical patients may contribute to postoperative changes including chronic pain. The results from this study indicate that NIRS may be a suitable technology for continuous nociceptive afferent monitoring in patients undergoing sedation and could have applications under sedation or anesthesia.

Brain Measures of Nociception using Near Infrared Spectroscopy in Patients Undergoing Routine Screening Colonoscopy

PubMed Central

Boas, David A.; George, Edward; Yücel, Meryem A.; Kussman, Barry D.; Kelsey, Peter; Borsook, David

2015-01-01

Colonoscopy is an invaluable tool for screening and diagnosis of many colonic diseases. For most colonoscopies, moderate sedation is used during the procedure. However, insufflation of the colon produces a nociceptive stimulus that is usually accompanied by facial grimacing/groaning while under sedation. The objective of the current study was to evaluate whether a nociceptive signal elicited by colonic insufflation could be measured from the brain. Seventeen otherwise healthy patients (age 54.8±9.1; 6 female) undergoing routine colonoscopy (i.e., no history of significant medical conditions) were monitored using near-infrared spectroscopy (NIRS). Moderate sedation was produced using standard clinical protocols for midazolam and meperidine, titrated to effect. NIRS data captured during the procedure was analyzed offline to evaluate the brains’ responses to nociceptive stimuli evoked by the insufflation events (defined by physician or observing patients’ facial responses). Analysis of NIRS data revealed a specific, reproducible prefrontal cortex activity corresponding to times when patients grimaced. The pattern of the activation is similar to that previously observed during nociceptive stimuli in awake healthy individuals, suggesting that this approach may be used to evaluate brain activity evoked by nociceptive stimuli under sedation, when there is incomplete analgesia. While some patients report recollection of procedural pain following the procedure, the effects of repeated nociceptive stimuli in surgical patients may contribute to postoperative changes including chronic pain. The results from this study indicate that NIRS may be a suitable technology for continuous nociceptive afferent monitoring in patients undergoing sedation and could have applications under sedation or anesthesia. PMID:26645550

Hormonal, metabolic and physiological effects of laparoscopic surgery using a detomidine-buprenorphine combination in standing horses.

PubMed

Van Dijk, P; Lankveld, Dpk; Rijkenhuizen, Abm; Jonker, F H

2003-04-01

To assess the hormonal, metabolic and physiological effects of laparascopic surgery performed under a sedative analgesic combination of detomidine and buprenorphine in standing horses. Prospective study. Eight healthy adult Dutch Warmblood horses and five healthy adult ponies undergoing laparoscopy were studied. Five healthy adult horses not undergoing laparoscopy were used as a control group. The sedative effect of an initial detomidine and buprenorphine injection was maintained using a continuous infusion of detomidine alone. The heart and respiratory rate, arterial blood pH and arterial oxygen and carbon dioxide tensions were monitored, while blood samples were taken for the measurement of glucose, lactate, cortisol, insulin and nonesterified fatty acids (NEFA). The same variables were monitored in a control group of horses which were sedated, but which did not undergo surgery. At the end of the sedation period the effects of detomidine were antagonized using atipamezole. The protocol provided suitable conditions for standing laparoscopy in horses. Laparoscopy induced obvious metabolic and endocrine responses which, with the exception of NEFA values, were not significantly different from changes found in the control group. While atipamezole did not produce detectable adverse effects, it is possible that anatagonism may not be essential. The technique described reliably produces adequate sedation and analgesia for laparoscopic procedures. The level of sedation/analgesia was controlled by decreasing or increasing the infusion rate. Antagonism of the effects of detomidine may not be necessary in all cases. Copyright © 2003 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil.

PubMed

Bourgoin, Aurélie; Albanèse, Jacques; Wereszczynski, Nicolas; Charbit, Martine; Vialet, Renaud; Martin, Claude

2003-03-01

The aim of the study was to compare the safety concerning cerebral hemodynamics of ketamine and sufentanil used for sedation of severe head injury patients, both drugs being used in combination with midazolam. Prospective, randomized, double-blind study. Intensive care unit in a trauma center. Twenty-five patients with severe head injury. Twelve patients received sedation with a continuous infusion of ketamine-midazolam and 13 with a continuous infusion of sufentanil-midazolam. All patients were mechanically ventilated with moderate hyperventilation. Prognostic indicators (age, Glasgow Coma Scale scores, computed tomography diagnosis, and Injury Severity Scale score) were similar in the two groups at study entry. Measurements were carried out during the first 4 days of sedation. The average infusion rates during this time were 82 +/- 25 micro x kg x min ketamine and 1.64 +/- 0.5 microg x kg x min midazolam in the ketamine group and 0.008 +/- 0.002 microg x kg x min sufentanil and 1.63 +/- 0.37 microg x kg x min midazolam in the sufentanil group. No significant differences were observed between the two groups in the mean daily values of intracranial pressure and cerebral perfusion pressure. The numbers of intracranial pressure elevations were similar in both groups. The requirements of neuromuscular blocking agents, propofol, and thiopental were similar. Heart rate values were significantly higher in the ketamine group on therapy days 3 and 4 ( <.05). With regard to arterial pressure control, more fluids were given on the first therapy day and there was a trend toward greater use of vasopressors in the sufentanil group. Sedative costs were similar in the two groups. The results of this study suggest that ketamine in combination with midazolam is comparable with a combination of midazolam-sufentanil in maintaining intracranial pressure and cerebral perfusion pressure of severe head injury patients placed under controlled mechanical ventilation.

Bundles to prevent ventilator-associated pneumonia: how valuable are they?

PubMed

Wip, Charity; Napolitano, Lena

2009-04-01

To review the value of care bundles to prevent ventilator-associated pneumonia (VAP). The Ventilator Bundle contains four components, elevation of the head of the bed to 30-45 degrees, daily 'sedation vacation' and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis, aimed to improve outcome in mechanically ventilated patients, but not all are associated with VAP prevention. Daily spontaneous awakening and breathing trials are associated with early liberation from mechanical ventilation and VAP reduction. Although a small prospective, randomized clinical study documented that the semirecumbent position was associated with a significant reduction in VAP, more recent studies have documented that the semirecumbent position is difficult to maintain in mechanically ventilated patients and may not impact VAP reduction. Prophylaxis for peptic ulcer disease and deep venous thrombosis do not directly impact VAP reduction. Other methods to reduce VAP, such as oral care and hygiene, chlorhexidine in the posterior pharynx, and specialized endotracheal tubes (continuous aspiration of subglottic secretions, silver-coated), should be considered for inclusion in a revised Ventilator Bundle more specifically aimed at VAP prevention. The Ventilator Bundle is an effective method to reduce VAP rates in ICUs. The ventilator bundle should be modified and expanded to include specific processes of care that have been definitively demonstrated to be effective in VAP reduction or a specific VAP bundle created to focus on VAP prevention.

Continuous palliative sedation: not only a response to physical suffering.

PubMed

Swart, Siebe J; van der Heide, Agnes; van Zuylen, Lia; Perez, Roberto S G M; Zuurmond, Wouter W A; van der Maas, Paul J; van Delden, Johannes J M; Rietjens, Judith A C

2014-01-01

Palliative sedation is a medical intervention aimed at relieving symptoms that can no longer be controlled by conventional treatment. Ample knowledge is available regarding the nature of such symptoms, but there is no in-depth information regarding how health care workers decide about palliative sedation. The study objective was to investigate considerations concerning the indications for continuous palliative sedation (CPS) and issues that influence these considerations. The study consisted of qualitative interviews regarding patients who had recently received CPS. The study involved physicians and nurses working in general practice, nursing homes, and hospitals. Analyses by a multidisciplinary research team used the constant comparative method. Together with physical symptoms, psychological and existential suffering may combine to produce a refractory state for which other treatment options than CPS were not available or considered inappropriate. A limited life expectancy was by many considered crucial (e.g., to avoid hastening death) and by some less important (e.g., because the patient's suffering was considered to be key). Issues influencing the decision to use CPS related to patient preferences (e.g., dignity, not wanting to experience further suffering) or family issues (impact of suffering on family, family requesting CPS). The indication for CPS typically originates from physical symptoms and nonphysical problems producing a refractory state in which a patient suffers unbearably. In such states, preferences of patients and families and the life expectancy criterion are weighed against the severity of refractory symptoms. Therefore the use of CPS is not only a response to the physical suffering of patients in the dying phase.

Time of elevation of head of bed for patients receiving mechanical ventilation and its related factors.

PubMed

Martí-Hereu, L; Arreciado Marañón, A

The semirecumbent position is a widespread recommendation for the prevention of pneumonia associated with mechanical ventilation. To identify the time of elevation of head of bed for patients under mechanical ventilation and the factors related to such elevation in an intensive care unit. An observational, descriptive cross-sectional study. Conducted in an intensive care unit of a tertiary hospital from April to June 2015. The studied population were mechanically ventilated patients. Daily hours in which patients remained with the head of the bed elevated (≥30°), socio-demographic data and clinical variables were recorded. 261 head elevation measurements were collected. The average daily hours that patients remained at ≥30° was 16h28' (SD ±5h38'), equivalent to 68.6% (SD ±23.5%) of the day. Factors related to elevations ≥30° for longer were: enteral nutrition, levels of deep sedation, cardiac and neurocritical diagnostics. Factors that hindered the position were: sedation levels for agitation and abdominal pathologies. Sex, age and ventilation mode did not show a significant relationship with bed head elevation. Although raising the head of the bed is an easy to perform, economical and measurable preventive measure, its compliance is low due to specific factors specific related o the patient's clinical condition. Using innovations such as continuous measurement of the head position helps to evaluate clinical practice and allows to carry out improvement actions whose impact is beneficial to the patient. Copyright © 2017 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment.

PubMed

Isenberg, Derek L; Jacobs, Dorian

2015-10-01

Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting. Hypothesis This study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting. This was a prospective, randomized, observational trial wherein agitated patients were administered intramuscular haloperidol or intramuscular midazolam to control agitation. Agitation was quantified by the Richmond Agitation and Sedation Scale (RASS). Paramedics recorded the RASS and vital signs every five minutes during transport and again upon arrival to the ED. The primary outcome was mean time to achieve a RASS less than +1. Secondary outcomes included mean time for patients to return to baseline mental status and adverse events. Five patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol. In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam. Midazolam and haloperidol administered intramuscularly appear equally effective for sedating an agitated patient in the prehospital setting. Midazolam appears to have a faster onset of action, as evidenced by the shorter time required to achieve a RASS score of less than +1 in the patients who received midazolam. Haloperidol offers an alternative option for the sedation of an agitated patient. Further studies should focus on continued investigation into appropriate sedation of agitated patients in the prehospital setting.

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia

PubMed Central

Soh, Tze Ling Gwendoline Beatrice; Krishna, Lalit Kumar Radha; Sim, Shin Wei; Yee, Alethea Chung Peng

2016-01-01

Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively ‘dead’. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma’s position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death. PMID:27211055

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia.

PubMed

Soh, Tze Ling Gwendoline Beatrice; Krishna, Lalit Kumar Radha; Sim, Shin Wei; Yee, Alethea Chung Peng

2016-05-01

Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively 'dead'. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma's position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death. Copyright: © Singapore Medical Association.

A study at Manchester Dental Hospital, of the compliance of IV sedation patients and their escorts.

PubMed

Lightfoot, Kate

2014-01-01

Oral surgery, under intravenous sedation, is carried out on a daily basis at Manchester Dental Hospital. This essay discusses the background of conscious sedation in the dental setting and looks at the compliance of patients (and escorts) when having intravenous sedation. The patient journey, from pre-operative assessment through to treatment is considered. Hospital instructions indicate an obligation for patients to attend with a responsible adult (eighteen or over) who remains with them throughout their treatment, escorts them home,and arranges their care for the next twenty-four hours. By following these instructions the patient should receive optimal care. Two questionnaires were devised and given to patients/escorts to assess their compliance with Manchester Dental Hospital postoperative protocols. 100% compliance was the set standard, with results presented as pie charts. This work began during the undergraduate summer vacation of 2012 and continued over a five-month period. Initial results suggested that compliance was generally good but certain improvements could be made. Suggestions for future development are presented. These aim to give clarity to all patients/escorts and their specific roles in the anticipated treatment.

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

PubMed

Webster, Craig S; Mason, Keira P; Shafer, Steven L

2016-03-01

From an understanding of human psychology and the reliability of high-technology systems, this review considers critical threats to the safety of patients undergoing sedation outside of the operating room, and will stratify these threats along what we define as the 'Patient Risk Continuum'. We then consider interventions suitable for addressing identified risks. The technology, organization and delivery of healthcare continue to become more complex, highlighting the importance of maintaining the safety of patients. Sedation outside of the operating room is known to be associated with higher rates of adverse events. However, a number of recent safety initiatives have shown benefit in improving patient safety. The following threats to patients undergoing sedation, in increasing order of risk, are discussed: equipment and environmental factors, known patient risks, poor team performance, combinatorial problems and egregious violations. To address these threats, we discuss a number of approaches consistent with the systems approach to safety, namely: encouraging functions, forcing functions, cognitive safety nets, information sharing, recovery strategies and regulatory change. Demonstrating improvement with any safety initiative relies critically on quality data collected on the problem area in question.

Propofol attenuates low-frequency fluctuations of resting-state fMRI BOLD signal in the anterior frontal cortex upon loss of consciousness.

PubMed

Liu, Xiaolin; Lauer, Kathryn K; Douglas Ward, B; Roberts, Christopher; Liu, Suyan; Gollapudy, Suneeta; Rohloff, Robert; Gross, William; Chen, Guangyu; Xu, Zhan; Binder, Jeffrey R; Li, Shi-Jiang; Hudetz, Anthony G

2017-02-15

Recent studies indicate that spontaneous low-frequency fluctuations (LFFs) of resting-state functional magnetic resonance imaging (rs-fMRI) blood oxygen level-dependent (BOLD) signals are driven by the slow (<0.1Hz) modulation of ongoing neuronal activity synchronized locally and across remote brain regions. How regional LFFs of the BOLD fMRI signal are altered during anesthetic-induced alteration of consciousness is not well understood. Using rs-fMRI in 15 healthy participants, we show that during administration of propofol to achieve loss of behavioral responsiveness indexing unconsciousness, the fractional amplitude of LFF (fALFF index) was reduced in comparison to wakeful baseline in the anterior frontal regions, temporal pole, hippocampus, parahippocampal gyrus, and amygdala. Such changes were absent in large areas of the motor, parietal, and sensory cortices. During light sedation characterized by the preservation of overt responsiveness and therefore consciousness, fALFF was reduced in the subcortical areas, temporal pole, medial orbital frontal cortex, cingulate cortex, and cerebellum. Between light sedation and deep sedation, fALFF was reduced primarily in the medial and dorsolateral frontal areas. The preferential reduction of LFFs in the anterior frontal regions is consistent with frontal to sensory-motor cortical disconnection and may contribute to the suppression of consciousness during general anesthesia. Copyright © 2016 Elsevier Inc. All rights reserved.

Propofol attenuates low-frequency fluctuations of resting-state fMRI BOLD signal in the anterior frontal cortex upon loss of consciousness

PubMed Central

Liu, Xiaolin; Lauer, Kathryn K.; Ward, B. Douglas; Roberts, Christopher; Liu, Suyan; Gollapudy, Suneeta; Rohloff, Robert; Gross, William; Chen, Guangyu; Xu, Zhan; Binder, Jeffrey R.; Li, Shi-Jiang; Hudetz, Anthony G.

2017-01-01

Recent studies indicate that spontaneous low-frequency fluctuations (LFFs) of resting-state functional magnetic resonance imaging (rs-fMRI) blood oxygen level-dependent (BOLD) signals are driven by the slow (<0.1 Hz) modulation of ongoing neuronal activity synchronized locally and across remote brain regions. How regional LFFs of the BOLD fMRI signal are altered during anesthetic-induced alteration of consciousness is not well understood. Using rs-fMRI in 15 healthy participants, we show that during administration of propofol to achieve loss of behavioral responsiveness indexing unconsciousness, the fractional amplitude of LFF (fALFF index) was reduced in comparison to wakeful baseline in the anterior frontal regions, temporal pole, hippocampus, parahippocampal gyrus, and amygdala. Such changes were absent in large areas of the motor, parietal, and sensory cortices. During light sedation characterized by the preservation of overt responsiveness and therefore consciousness, fALFF was reduced in the subcortical areas, temporal pole, medial orbital frontal cortex, cingulate cortex, and cerebellum. Between light sedation and deep sedation, fALFF was reduced primarily in the medial and dorsolateral frontal areas. The preferential reduction of LFFs in the anterior frontal regions is consistent with frontal to sensory-motor cortical disconnection and may contribute to the suppression of consciousness during general anesthesia. PMID:27993673

[Sedation with stimulative circadian rhythm in mechanically ventilation patients in intensive care unit].

PubMed

Guo, Jian-ying; Deng, Qun; Guo, Xu-sheng; Liu, Shuang-qing; Zhang, Yu-hong; He, Zhong-jie; Yao, Yong-ming; Lin, Hong-yuan

2012-07-01

To sedate the mechanically ventilation patients in intensive care unit (ICU) with stimulative circadian rhythm, and evaluate whether the protocol has advantages in recovering natural circadian rhythm, duration of mechanical ventilation, and length of ICU stay after weaning of sedation. A prospective random control trial was conducted. One hundred and twenty ventilated patients in ICU were randomly assigned to four groups: circadian rhythm (CR), daily interruption (DI), continuous sedation (CS) or demand sedation (DS) group, each n = 30. Given more complications, DS group was deleted after recruiting 10 cases and 90 patients were admitted ultimately. Patients' age, gender, body weight, acute physiology and chronic health evaluation II (APACHE II) scores, sedatives dosages, daily arousal time, duration of mechanical ventilation, length of ICU stay, complications (ventilator-associated pneumonia, barotrauma with intrathoracic drain tube) and untoward reactions (accidental extubation, reintubation, tracheotomy, death) were recorded, the biochemical indicators were determined, as well as number of nurses on duty at 10:00 and 22:00. The patients' sex ratio, age, body weight, APACHEII scores, duration of mechanical ventilation, length of ICU stay showed no difference among CR, DI and CS groups. The total sedatives dosages (mg: 5466.7 ± 620.4) and average sedatives dosages [mg×h(-1) ×kg(-1): 2.19 ± 0.61] in CS group were significantly higher than those in CR group (4344.5 ± 816.0, 1.00 ± 0.51) and DI group (4154.3 ± 649.4, 1.23 ± 0.62, all P < 0.01), and there was no difference between CR group and DI group. Daily arousal time in the CR group (hours: 4.40 ± 1.30) was significantly lengthened compared with that in DI group (0.59 ± 0.26) and CS group (0.15 ± 0.02, both P < 0.05). The complications showed no differences in each group, but incidences of the untoward reactions in DI group (2 cases) were significantly increased compared with that in CR group (1 case) and CS group (0 case, P = 0.0477). After weaning of sedation, patients with normal circadian rhythm were significantly more in CR group than that in CS group (19 vs. 9, P = 0.0339). Among CR group, DI group and CS group, there were significant differences in the numbers of nurses on duty in the daytime (1.65, 1.41, 1.14, all P < 0.01), but there was no difference in the night. The biochemistry index showed no difference in each group. It demonstrated that sedation with stimulative circadian rhythm be helpful to create circadian rhythm after weaning of sedation. While complications and untoward reactions did not increase, as well as duration of mechanical ventilation and length of ICU stay. Therefore, the clinical applicability of this sedative strategy was highlighted.

Onyx HD-500 embolization of intracranial aneurysms: modified technique using continuous balloon inflation under conscious sedation.

PubMed

Rahme, Ralph; Grande, Andrew; Jimenez, Lincoln; Abruzzo, Todd A; Ringer, Andrew J

2014-08-01

The conventional technique of intracranial aneurysm embolization using Onyx HD-500 (ev3 Neurovascular, Irvine, CA, USA) involves repetitive balloon inflation-deflation cycles under general anesthesia. By limiting parent artery occlusion to 5 minutes, this cyclic technique is thought to minimize cerebral ischemia. However, intermittent balloon deflation may lengthen procedure time and allow balloon migration, resulting in intimal injury or Onyx leakage. We report our experience using a modified technique of uninterrupted Onyx injection with continuous balloon occlusion under conscious sedation. All Onyx embolization procedures for unruptured aneurysms performed by the senior author (A.J.R.) between September 2008 and April 2010 were retrospectively reviewed. Demographic, clinical, angiographic, and procedural data were recorded. Twenty-four embolization procedures were performed in 21 patients with 23 aneurysms, including four recurrences. Twenty aneurysms (87%) involved the paraclinoid or proximal supraclinoid internal carotid artery. Size ranged from 2.5 to 24mm and neck diameter from 2 to 8mm. The modified technique was employed in 19 cases. All but one patient (94.4%) tolerated continuous balloon inflation. Complete occlusion was achieved in 20 aneurysms (83.3%) and subtotal occlusion in three (12.5%). Stable angiographic results were seen in 85%, 94%, 94%, and 100% of patients at 6, 12, 24, and 36months, respectively. There were no deaths. Permanent non-disabling neurological morbidity occurred in one patient (4.2%). Minor, transient, and/or angiographic complications were seen in three patients (12.5%), none related to the technique itself. Onyx embolization of unruptured intracranial aneurysms can be safely and effectively performed using continuous balloon inflation under conscious sedation. Copyright © 2014 Elsevier Ltd. All rights reserved.

Pediatric Palliative Sedation Therapy with Propofol: Recommendations Based on Experience in Children with Terminal Cancer

PubMed Central

Hamilton, Hunter; Faughnan, Lane G.; Johnson, Liza-Marie; Baker, Justin N.

2012-01-01

Abstract Background The use of propofol for palliative sedation of children is not well documented. Objective Here we describe our experience with the use of propofol palliative sedation therapy (PST) to alleviate intractable end-of-life suffering in three pediatric oncology patients, and propose an algorithm for the selection of such candidates for PST. Patients and Methods We identified inpatients who had received propofol PST within 20 days of death at our institution between 2003 and 2010. Their medical records were reviewed for indicators of pain, suffering, and sedation from 48 hours before PST to the time of death. We also tabulated consumption of opioids and other symptom management medications, pain scores, and adverse events of propofol, and reviewed clinical notes for descriptors of suffering and/or palliation. Results Three of 192 (1.6%) inpatients (aged 6–15 years) received propofol PST at the end of life. Consumption of opioids and other supportive medications decreased during PST in two cases. In the third case, pain scores remained high and sedation was the only effective comfort measure. Clinical notes suggested improved comfort and rest in all patients. Propofol infusions were continued until the time of death. Conclusions Our experience demonstrates that propofol PST is a useful palliative option for pediatric patients experiencing intractable suffering at the end of life. We describe an algorithm that can be used to identify such children who are candidates for PST. PMID:22731512

Expanding the Use of Continuous Sedation Until Death: Moving Beyond the Last Resort for the Terminally Ill.

PubMed

LiPuma, Samuel H; DeMarco, Joseph P

2015-01-01

As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a "last resort," and a position statement from the American Academy of Hospice and Palliative Medicine describe it as "an intervention reserved for extreme situations." Accordingly, patients must progress to unremitting pain and suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of "last resort." Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Energy demand in patients with stroke who are sedated and receiving mechanical ventilation.

PubMed

Bardutzky, Juergen; Georgiadis, Dimitrios; Kollmar, Rainer; Schwarz, Stefan; Schwab, Stefan

2004-02-01

The purpose of this study was 1) to determine the total energy expenditure (TEE) in patients with acute stroke who are sedated and receiving mechanical ventilation; and 2) to compare the TEE between patients with ischemic and hemorrhagic stroke. Thirty-four consecutive nonseptic patients with stroke requiring sedation and mechanical ventilation were prospectively examined; 13 of the patients had experienced spontaneous intracerebral hemorrhage and 21 cerebral ischemia of the middle cerebral artery territory. The TEE was evaluated using continuous indirect calorimetry during the first 5 days after admission to the intensive care unit. The serum albumin concentration was determined on admission and on Day 5. The TEE varied from 1560 +/- 240 to 1623 +/- 251 kcal/day. A highly significant correlation between the TEE and the basal energy expenditure (BEE), as predicted using the Harris-Benedict equation, was observed in both groups. No significant differences in the TEE were detected between the two groups or among the different study days. A highly significant correlation was found between the TEE and the predicted BEE in patients with acute stroke who have been sedated and have received mechanical ventilation. No significant differences were observed between patients with hemorrhagic and ischemic stroke. Further studies are needed to evaluate the effect of tailored feeding on clinical outcome in these patients.

Influence of reserpine on in vivo localization of injected lymph node cells in the mouse.

PubMed Central

Bellavia, A; Micklem, H S

1987-01-01

The effects of reserpine, and other agents that affect the storage and availability of 5-hydroxytryptamine (5HT), on the localization of injected 51Cr-labelled syngeneic lymph node cells have been investigated. A high dose (5 mg/kg) of reserpine to the recipients reduced localization in the lymph nodes and prevented the usual accumulation of lymphocytes in lymph nodes draining the site of an antigen (sheep erythrocytes: SE) injection. These effects were partially reversible by the monoamine oxidase inhibitor nialamide. This dose of reserpine produced deep sedation throughout the period of the experiment. Lower doses, up to 2.5 mg/kg, produced little sedation and had no effect on the localization of lymphocytes. Other workers had previously reported reduced localization of cells in delayed-type hypersensitivity (DTH) lesions after treatment of the recipients with 5 mg/kg reserpine, and had interpreted this in terms of a role of 5HT in promoting vascular permeability and egress of blood cells. The effect of lower doses of reserpine was not reported. We suggest that the effects on cell localization in both sets of experiments may have been secondary to the general state of sedation and not attributable to a direct local influence of 5HT. Other effects of reserpine included prolonged retention of lymphocytes in lungs and blood, and a reduction of cellularity and DNA synthesis in the thymus, spleen and lymph nodes. PMID:3817871

Inhaled methoxyflurane as a prehospital analgesic in children.

PubMed

Babl, Franz E; Jamison, Sarah R; Spicer, Maureen; Bernard, Stephen

2006-08-01

Despite widespread use of methoxyflurane as an inhaled analgesic by ambulance services in Australia there are no published data as to its use pattern, efficacy and safety in the prehospital setting. We set out to characterize methoxyflurane use in children in the prehospital setting. An observational case series was conducted over an 8 month period. Children who received methoxyflurane while being transported to a tertiary children's hospital by ambulance were enrolled. We analysed indications for use, verbal numerical pain scores, adverse events and depth of sedation based on paramedic, patient, parent and ED staff surveys and review of ambulance care records. During the study period 105 patients were enrolled with an age range of 15 months to 17 years (median age 11 years). Methoxyflurane was mainly used for extremity injuries (82%). Paramedic pain scores dropped from a mean of 7.9 (95% confidence interval [CI] 7.5-8.3) prior to methoxyflurane use to 4.5 (95% CI 3.9-5.0) at 2-5 min and to 3.2 (95% CI 2.8-3.7) at 10 min. There were no serious adverse events (one-sided 97.5% CI 0-3%). Mild adverse events occurred in 38 patients (36.2%; 95% CI 27.0-46.1%). Five of 15 (33.3%) patients under 5 years of age were deeply sedated. In the present paediatric case series methoxyflurane appears to be an efficacious analgesic with a low adverse events profile. In young children in particular it can briefly lead to deep sedation.

21 CFR 522.147 - Atipamezole.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) ANIMAL DRUGS, FEEDS, AND RELATED PRODUCTS IMPLANTATION OR INJECTABLE DOSAGE FORM NEW ANIMAL DRUGS § 522.147... for use. For reversal of the sedative and analgesic effects of dexmedetomidine hydrochloride or...

21 CFR 522.147 - Atipamezole.

Code of Federal Regulations, 2011 CFR

2011-04-01

... Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) ANIMAL DRUGS, FEEDS, AND RELATED PRODUCTS IMPLANTATION OR INJECTABLE DOSAGE FORM NEW ANIMAL DRUGS § 522.147... for use. For reversal of the sedative and analgesic effects of dexmedetomidine hydrochloride or...

Occlusion therapy of unilateral amblyopia with botulinum toxin induced ptosis.

PubMed

Halkiadakis, Ioannis; Iliaki, Olga; Kalyvianaki, Maria I; Tsilimbaris, Miltiadis K

2007-01-01

In order to evaluate the role of botulinum toxin induced ptosis as an occlusion method to treat unilateral deep strabismic amblyopia in two uncooperative children, we injected 0.2 ml of diluted botulinum toxin in the levator palpaebrae; low sedation was necessary in one of the two children. In both cases a marked ptosis was achieved, which lasted about four weeks and then gradually resolved completely. The visual acuity of the ablyopic eye increased in both children, making patching easy thereafter. One child developed amblyopia in the injected eye, which was handled successfully using part-time occlusion. No other side effects were noted. Whether this new method could be a simple, safe and effective alternative method of occlusion for the treatment of deep amblyopia in uncooperative children needs to be proven with a larger series of children.

A favorable course of palliative sedation: searching for indicators using caregivers' perspectives.

PubMed

Brinkkemper, Tijn; Rietjens, Judith A C; Deliens, Luc; Ribbe, Miel W; Swart, Siebe J; Loer, Stephan A; Zuurmond, Wouter W A; Perez, Roberto S G M

2015-03-01

Comparing characteristics of a favorable sedation course during palliative sedation to a less favorable course based on the reports Dutch physicians and nurses. Cases identified as having a favorable sedation course less often concerned a male patient (P = .019 nurses' cases), reached the intended sedation depth significantly quicker (P < .05 both nurses and physicians' cases), reached a deeper level of sedation (P = .015 physicians' cases), and had a shorter total duration of sedation compared (P < .001 physicians' cases) to patients with a less favorable sedation course. A favorable course during palliative sedation seems more probable when health care professionals report on a (relatively) shorter time to reach the required depth of sedation and when a deeper level of sedation can be obtained. © The Author(s) 2013.

Tone-Evoked Acoustic Change Complex (ACC) Recorded in a Sedated Animal Model.

PubMed

Presacco, Alessandro; Middlebrooks, John C

2018-05-10

The acoustic change complex (ACC) is a scalp-recorded cortical evoked potential complex generated in response to changes (e.g., frequency, amplitude) in an auditory stimulus. The ACC has been well studied in humans, but to our knowledge, no animal model has been evaluated. In particular, it was not known whether the ACC could be recorded under the conditions of sedation that likely would be necessary for recordings from animals. For that reason, we tested the feasibility of recording ACC from sedated cats in response to changes of frequency and amplitude of pure-tone stimuli. Cats were sedated with ketamine and acepromazine, and subdermal needle electrodes were used to record electroencephalographic (EEG) activity. Tones were presented from a small loudspeaker located near the right ear. Continuous tones alternated at 500-ms intervals between two frequencies or two levels. Neurometric functions were created by recording neural response amplitudes while systematically varying the magnitude of steps in frequency centered in octave frequency around 2, 4, 8, and 16 kHz, all at 75 dB SPL, or in decibel level around 75 dB SPL tested at 4 and 8 kHz. The ACC could be recorded readily under this ketamine/azepromazine sedation. In contrast, ACC could not be recorded reliably under any level of isoflurane anesthesia that was tested. The minimum frequency (expressed as Weber fractions (df/f)) or level steps (expressed in dB) needed to elicit ACC fell in the range of previous thresholds reported in animal psychophysical tests of discrimination. The success in recording ACC in sedated animals suggests that the ACC will be a useful tool for evaluation of other aspects of auditory acuity in normal hearing and, presumably, in electrical cochlear stimulation, especially for novel stimulation modes that are not yet feasible in humans.

Xenon depresses aEEG background voltage activity whilst maintaining cardiovascular stability in sedated healthy newborn pigs.

PubMed

Sabir, Hemmen; Wood, Thomas; Gill, Hannah; Liu, Xun; Dingley, John; Thoresen, Marianne

2016-04-15

Changes in electroencephalography (EEG) voltage range are used to monitor the depth of anaesthesia, as well as predict outcome after hypoxia-ischaemia in neonates. Xenon is being investigated as a potential neuroprotectant after hypoxic-ischaemic brain injury, but the effect of Xenon on EEG parameters in children or neonates is not known. This study aimed to examine the effect of 50% inhaled Xenon on background amplitude-integrated EEG (aEEG) activity in sedated healthy newborn pigs. Five healthy newborn pigs, receiving intravenous fentanyl sedation, were ventilated for 24 h with 50%Xenon, 30%O2 and 20%N2 at normothermia. The upper and lower voltage-range of the aEEG was continuously monitored together with cardiovascular parameters throughout a 1 h baseline period with fentanyl sedation only, followed by 24 h of Xenon administration. The median (IQR) upper and lower aEEG voltage during 1 h baseline was 48.0 μV (46.0-50.0) and 25.0 μV (23.0-26.0), respectively. The median (IQR) aEEG upper and lower voltage ranges were significantly depressed to 21.5 μV (20.0-26.5) and 12.0 μV (12.0-16.5) from 10 min after the onset of 50% Xenon administration (p=0.002). After the initial Xenon induced depression in background aEEG voltage, no further aEEG changes were seen over the following 24h of ventilation with 50% xenon under fentanyl sedation. Mean arterial blood pressure and heart rate remained stable. Mean arterial blood pressure and heart rate were not significantly influenced by 24h Xenon ventilation. 50% Xenon rapidly depresses background aEEG voltage to a steady ~50% lower level in sedated healthy newborn pigs. Therefore, care must be taken when interpreting the background voltage in neonates also receiving Xenon. Copyright © 2016 Elsevier B.V. All rights reserved.

Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies.

PubMed

Grunwell, Jocelyn R; Marupudi, Neelima K; Gupta, Rohan V; Travers, Curtis D; McCracken, Courtney E; Williamson, Julie L; Stockwell, Jana A; Fortenberry, James D; Couloures, Kevin; Cravero, Joseph; Kamat, Pradip P

2016-06-01

Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services. © 2016 John Wiley & Sons Ltd.

Preventing ICU Subsyndromal Delirium Conversion to Delirium With Low-Dose IV Haloperidol: A Double-Blind, Placebo-Controlled Pilot Study.

PubMed

Al-Qadheeb, Nada S; Skrobik, Yoanna; Schumaker, Greg; Pacheco, Manuel N; Roberts, Russel J; Ruthazer, Robin R; Devlin, John W

2016-03-01

To compare the efficacy and safety of scheduled low-dose haloperidol versus placebo for the prevention of delirium (Intensive Care Delirium Screening Checklist ≥ 4) administered to critically ill adults with subsyndromal delirium (Intensive Care Delirium Screening Checklist = 1-3). Randomized, double-blind, placebo-controlled trial. Three 10-bed ICUs (two medical and one surgical) at an academic medical center in the United States. Sixty-eight mechanically ventilated patients with subsyndromal delirium without complicating neurologic conditions, cardiac surgery, or requiring deep sedation. Patients were randomly assigned to receive IV haloperidol 1 mg or placebo every 6 hours until delirium occurred (Intensive Care Delirium Screening Checklist ≥ 4 with psychiatric confirmation), 10 days of therapy had elapsed, or ICU discharge. Baseline characteristics were similar between the haloperidol (n = 34) and placebo (n = 34) groups. A similar number of patients given haloperidol (12/34 [35%]) and placebo (8/34 [23%]) developed delirium (p = 0.29). Haloperidol use reduced the hours per study day spent agitated (Sedation Agitation Scale ≥ 5) (p = 0.008), but it did not influence the proportion of 12-hour ICU shifts patients spent alive without coma (Sedation Agitation Scale ≤ 2) or delirium (p = 0.36), the time to first delirium occurrence (p = 0.22), nor delirium duration (p = 0.26). Days of mechanical ventilation (p = 0.80), ICU mortality (p = 0.55), and ICU patient disposition (p = 0.22) were similar in the two groups. The proportion of patients who developed corrected QT-interval prolongation (p = 0.16), extrapyramidal symptoms (p = 0.31), excessive sedation (p = 0.31), or new-onset hypotension (p = 1.0) that resulted in study drug discontinuation was comparable between the two groups. Low-dose scheduled haloperidol, initiated early in the ICU stay, does not prevent delirium and has little therapeutic advantage in mechanically ventilated, critically ill adults with subsyndromal delirium.

Palliative sedation for terminally ill cancer patients in a tertiary cancer center in Shanghai, China.

PubMed

Gu, Xiaoli; Cheng, Wenwu; Chen, Menglei; Liu, Minghui; Zhang, Zhe

2015-01-01

There are a number of studies dedicated to characteristics of sedation, but these studies are mostly bound to western country practices. The aim of this study is to describe the characteristics of patients who suffered from cancer and who had been sedated until their death in Shanghai, China. Retrospective medical data of 244 terminally ill cancer patients including 82 sedated patients were collected. Data collected included demographic characteristics, disease-related characteristics and details of the sedation. In sedated cases, patients and/or caregivers gave the consent to start palliative sedation due to unmanageable symptoms. On average, sedation was performed 24.65(±1.78)hours before death. Agitated delirium and dyspnea were the most frequent indications for palliative sedation. There was no significant difference in survival time from admission till death between sedated and non-sedated patients (p > 0.05). Palliative sedation is effective for reducing terminally ill cancer patients' suffering without hastening death. Prospective research is needed to determine the optimal conditions for Chinese patients including indications, decision making process, informed consent, cultural and ethical issues, type of sedation and drugs.

Efficacy of Reconstituted Oral Chloral Hydrate from Crystals for Echocardiography Sedation.

PubMed

Hill, Garick D; Walbergh, Deborah B; Frommelt, Peter C

2016-04-01

Chloral hydrate has been the drug of choice for uncooperative infants and children requiring sedation for echocardiography. Recently, the commercially available liquid formulation was discontinued by the manufacturer, and the only oral form of chloral hydrate available was made using reconstituted crystals. The aim of this study was to compare sedation efficacy before and after this change in chloral hydrate formulas. Consecutive patients presenting for echocardiography sedation during the transition from the manufacturer-derived old formulation to the locally reconstituted new formulation were retrospectively reviewed for time to onset of level 3 sedation, duration of level ≤3 sedation, requirement for additional sedative medications, sedation failure, ability to complete the echocardiographic examination, and adverse events related to the sedatives. The cohort included 124 patients (63 old, 61 new). Although the mean age at sedation was younger for the new group, the weight and average dose of chloral hydrate used were not significantly different. There were no adverse events in either group. Time to onset of sedation was the same between the two formulations, but the duration of sedation was significantly shorter for the new group (42.4 ± 24.5 vs 55.3 ± 26.2 min, P = .01). In addition, the need for secondary sedating agents because of inadequate sedation and sedation failure were significantly greater using the new compared with the old formulation. Chloral hydrate reformulation using reconstituted crystals results in a shorter duration of sedation, more frequent requirement for a secondary sedative agent, more frequent sedation failure, and occasional inability to complete the echocardiographic examination compared with the manufacturer's formulation. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Thoracic Epidural Anesthesia Can Be Effective for the Short-Term Management of Ventricular Tachycardia Storm.

PubMed

Do, Duc H; Bradfield, Jason; Ajijola, Olujimi A; Vaseghi, Marmar; Le, John; Rahman, Siamak; Mahajan, Aman; Nogami, Akihiko; Boyle, Noel G; Shivkumar, Kalyanam

2017-10-27

Novel therapies aimed at modulating the autonomic nervous system, including thoracic epidural anesthesia (TEA), have been shown in small case series to be beneficial in treating medically refractory ventricular tachycardia (VT) storm. However, it is not clear when these options should be considered. We reviewed a multicenter experience with TEA in the management of VT storm to determine its optimal therapeutic use. Data for 11 patients in whom TEA was instituted for VT storm between July 2005 and March 2016 were reviewed to determine the clinical characteristics, outcomes, and role in management. The clinical presentation was incessant VT in 7 (64%), with polymorphic VT in 3 (27%) and monomorphic VT in 8 (73%). The underlying conditions were nonischemic cardiomyopathy in 5 (45%), ischemic cardiomyopathy in 3 (27%), and hypertrophic cardiomyopathy, Brugada syndrome, and cardiac lipoma in 1 (9%) each. Five (45%) had a complete and 1 (9%) had a partial response to TEA; 4 of the complete responders had incessant VT. All 4 patients with a documented response to deep sedation demonstrated a complete response to TEA. More than half of the patients with VT storm in our series responded to TEA. TEA may be effective and should be considered as a therapeutic option in patients with VT storm, especially incessant VT, who are refractory to initial management. Improvement in VT burden with deep sedation may suggest that sympathoexcitation plays a key role in perpetuating VT and predict a positive response to TEA. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Safety and clinical effect of i.v. infusion of cyclopropyl-methoxycarbonyl etomidate (ABP-700), a soft analogue of etomidate, in healthy subjects.

PubMed

Valk, B I; Absalom, A R; Meyer, P; Meier, S; den Daas, I; van Amsterdam, K; Campagna, J A; Sweeney, S P; Struys, M M R F

2018-06-01

Cyclopropyl-methoxycarbonyl metomidate, or ABP-700, is a second generation analogue of etomidate, developed to retain etomidate's beneficial haemodynamic and respiratory profile but diminishing its suppression of the adrenocortical axis. The objective of this study was to characterise the safety and efficacy of 30-min continuous infusions of ABP-700, and to assess its effect on haemodynamics and the adrenocortical response in healthy human volunteers. Five cohorts involving 40 subjects received increasing infusion doses of ABP-700, propofol 60 μg kg -1  min -1 or placebo. Safety was evaluated through adverse event (AE) monitoring, safety laboratory tests, and arterial blood gasses. Haemodynamic and respiratory stability were assessed by continuous monitoring. Adrenocortical function was analysed by adrenocorticotropic hormone (ACTH) stimulation tests. Clinical effect was measured using the modified observer's assessment of alertness/sedation (MOAA/S) and continuous bispectral index monitoring. No serious AEs were reported. Haemodynamic and respiratory effects included mild dose-dependent tachycardia, slightly elevated blood pressure, and no centrally mediated apnoea. Upon stimulation with ACTH, no adrenocortical depression was observed in any subject. Involuntary muscle movements (IMM) were reported, which were more extensive with higher dosing regimens. Higher dosages of ABP-700 were associated with deeper sedation and increased likelihood of sedation. Time to onset of clinical effect was variable throughout the cohorts and recovery was swift. Infusions of ABP-700 showed a dose-dependent hypnotic effect, and did not cause severe hypotension, severe respiratory depression, or adrenocortical suppression. The presentation and nature of IMM is a matter of concern. NTR4735. Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

75 FR 73104 - Clinical Development Programs for Sedation Products; Request for Assistance

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-29

... sedation claims? Would dose-escalation comparative trial designs be useful in studying sedation products? 5... understanding the physiology of sedation and clinical trial design issues related to the development of sedation... to procedural and intensive care unit (ICU) sedation, as well as associated clinical trial design...

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

PubMed Central

Fanti, Lorella; Testoni, Pier Alberto

2010-01-01

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures. The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated. Providing an adequate regimen of sedation/analgesia might be considered an art, influencing several aspects of endoscopic procedures: the quality of the examination, the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation. The properties of a model sedative agent for endoscopy would include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level of sedation, rapid recovery and an excellent safety profile. Therefore there is an impulse for development of new approaches to endoscopic sedation. This article provides an update on the methods of sedation today available and future directions in endoscopic sedation. PMID:20503443

Outcomes of General Anesthesia and Conscious Sedation in Endovascular Treatment for Stroke.

PubMed

Just, Caroline; Rizek, Philippe; Tryphonopoulos, Peter; Pelz, David; Arango, Miguel

2016-09-01

Background Recent studies have strongly indicated the benefits of endovascular therapy for acute ischemic stroke, but what remains a continued debate is the role for general anaesthesia versus conscious sedation (CS) for such procedures. Retrospective studies have found poorer neurological outcomes in patients who underwent general anesthesia (GA); however, some have revealed worse baseline stroke severity in these patients. Methods This study is a retrospective cohort study aimed at comparing mortality and morbidity of GA versus CS in patients treated with endovascular intervention in acute ischemic stroke. Chi-square and t-test analyses were used. Results Patients in the GA (n=42) group were more likely to be deceased than those in the CS (n=67) group at hospital discharge, 3 months, and 6 months poststroke onset. Morbidity, as defined by modified Rankin Score, was significantly greater in the GA group at hospital discharge, and a similar trend was seen in morbidity at 3 months postdischarge. Conclusion General anesthesia for endovascular intervention in acute ischemic stroke was associated with increased mortality and poorer neurological incomes compared with conscious sedation. In our study, age, gender, history of hypertension, history of diabetes, and baseline National Institute of Health Stroke Scale were not significantly different between the groups. Although the need for a randomized, prospective study on this topic is clear, our study represents further corroboration of the safety and efficacy of conscious sedation in these procedures.

Prospective cohort study on noise levels in a pediatric cardiac intensive care unit.

PubMed

Garcia Guerra, Gonzalo; Joffe, Ari R; Sheppard, Cathy; Pugh, Jodie; Moez, Elham Khodayari; Dinu, Irina A; Jou, Hsing; Hartling, Lisa; Vohra, Sunita

2018-04-01

To describe noise levels in a pediatric cardiac intensive care unit, and to determine the relationship between sound levels and patient sedation requirements. Prospective observational study at a pediatric cardiac intensive care unit (PCICU). Sound levels were measured continuously in slow A weighted decibels dB(A) with a sound level meter SoundEarPro® during a 4-week period. Sedation requirement was assessed using the number of intermittent (PRNs) doses given per hour. Analysis was conducted with autoregressive moving average models and the Granger test for causality. 39 children were included in the study. The average (SD) sound level in the open area was 59.4 (2.5) dB(A) with a statistically significant but clinically unimportant difference between day/night hours (60.1 vs. 58.6; p-value < 0.001). There was no significant difference between sound levels in the open area/single room (59.4 vs. 60.8, p-value = 0.108). Peak noise levels were > 90 dB. There was a significant association between average (p-value = 0.030) and peak sound levels (p-value = 0.006), and number of sedation PRNs. Sound levels were above the recommended values with no differences between day/night or open area/single room. High sound levels were significantly associated with sedation requirements. Copyright © 2017 Elsevier Inc. All rights reserved.

Anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: Perspectives from the clinical experience of a US panel of physicians.

PubMed

Essandoh, Michael K; Mark, George E; Aasbo, Johan D; Joyner, Charles A; Sharma, Saumya; Decena, Beningo F; Bolin, Eric D; Weiss, Raul; Burke, Martin C; McClernon, Timothy R; Daoud, Emile G; Gold, Michael R

2018-05-13

Worldwide adoption of the subcutaneous implantable cardioverter-defibrillator (S-ICD) for preventing sudden cardiac death continues to increase, as longer-term evidence demonstrating the safety and efficacy of the S-ICD expands. As a relatively new technology, comprehensive anesthesia guidance for the management of patients undergoing S-ICD placement is lacking. This article presents advantages and disadvantages of different peri-procedural sedation and anesthesia options for S-ICD implants including general anesthesia, monitored anesthesia care, regional anesthesia, and nonanesthesia personnel administered sedation and analgesia. Guidance, for approaches to anesthesia care during S-ICD implantation, are presented based upon literature review and consensus of a panel of high volume S-ICD implanters, a regional anesthesiologist, and a cardiothoracic anesthesiologist with significant S-ICD experience. The panel developed suggested actions for perioperative sedation, anesthesia, surgical practices and a decision algorithm for S-ICD implantation. While S-ICD implantation currently requires higher sedation than transvenous ICD systems, the panel consensus is that general anesthesia is not required or is obligatory for the majority of patients for the experienced S-ICD implanter. The focus of the implanting physician and the anesthesia services should be to maximize patient comfort and take into consideration patient specific co-morbidities, with a low threshold to consult the anesthesiology team. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Effect of intravenous infusion of dexmedetomidine on perioperative haemodynamic changes and postoperative recovery: A study with entropy analysis

PubMed Central

Patel, Chirag Ramanlal; Engineer, Smita R; Shah, Bharat J; Madhu, S

2012-01-01

Background: Dexmedetomidine, an α2 agonist, when used as an adjuvant in general anaesthesia attenuates stress response to various noxious stimuli, maintains perioperative haemodynamic stability and provides sedation without significant respiratory depression postoperatively. Methods: Sixty patients were randomly divided into two groups of 30 each. In group A, fentanyl 2 μg/kg and in group B dexmedetomidine were given intravenously as loading dose of 1 μg/kg over 10 min prior to induction. After induction with thiopentone, in group B, dexmedetomidine was given as infusion at a dose of 0.2–0.8 μg/kg. Sevoflurane was used as inhalation agent in both groups. Haemodynamic variables and entropy (response entropy and state entropy) were recorded continuously. Postoperative sedation and recovery were assessed by sedation score and modified Aldrete's score, respectively. Results: Dexmedetomidine significantly attenuates stress response at intubation with lesser increase in heart rate (10% vs. 17%), systolic blood pressure (6% vs. 23%) and diastolic blood pressure (7% vs. 20%) as compared to the control group (P<0.05). Intraoperatively, an average of 8% fall in systolic blood pressure and 8.16% fall in diastolic pressure in the test group as compared to 3.6% rise in systolic and 3.3% in diastolic pressure of the control group was observed. Postoperatively, the test group showed significant sedation at 2 h as compared to the control group (P=0.00) and recovery was better in the control group for the first 2 h post extubation. Conclusion: Dexmedetomidine attenuates various stress responses during surgery and maintains the haemodynamic stability when used as an adjuvant in general anaesthesia. Also, the sedative action of dexmedetomidine delays recovery for the first few hours post extubation. PMID:23325938

Does a history of psychoactive substances abuse play a role in the level of pain of the patient with severe trauma?

PubMed

López-López, C; Arranz-Esteban, A; Martinez-Ureta, M V; Sánchez-Rascón, M C; Morales-Sánchez, C; Chico-Fernández, M

To analyse the influence of psychotropic substance use on the level of pain in patients with severe trauma. Longitudinal analytical study. Intensive Care Unit (ICU) of Trauma and Emergencies. severe trauma, non-communicative and mechanical ventilation >48hours. Two groups of patients were created: users and non-users of psychotropic substances according to medical records. Measurement of pain level at baseline and during mobilization, using the Pain Indicator Behaviour Scale. demographic characteristics, pain score, sedation level and type and dose of analgesia and sedation. Sample of 84 patients, 42 in each group. The pain level in both groups, during mobilisation, showed significant differences p=0.011, with a mean of 3.11(2.40) for the user group and 1.83(2.14) for the non-user group. A relative risk of 2.5 CI (1,014-6,163) was found to have moderate / severe pain in the user group compared to the non-user group. The mean dose of analgesia and continuous sedation was significantly higher in the user group: P=.032 and P=.004 respectively. There was no difference in bolus dose of analgesia and sedation with P=.624 and P=.690 respectively. Patients with a history of consumption of psychoactive substances show higher levels of pain and experience a higher risk of this being moderate/severe compared to non-users despite receiving higher doses of analgesia and sedation infusion. Key words: pain, multiple trauma, drug users. Copyright © 2017 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

Effect of intravenous infusion of dexmedetomidine on perioperative haemodynamic changes and postoperative recovery: A study with entropy analysis.

PubMed

Patel, Chirag Ramanlal; Engineer, Smita R; Shah, Bharat J; Madhu, S

2012-11-01

Dexmedetomidine, an α2 agonist, when used as an adjuvant in general anaesthesia attenuates stress response to various noxious stimuli, maintains perioperative haemodynamic stability and provides sedation without significant respiratory depression postoperatively. Sixty patients were randomly divided into two groups of 30 each. In group A, fentanyl 2 μg/kg and in group B dexmedetomidine were given intravenously as loading dose of 1 μg/kg over 10 min prior to induction. After induction with thiopentone, in group B, dexmedetomidine was given as infusion at a dose of 0.2-0.8 μg/kg. Sevoflurane was used as inhalation agent in both groups. Haemodynamic variables and entropy (response entropy and state entropy) were recorded continuously. Postoperative sedation and recovery were assessed by sedation score and modified Aldrete's score, respectively. Dexmedetomidine significantly attenuates stress response at intubation with lesser increase in heart rate (10% vs. 17%), systolic blood pressure (6% vs. 23%) and diastolic blood pressure (7% vs. 20%) as compared to the control group (P<0.05). Intraoperatively, an average of 8% fall in systolic blood pressure and 8.16% fall in diastolic pressure in the test group as compared to 3.6% rise in systolic and 3.3% in diastolic pressure of the control group was observed. Postoperatively, the test group showed significant sedation at 2 h as compared to the control group (P=0.00) and recovery was better in the control group for the first 2 h post extubation. Dexmedetomidine attenuates various stress responses during surgery and maintains the haemodynamic stability when used as an adjuvant in general anaesthesia. Also, the sedative action of dexmedetomidine delays recovery for the first few hours post extubation.

The dexmedetomidine concentration required after remifentanil anesthesia is three-fold higher than that after fentanyl anesthesia or that for general sedation in the ICU

PubMed Central

Kunisawa, Takayuki; Fujimoto, Kazuhiro; Kurosawa, Atsushi; Nagashima, Michio; Matsui, Koji; Hayashi, Dai; Yamamoto, Kunihiko; Goto, Yuya; Akutsu, Hiroaki; Iwasaki, Hiroshi

2014-01-01

Purpose The general dexmedetomidine (DEX) concentration required for sedation of intensive care unit patients is considered to be approximately 0.7 ng/mL. However, higher DEX concentrations are considered to be required for sedation and/or pain management after major surgery using remifentanil. We determined the DEX concentration required after major surgery by using a target-controlled infusion (TCI) system for DEX. Methods Fourteen patients undergoing surgery for abdominal aortic aneurysms (AAA) were randomly, double-blindly assigned to two groups and underwent fentanyl- or remifentanil-based anesthetic management. DEX TCI was started at the time of closing the peritoneum and continued for 12 hours after stopping propofol administration (M0); DEX TCI was adjusted according to the sedation score and complaints of pain. The doses and concentrations of all anesthetics and postoperative conditions were investigated. Results Throughout the observation period, the predicted plasma concentration of DEX in the fentanyl group was stable at approximately 0.7 ng/mL. In contrast, the predicted plasma concentration of DEX in the remifentanil group rapidly increased and stabilized at approximately 2 ng/mL. The actual DEX concentration at 540 minutes after M0 showed a similar trend (0.54±0.14 [fentanyl] versus 1.57±0.39 ng/mL [remifentanil]). In the remifentanil group, the dopamine dose required and the duration of intubation decreased, and urine output increased; however, no other outcomes improved. Conclusion The DEX concentration required after AAA surgery with remifentanil was three-fold higher than that required after AAA surgery with fentanyl or the conventional DEX concentration for sedation. High DEX concentration after remifentanil affords some benefits in anesthetic management. PMID:25328395

Sedative and cardiorespiratory effects of detomidine constant rate infusion in sheep.

PubMed

de Moura, Rauane Sousa; Bittar, Isabela Plazza; da Silva, Luiz Henrique; Villela, Ana Carolina Vasquez; Dos Santos Júnior, Marcelo Borges; Borges, Naida Cristina; Franco, Leandro Guimarães

2018-02-01

The use of sheep in experiments is widespread and is increasing worldwide, and so is the need to develop species-specific anaesthetic techniques to ensure animal safety. Previous studies have mentioned several protocols involving the administration of alpha-2 adrenergic agonists in sheep; however, assessment of the efficacy and safety of these infusion techniques is still relatively new. Thus, the aim of the present study is to assess the effectiveness of detomidine constant rate infusion (CRI) in sheep by measuring the cardiovascular and respiratory parameters, blood gas variables and sedation scores. Eight adult female Santa Inês sheep received 20 µg/kg of detomidine hydrochloride intravenously as a bolus loading dose, followed by an infusion rate of 60 µg/kg/h. The heart rates and respiratory rates changed continuously during the CRI period. No arrhythmias were observed. The reduction in arterial partial pressure of oxygen (PaO 2 ) was not significant, but one animal showed signs of hypoxaemia (minimum PaO 2 of 66.9 mmHg). The arterial partial pressure of carbon dioxide (PaCO 2 ) increased, but the animals did not become hypercapnic. The bicarbonate (HCO 3- ), pH and base excess (BE) tended towards metabolic alkalosis. The cardiac output (CO), stroke volume (SV), cardiac index (CI) and ejection fraction (EF%) showed no significant changes. The fractional shortening (FS%) decreased slightly, starting at T 45min . Sedation scores varied between 3 (0/10) after sedation and during recovery and 7 (0/10) during CRI. We concluded that administering detomidine at an infusion rate of 60 µg/kg/h in Santa Inês sheep is a simple technique that produces satisfactory sedation for minimally invasive procedures.

Occupational Therapy for Patients With Acute Lung Injury: Factors Associated With Time to First Intervention in the Intensive Care Unit

PubMed Central

Dinglas, Victor D.; Colantuoni, Elizabeth; Ciesla, Nancy; Mendez-Tellez, Pedro A.; Shanholtz, Carl

2013-01-01

OBJECTIVE. Very early occupational therapy intervention in the intensive care unit (ICU) improves patients’ physical recovery. We evaluated the association of patient, ICU, and hospital factors with time to first occupational therapy intervention in ICU patients with acute lung injury (ALI). METHOD. We conducted a prospective cohort study of 514 consecutive patients with ALI from 11 ICUs in three hospitals in Baltimore, MD. RESULTS. Only 30% of patients ever received occupational therapy during their ICU stay. Worse organ failure, continuous hemodialysis, and uninterrupted continuous infusion of sedation were independently associated with delayed occupational therapy initiation, and hospital study site and admission to a trauma ICU were independently associated with earlier occupational therapy. CONCLUSION. Severity of illness and ICU practices for sedation administration were associated with delayed occupational therapy. Both hospital study site and type of ICU were independently associated with timing of occupational therapy, indicating modifiable environmental factors for promoting early occupational therapy in the ICU. PMID:23597694

[Analgesia, sedation and relaxation in the child with mechanical ventilation].

PubMed

Valdivielso-Serna, A

2008-02-01

The basic concepts of sedation and analgesia and the tools to asses the level of sedation and analgesia are review. The different methods of sedation and the non pharmacological interventions are described. Sedatives, analgesics and muscle relaxants, their pharmacodynamics and pharmacokinetics in children, their indications in specific situations (intubation, pain control, sedation and neuromuscular blocking) are reviewed. The etiology of patient-ventilator asynchrony in ventilated children and how to treat it are analyzed, giving guides of how to adapt sedation to the level of mechanical ventilation therapy. Finally, general recommendations are given for the analgesia and sedation in mechanically ventilated children.

A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department.

PubMed

Blaivas, Michael; Adhikari, Srikar; Lander, Lina

2011-09-01

Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups. This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher's exact test, and continuous variables were analyzed using the Wilcoxon rank sum test. Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p < 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p < 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49). In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients. © 2011 by the Society for Academic Emergency Medicine.

Sedation and monitoring for gastrointestinal endoscopy

PubMed Central

Amornyotin, Somchai

2013-01-01

The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities. Additionally, appropriate selection and preparation of patients, suitable sedative technique, application of drugs, adequate monitoring, and proper recovery of patients is essential. The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation practices for gastrointestinal endoscopy (GIE) vary widely. The majority of GIE patients are ambulatory cases. Most of this procedure requires a short time. So, short acting, rapid onset drugs with little adverse effects and improved safety profiles are commonly used. The present review focuses on commonly used regimens and monitoring practices in GIE sedation. This article is to discuss the decision making process used to determine appropriate pre-sedation assessment, monitoring, drug selection, dose of sedative agents, sedation endpoint and post-sedation care. It also reviews the current status of sedation and monitoring for GIE procedures in Thailand. PMID:23424050

Development of a Web-Based Nationwide Korean Pediatric Dental Sedation Registry.

PubMed

Choi, Sung Chul; Yang, Yeonmi; Yoo, Seunghoon; Kim, Jiyeon; Jeong, Taesung; Shin, Teo Jeon

Finding a balance between sedation efficacy and safety remains an ongoing challenge. In children, the risk of sedation-related complications is relatively high. It is of utmost importance to determine the factors related to improved overall sedation outcomes. However, most previous reports have been based on small samples at single institutions. The Korean Academy of Pediatric Dentistry (KAPD) developed a Korean Pediatric Dental Sedation Registry using a web-based platform. Specialists in pediatric dental sedation selected the itemized list included within the registry through an extensive literature review. The web-based registry was built into the KAPD homepage to facilitate easy access to the sedation data. All teaching and university hospitals agreed to participate in the Korean Pediatric Dental Sedation Registry. This is the first attempt to collect sedation data on a nationwide scale in the field of pediatric dentistry. The sedation database established with the registry may facilitate standardizing and improving pediatric dental sedation clinical practices.

Continuous palliative sedation for patients with advanced cancer at a tertiary care cancer center.

PubMed

Prado, Bernard Lobato; Gomes, Diogo Bugano Diniz; Usón Júnior, Pedro Luiz Serrano; Taranto, Patricia; França, Monique Sedlmaier; Eiger, Daniel; Mariano, Rodrigo Coutinho; Hui, David; Del Giglio, Auro

2018-01-04

Palliative sedation (PS) is an intervention to treat refractory symptoms and to relieve suffering at the end of life. Its prevalence and practice patterns vary widely worldwide. The aim of our study was to evaluate the frequency, clinical indications and outcomes of PS in advanced cancer patients admitted to our tertiary comprehensive cancer center. We retrospectively studied the use of PS in advanced cancer patients who died between March 1st, 2012 and December 31st, 2014. PS was defined as the use of continuous infusion of midazolam or neuroleptics for refractory symptoms in the end of life. This study was approved by the Research Ethics Committee of our institution (project number 2481-15). During the study period, 552 cancer patients died at the institution and 374 met the inclusion criteria for this study. Main reason for exclusion was death in the Intensive Care Unit. Among all included patients, 54.2% (n = 203) received PS. Patients who received PS as compared to those not sedated were younger (67.8 vs. 76.4 years-old, p < 0.001) and more likely to have a diagnosis of lung cancer (23% vs. 14%, p = 0.028). The most common indications for sedation were dyspnea (55%) and delirium (19.7%) and the most common drugs used were midazolam (52.7%) or midazolam and a neuroleptic (39.4%). Median initial midazolam infusion rate was 0.75 mg/h (interquartile range - IQR - 0.6-1.5) and final rate was 1.5 mg/h (IQR 0.9-3.0). Patient survival (length of hospital stay from admission to death) of those who had PS was more than the double of those who did not (33.6 days vs 16 days, p < 0.001). The palliative care team was involved in the care of 12% (n = 25) of sedated patients. PS is a relatively common practice in the end-of-life of cancer patients at our hospital and it is not associated with shortening of hospital stay. Involvement of a dedicated palliative care team is strongly recommended if this procedure is being considered. Further research is needed to identify factors that may affect the frequency and outcomes associated with PS.

Continuous positive airway pressure with helmet versus mask in infants with bronchiolitis: an RCT.

PubMed

Chidini, Giovanna; Piastra, Marco; Marchesi, Tiziana; De Luca, Daniele; Napolitano, Luisa; Salvo, Ida; Wolfler, Andrea; Pelosi, Paolo; Damasco, Mirco; Conti, Giorgio; Calderini, Edoardo

2015-04-01

Noninvasive continuous positive airway pressure (CPAP) is usually applied with a nasal or facial mask to treat mild acute respiratory failure (ARF) in infants. A pediatric helmet has now been introduced in clinical practice to deliver CPAP. This study compared treatment failure rates during CPAP delivered by helmet or facial mask in infants with respiratory syncytial virus-induced ARF. In this multicenter randomized controlled trial, 30 infants with respiratory syncytial virus-induced ARF were randomized to receive CPAP by helmet (n = 17) or facial mask (n = 13). The primary endpoint was treatment failure rate (defined as due to intolerance or need for intubation). Secondary outcomes were CPAP application time, number of patients requiring sedation, and complications with each interface. Compared with the facial mask, CPAP by helmet had a lower treatment failure rate due to intolerance (3/17 [17%] vs 7/13 [54%], P = .009), and fewer infants required sedation (6/17 [35%] vs 13/13 [100%], P = .023); the intubation rates were similar. In successfully treated patients, CPAP resulted in better gas exchange and breathing pattern with both interfaces. No major complications due to the interfaces occurred, but CPAP by mask had higher rates of cutaneous sores and leaks. These findings confirm that CPAP delivered by helmet is better tolerated than CPAP delivered by facial mask and requires less sedation. In addition, it is safe to use and free from adverse events, even in a prolonged clinical setting. Copyright © 2015 by the American Academy of Pediatrics.

A survey to assess the provision of conscious sedation by general dental practitioners in the Republic of Ireland.

PubMed

Fisher, Veronica; Stassen, Leo F A; Nunn, June

2011-01-01

To quantify and qualify how conscious sedation was used in general dental practice before the introduction of formal sedation teaching in the Republic of Ireland. 1. To determine the extent of use of oral, inhalational and intravenous sedation; 2. to determine the training and experience of general dental practitioners providing conscious sedation; 3. to determine the perceived barriers to the practice of conscious sedation; and, 4. to gauge the level of interest in a postgraduate course in conscious sedation. Postal questionnaire sent to one general practitioner in seven, selected randomly from the General Dental Council register, in 2007. Seventy six percent of respondents agreed that the provision of conscious sedation in general dental practice is important. However, the current provision of inhalation and intravenous sedation by respondents is low in comparison to provision in the UK. The main barrier to the use of conscious sedation in general dental practice appears to be lack of availability of training. The data from this study indicated the need for postgraduate training in conscious sedation in Ireland and a need for increased awareness of the Dental Council Code of Practice on sedation.

Levomepromazine (methotrimeprazine) and the last 48 hours.

PubMed

O'Neill, J; Fountain, A

1999-08-01

Levomepromazine (previously known as methotrimeprazine) has a broad range of beneficial effects in the terminal phase of many illnesses, resulting from its combined antipsychotic, anxiolytic and sedative actions. Levomepromazine can safely be administered in a continuous subcutaneous infusion with most other commonly used drugs in palliative care.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

PubMed

Fong, Choong Yi; Tay, Chee Geap; Ong, Lai Choo; Lai, Nai Ming

2017-11-03

Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non-invasive neurodiagnostic procedures in children. We used the standard search strategy of the Cochrane Epilepsy Group. We searched MEDLINE (OVID SP) (1950 to July 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 7, 2017), Embase (1980 to July 2017), and the Cochrane Epilepsy Group Specialized Register (via CENTRAL) using a combination of keywords and MeSH headings. We included randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non-drug agent(s), or placebo for children undergoing non-invasive neurodiagnostic procedures. Two review authors independently assessed the studies for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data, mean difference (MD) for continuous data, with 95% confidence intervals (CIs). We included 13 studies with a total of 2390 children. The studies were all conducted in hospitals that provided neurodiagnostic services. Most studies assessed the proportion of sedation failure during the neurodiagnostic procedure, time for adequate sedation, and potential adverse effects associated with the sedative agent.The methodological quality of the included studies was mixed, as reflected by a wide variation in their 'Risk of bias' profiles. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 13 studies had high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in single small studies.Children who received oral chloral hydrate had lower sedation failure when compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study, moderate-quality evidence). Children who received oral chloral hydrate had a higher risk of sedation failure after one dose compared to those who received intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study, low-quality evidence), but after two doses there was no evidence of a significant difference between the two groups (RR 3.00, 95% CI 0.33 to 27.46; 1 study, very low-quality evidence). Children who received oral chloral hydrate appeared to have more sedation failure when compared with music therapy, but the quality of evidence was very low for this outcome (RR 17.00, 95% CI 2.37 to 122.14; 1 study). Sedation failure rates were similar between oral chloral hydrate, oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam.Children who received oral chloral hydrate had a shorter time to achieve adequate sedation when compared with those who received oral dexmedetomidine (MD -3.86, 95% CI -5.12 to -2.6; 1 study, moderate-quality evidence), oral hydroxyzine hydrochloride (MD -7.5, 95% CI -7.85 to -7.15; 1 study, moderate-quality evidence), oral promethazine (MD -12.11, 95% CI -18.48 to -5.74; 1 study, moderate-quality evidence), and rectal midazolam (MD -95.70, 95% CI -114.51 to -76.89; 1 study). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study, low-quality evidence) and intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study, moderate-quality evidence).No data were available to assess the proportion of children with successful completion of neurodiagnostic procedure without interruption by the child awakening. Most trials did not assess adequate sedation as measured by specific validated scales, except in the comparison of chloral hydrate versus intranasal midazolam and oral promethazine.Compared to dexmedetomidine, chloral hydrate was associated with a higher risk of nausea and vomiting (RR 12.04 95% CI 1.58 to 91.96). No other adverse events were significantly associated with chloral hydrate (including behavioural change, oxygen desaturation) although there was an increased risk of adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study, low-quality evidence). The quality of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was very variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine for children undergoing paediatric neurodiagnostic procedures. The sedation failure was similar for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. When compared with intravenous pentobarbital and music therapy, oral chloral hydrate had a higher sedation failure rate. However, it must be noted that the evidence for the outcomes for the comparisons of oral chloral hydrate against intravenous pentobarbital and music therapy was of very low to low quality, therefore the corresponding findings should be interpreted with caution.Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially the risk of major adverse effects such as bradycardia, hypotension, and oxygen desaturation.

Organ toxicity and mortality in propofol-sedated rabbits under prolonged mechanical ventilation.

PubMed

Ypsilantis, Petros; Politou, Maria; Mikroulis, Dimitrios; Pitiakoudis, Michail; Lambropoulou, Maria; Tsigalou, Christina; Didilis, Vasilios; Bougioukas, Georgios; Papadopoulos, Nikolaos; Manolas, Constantinos; Simopoulos, Constantinos

2007-07-01

Prolonged administration of propofol at large doses has been implicated in propofol infusion syndrome in intensive care unit patients. In this study we investigated organ toxicity and mortality of propofol sedation at large doses in prolonged mechanically ventilated rabbits and determined the role of propofol's lipid vehicle. Eighteen healthy male rabbits were endotracheally intubated and sedated with propofol 2% (Group P), sevoflurane (Group S) or sevoflurane while receiving Intralipid 10% (Group SI). Sedation lasted 48 h or until death (Group P) or the maximum surviving period of Group P (Groups S and SI). The initial propofol infusion rate (20 mg x kg(-1) x h(-1)) or sevoflurane concentration (1.5%) was adjusted, if needed, to maintain a standard level of sedation. Blood biochemical analysis was performed in serial blood samples and histologic examination in the heart, lungs, liver, gallbladder, kidneys, urinary bladder, and quadriceps femoris muscle at autopsy. The mortality rate was 100% (surviving period, 26-38 h) for Group P, whereas 0% for Groups S and SI. The initial propofol infusion rate had to be increased up to 65.7 +/- 4.6 mg x kg(-1) x h(-1) and sevoflurane concentration up to 4%. Serum liver function indices, lipids and creatine kinase were significantly increased (P < 0.05) in Groups P and SI and lactate was increased only in Group P, whereas amylase was increased in all groups. In Group P, histologic examination revealed myocarditis, pulmonary edema with interstitial pneumonia, hepatitis, steatosis, and focal liver necrosis, cholangitis, gallbladder necrosis, acute tubular necrosis of the kidneys, focal loss of the urinary bladder epithelium, and rhabdomyolysis of skeletal muscles; in Group S, low-grade bronchitis and incipient inflammation of the liver and the kidneys; and in Group SI, low-grade bronchitis, liver steatosis and hepatitis, and incipient inflammation of the gallbladder, kidneys, and urinary bladder. Continuous infusion of 2% propofol at large doses for the sedation of rabbits undergoing prolonged mechanical ventilation induced fatal multiorgan dysfunction syndrome similar to the propofol infusion syndrome seen in humans. Our novel findings including lung, liver, gallbladder, and urinary bladder injury were also noted. The role of propofol's lipid vehicle in the manifestation of the syndrome was minor. Sevoflurane proved to be a safe alternative medication for prolonged sedation.

Inhaled methoxyflurane (Penthrox) sedation for third molar extraction: a comparison to nitrous oxide sedation.

PubMed

Abdullah, W A; Sheta, S A; Nooh, N S

2011-09-01

The aim of this study was to evaluate the use of inhaled methoxyflurane (Penthrox) in the reduction of dental anxiety in patients undergoing mandibular third molar removal in a specialist surgical suite and compare it to the conventional nitrous oxide sedation. A prospective randomized, non-blinded crossover design study of 20 patients receiving two types of sedation for their third molar extraction who participated in 40 treatment sessions. At first appointment, a patient was randomly assigned to receive either nitrous oxide sedation or intermittent Penthrox inhaler sedation, with the alternate regimen administered during the second appointment. Peri-procedural vital signs (heart rate and blood pressure) were recorded and any deviations from 20% from the baseline values, as well as any drop in oxygen saturation below 92% were documented. The Ramsay Sedation Scale (RSS) score was recorded every five minutes. Patient cooperation during the procedure, patients' general opinion about the sedation technique, surgeon satisfaction and the occurrence of side effects were all recorded. After the second procedure, the patient was also asked if he or she had any preference of one sedation technique over the other. Levels of sedation were comparable in nitrous oxide and Penthrox sedation sessions. However, at 15 minutes of sedation it was significantly lighter (p < 0.05) in Penthrox. No patient in both regimens reached a RSS deeper than a score of 4. Parameters measured for assessment of sedation (patient cooperation, surgeon satisfaction and patient general opinion about sedation technique) were all similarly comparable for both nitrous oxide and Penthrox. In both sedation sessions, the odour of the inhalational agent was accepted by the patients; half of the patients (10 patients) who received methoxyflurane thought its odour was pleasant. Patients preferred methoxyflurane (Penthrox) inhalation over nitrous oxide sedation (Fisher's Exact test, p < 0.05). Adverse events were minimal. No patient was either deeply sedated or agitated. Blood pressure was within ± 20% from the baseline values. No patient had oxygen saturation less than 92%. Dizziness was the most frequently encountered side effect in both regimens (four patients each). Two patients had bradycardia (HR < 60 beats/minute) when nitrous oxide was used in comparison to one patient with Penthrox sedation. Paraesthesia of fingers and heaviness of the chest was encountered only with nitrous oxide sedation (four patients). Mild self-limited shivering occurred in one patient with Penthrox sedation. The Penthrox Inhaler can produce a comparable sedation to that of nitrous oxide for the surgical extraction of third molars under local anaesthesia. © 2011 Australian Dental Association.

Intra- and inter-individual variation of BIS-index and Entropy during controlled sedation with midazolam/remifentanil and dexmedetomidine/remifentanil in healthy volunteers: an interventional study.

PubMed

Haenggi, Matthias; Ypparila-Wolters, Heidi; Hauser, Kathrin; Caviezel, Claudio; Takala, Jukka; Korhonen, Ilkka; Jakob, Stephan M

2009-01-01

We studied intra-individual and inter-individual variability of two online sedation monitors, BIS and Entropy, in volunteers under sedation. Ten healthy volunteers were sedated in a stepwise manner with doses of either midazolam and remifentanil or dexmedetomidine and remifentanil. One week later the procedure was repeated with the remaining drug combination. The doses were adjusted to achieve three different sedation levels (Ramsay Scores 2, 3 and 4) and controlled by a computer-driven drug-delivery system to maintain stable plasma concentrations of the drugs. At each level of sedation, BIS and Entropy (response entropy and state entropy) values were recorded for 20 minutes. Baseline recordings were obtained before the sedative medications were administered. Both inter-individual and intra-individual variability increased as the sedation level deepened. Entropy values showed greater variability than BIS(R) values, and the variability was greater during dexmedetomidine/remifentanil sedation than during midazolam/remifentanil sedation. The large intra-individual and inter-individual variability of BIS and Entropy values in sedated volunteers makes the determination of sedation levels by processed electroencephalogram (EEG) variables impossible. Reports in the literature which draw conclusions based on processed EEG variables obtained from sedated intensive care unit (ICU) patients may be inaccurate due to this variability. clinicaltrials.gov Nr. NCT00641563.

At-home palliative sedation for end-of-life cancer patients.

PubMed

Alonso-Babarro, Alberto; Varela-Cerdeira, Maria; Torres-Vigil, Isabel; Rodríguez-Barrientos, Ricardo; Bruera, Eduardo

2010-07-01

Using a decision-making and treatment checklist developed to facilitate the at-home palliative sedation process, we assessed the incidence and efficacy of palliative sedation for end-of-life cancer patients with intractable symptoms who died at home. We retrospectively reviewed the medical records of 370 patients who were followed by a palliative home care team. Twenty-nine of 245 patients (12%) who died at home had received palliative sedation. The mean age of the patients who received palliative sedation was 58 +/- 17 years, and the mean age of the patients who did not receive palliative sedation was 69 +/- 15 years (p = 0.002). No other differences were detected between patients who did or did not receive palliative sedation. The most common indications for palliative sedation were delirium (62%) and dyspnea (14%). Twenty-seven patients (93%) received midazolam for palliative sedation (final mean dose of 74 mg), and two (7%) received levomepromazine (final mean dose of 125 mg). The mean time between palliative sedation initiation and time of death was 2.6 days. In 13 of the cases (45%), the palliative sedation decision was made with the patient and his or her family members, and in another 13 patients (45%), the palliative sedation decision was made only with the patient's family members. We concluded that palliative sedation may be used safely and efficaciously to treat dying cancer patients with refractory symptoms at home.

[Degree of sedation. Incidence of vomiting and time of postoperative sleep with 3 different oral administration schedules of hydroxyzine chlorhydrate and chloral hydrate].

PubMed

Díaz-Barriga, M G; Jackson-Herrerías, G

1990-01-01

In this paper a comparison of sedation effectiveness, vomiting incidence and postoperative sleeping time with three sedation schemes: Chloral hydrate exclusively, hidroxicine chlorhydrate the night before and 15 minutes before chloral hydrate administration and hidroxicine chlorhydrate 15 minutes before chloral hydrate. We find that there is no significant differences between these three sedation schemes in sedation, degree of postoperative sleeping time and vomiting incidence, therefore we can expect an effective sedation degree using any of these sedation methods.

Palliative sedation: not just normal medical practice. Ethical reflections on the Royal Dutch Medical Association's guideline on palliative sedation.

PubMed

Janssens, Rien; van Delden, Johannes J M; Widdershoven, Guy A M

2012-11-01

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline.

Propofol disrupts functional interactions between sensory and high-order processing of auditory verbal memory.

PubMed

Liu, Xiaolin; Lauer, Kathryn K; Ward, Barney D; Rao, Stephen M; Li, Shi-Jiang; Hudetz, Anthony G

2012-10-01

Current theories suggest that disrupting cortical information integration may account for the mechanism of general anesthesia in suppressing consciousness. Human cognitive operations take place in hierarchically structured neural organizations in the brain. The process of low-order neural representation of sensory stimuli becoming integrated in high-order cortices is also known as cognitive binding. Combining neuroimaging, cognitive neuroscience, and anesthetic manipulation, we examined how cognitive networks involved in auditory verbal memory are maintained in wakefulness, disrupted in propofol-induced deep sedation, and re-established in recovery. Inspired by the notion of cognitive binding, an functional magnetic resonance imaging-guided connectivity analysis was utilized to assess the integrity of functional interactions within and between different levels of the task-defined brain regions. Task-related responses persisted in the primary auditory cortex (PAC), but vanished in the inferior frontal gyrus (IFG) and premotor areas in deep sedation. For connectivity analysis, seed regions representing sensory and high-order processing of the memory task were identified in the PAC and IFG. Propofol disrupted connections from the PAC seed to the frontal regions and thalamus, but not the connections from the IFG seed to a set of widely distributed brain regions in the temporal, frontal, and parietal lobes (with exception of the PAC). These later regions have been implicated in mediating verbal comprehension and memory. These results suggest that propofol disrupts cognition by blocking the projection of sensory information to high-order processing networks and thus preventing information integration. Such findings contribute to our understanding of anesthetic mechanisms as related to information and integration in the brain. Copyright © 2011 Wiley Periodicals, Inc.

Anatomy and Pathophysiology of Spinal Cord Injury Associated With Regional Anesthesia and Pain Medicine: 2015 Update.

PubMed

Neal, Joseph M; Kopp, Sandra L; Pasternak, Jeffrey J; Lanier, William L; Rathmell, James P

2015-01-01

In March 2012, the American Society of Regional Anesthesia and Pain Medicine convened its second Practice Advisory on Neurological Complications in Regional Anesthesia and Pain Medicine. This update is based on the proceedings of that conference and relevant information published since its conclusion. This article updates previously described information on the pathophysiology of spinal cord injury and adds new material on spinal stenosis, blood pressure control during neuraxial blockade, neuraxial injury subsequent to transforaminal procedures, cauda equina syndrome/local anesthetic neurotoxicity/arachnoiditis, and performing regional anesthetic or pain medicine procedures in patients concomitantly receiving general anesthesia or deep sedation. Recommendations are based on extensive review of research on humans or employing animal models, case reports, pathophysiology research, and expert opinion. The pathophysiology of spinal cord injury associated with regional anesthetic techniques is reviewed in depth, including that related to mechanical trauma from direct needle/catheter injury or mass lesions, spinal cord ischemia or vascular injury from direct needle/catheter trauma, and neurotoxicity from local anesthetics, adjuvants, or antiseptics. Specific recommendations are offered that may reduce the likelihood of spinal cord injury associated with regional anesthetic or interventional pain medicine techniques. The practice advisory's recommendations may, in select cases, reduce the likelihood of injury. However, many of the described injuries are neither predictable nor preventable based on our current state of knowledge. Since publication of initial recommendations in 2008, new information has enhanced our understanding of 5 specific entities: spinal stenosis, blood pressure control during neuraxial anesthesia, neuraxial injury subsequent to transforaminal techniques, cauda equina syndrome/local anesthetic neurotoxicity/arachnoiditis, and performing regional anesthetic or pain procedures in patients concomitantly receiving general anesthesia or deep sedation.

Deep sedation versus general anesthesia in percutaneous edge-to-edge mitral valve reconstruction using the MitraClip system.

PubMed

de Waha, Suzanne; Seeburger, Joerg; Ender, Joerg; Desch, Steffen; Eitel, Ingo; Reinhardt, Adrian; Pöss, Janine; Fuernau, Georg; Noack, Thilo; Merk, Denis Rouven; Schuler, Gerhard; Sievers, Hans-Hinrich; Mohr, Friedrich-Wilhelm; Thiele, Holger

2016-06-01

Percutaneous edge-to-edge mitral valve reconstruction (PMVR) has emerged as a treatment option in patients with severe mitral regurgitation not considered suitable candidates for surgery. The majority of PMVR procedures are performed under general anesthesia (GA), although deep sedation (DS) appears to be an attractive alternative. We thus sought to assess the impact on intensive care unit (ICU) length of stay, efficacy, and safety of DS in comparison to GA in patients undergoing PMVR using the MitraClip(®) system. Sixty consecutive patients underwent PMVR procedures at two centers. The first 30 patients were treated by GA followed by 30 patients undergoing DS under different settings. The primary clinical endpoint was ICU length of stay. The primary efficacy endpoint included procedural success and procedural duration. The safety endpoint was defined as a composite of death, stroke, cardiogenic shock, moderate and severe bleeding as well as pneumonia. The ICU length of stay was significantly shorter in the DS group in comparison to GA patients (p = 0.001). The hospital length of stay did not differ following DS in comparison to GA (p = 0.96). Procedural success was high in both groups (100 versus 96.7 %, p = 0.34) at similar procedural duration time (p = 0.60). No difference between GA and DS was observed with respect to the occurrence of the combined safety endpoint (p = 0.47). In comparison to GA, DS reduces the ICU length of stay in PMVR without negative effects on safety and efficacy. Prospective randomized trials are needed to confirm these findings.

Assessment of sedation level for endoscopic retrograde cholangiopancreatography - a prospective validation study.

PubMed

Jokelainen, Jarno; Mustonen, Harri; Kylänpää, Leena; Udd, Marianne; Lindström, Outi; Pöyhiä, Reino

2018-03-01

There is no consensus on how to assess the depth of sedation for endoscopic retrograde cholangiopancreatography (ERCP). This study was carried out in order to evaluate different methods of assessment of depth of sedation: bispectral index (BiS), modified Richmond Agitation/Sedation Scale (mRASS), modified Ramsay Sedation Scale (mRSS) and modified Observer Assessment of Alertness and Sedation (mOAAS) and their applicability to clinical practice. Two hundred patients were recruited. Sedation was given by standard clinical practice using propofol sedation or patient controlled sedation. Sedation was assessed on all patients using the above-mentioned methods. BiS was considered the reference point for sedation scales. Cronbach's alpha was calculated to determine the consistency of different scales in respect to each other and prediction probability and Spearman's correlation coefficients of sedation scales were calculated to show the relationship between sedation scales and BiS. All scales showed high reliability with overall Cronbach's alpha 0.943. Dropping scales suggested better consistency between mOAAS, mRSS and mRASS than with BiS. Spearman's correlation and prediction probability showed similar results with all tested scales: mOAAS (0.695, 0.739), mRSS (0.673, 0.735), mRASS (0.683, 0.738), p < .01 for all scales. All tested methods were found to be reliable in the assessment of the depth of sedation when compared with each other. However, mRASS, mRSS and mOAAS require the patient to respond to verbal or tactile stimulus, which may impair execution of ERCP, whereas BiS information is collected directly from electroencephalogram and thus may be preferable in clinical setting.

Use of computer-assisted drug therapy outside the operating room.

PubMed

Singh, Preet Mohinder; Borle, Anuradha; Goudra, Basavana G

2016-08-01

The number of procedures performed in the out-of-operating room setting under sedation has increased many fold in recent years. Sedation techniques aim to achieve rapid patient turnover through the use of short-acting drugs with minimal residual side-effects (mainly propofol and opioids). Even for common procedures, the practice of sedation delivery varies widely among providers. Computer-based sedation models have the potential to assist sedation providers and offer a more consistent and safer sedation experience for patients. Target-controlled infusions using propofol and other short-acting opioids for sedation have shown promising results in terms of increasing patient safety and allowing for more rapid wake-up times. Target-controlled infusion systems with real-time patient monitoring can titrate drug doses automatically to maintain optimal depth of sedation. The best recent example of this is the propofol-based Sedasys sedation system. Sedasys redefined individualized sedation by the addition of an automated clinical parameter that monitors depth of sedation. However, because of poor adoption and cost issues, it has been recently withdrawn by the manufacturer. Present automated drug delivery systems can assist in the provision of sedation for out-of-operating room procedures but cannot substitute for anesthesia providers. Use of the available technology has the potential to improve patient outcomes, decrease provider workload, and have a long-term economic impact on anesthesia care delivery outside of the operating room.

Current UK dental sedation practice and the 'National Institute for Health and Care Excellence' (NICE) guideline 112: sedation in children and young people.

PubMed

Coulthard, P; Craig, D; Holden, C; Robb, N D; Sury, M; Chopra, S; Holroyd, I

2015-04-24

Describe current dental sedation practice for under 19-year-olds in the UK and compare it with the recommendations of NICE guidance 112. Members of the Society for the Advancement of Anaesthesia in Dentistry and members of the Dental Sedation Teachers Group were invited to participate in an online survey. Two hundred and sixty-six dentists and doctors completed the survey. Eighty-two percent were operator and sedationist (operator-sedationist). Ninety-five percent provided written information and 94% obtained written consent. Eighty-four percent kept a written or electronic sedation record. Eighty-six percent complied with life support training expectations. Eighty-six percent had immediate access to resuscitation equipment. Sixty-seven percent of sedationists reported that treatment could not be completed under sedation for <10% of cases during the previous year. When sedation was unsuccessful, 61% said they would schedule general anaesthesia and 54.5% would schedule advanced sedation care. Forty-nine percent believed that a dentist was an appropriate person to provide advanced sedation for 12-18 years. Only 24% thought a dentist should provide advanced sedation for children<12 years, with 75% preferring an anaesthetist. The appropriate setting for advanced sedation was thought to be primary care by 33% and secondary care by 68%. We found good agreement between the current practice of sedation and the recommendations of the NICE guidance 112.

Assessment of recovery in patients undergoing intravenous conscious sedation using bispectral analysis.

PubMed

Sandler, N A; Hodges, J; Sabino, M

2001-06-01

The Bispectral Index (BIS) has been recently shown to objectively predict the level of sedation in patients undergoing conscious sedation. It was the goal of this study to directly compare the recovery profile of patients where the BIS was used to monitor sedation with a control group where the monitor was not used. Forty patients undergoing third molar extractions under intravenous conscious sedation were randomly assigned to 2 groups. In both groups, induction of sedation was performed using a standard dose of fentanyl (1.5 microg/kg) and midazolam (0.05 mg/kg). Propofol was then given in 10 to 20 mg boluses until a clinically desirable sedation level was achieved. In 1 group, the BIS was then monitored continually during surgery using a microcomputer (Aspect-1050 Monitor, Aspect Co, Natick, MA) and recorded at 5-minute intervals. The anesthetist (N.A.S.) provided additional propofol boluses to maintain a BIS level of 70 to 80. In the other group, the BIS sensor was applied, but the monitor was not used. In this group, the sedation was modified, and additional propofol was given based solely on the anesthetist's subjective assessment of the desired level of sedation (Observer's Assessment of Alertness/Sedation [OAA/S] scale level 2 to 3). Additional boluses of 1 mg of midazolam were given during the procedure if patients required repeated boluses of propofol at less than 5-minute intervals to maintain the desired sedation level (BIS level of 70 to 80 or OAA/S level of 2 to 3). These additional midazolam boluses, as well as the time of the last sedative dose (propofol or midazolam) were recorded to study the effect of these factors on recovery. Of the 40 patients initially included in the study, 1 subject in the BIS-monitored group was excluded due to the loss of intravenous access at initiation of the case. For the remaining 39 subjects, 19 were assessed objectively using the BIS monitor, whereas 20 were assessed subjectively using the OAA/S scale. The BIS cases were slightly longer in duration than the OAA/S cases, lasting an average of 26 minutes versus 22 minutes. This difference was statistically nonsignificant (P =.19). Less propofol was used in the BIS cases, with an average of 98 mg for BIS cases versus 106 mg for OAA/S cases (P =.59). The total dose in mg/kg/min was significantly less in the BIS group (0.054 mg/kg/min) than in the OAA/S group (0.074 mg/kg/min; P =.0082). There was no significant difference in the amount of midazolam administered after induction between the 2 groups (P =.60). The surgeon, who was blinded to whether the monitor was used, ranked the third molar extractions more difficult in the BIS group (P =.05). However, patients in the BIS group were on average more cooperative, with better maintenance of muscle tone. The difference in these parameters were nonsignificant (P =.15 and .092, respectively). A positive Romberg test was obtained earlier in BIS patients, although this difference was nonsignificant (P =.097). The straight-line test was completed significantly sooner in BIS patients (P =.013). There was no significant difference between the BIS and OAA/S groups in perceptual speed (P =.55) or computation (P =.32). There was essentially no difference between groups in patient-assessed comfort or recall of the procedure. There were also no notable differences in anesthesia complications, return to activities of daily life, or pain medication use between the 2 groups. The BIS provides additional information for standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. It appears that use of the BIS monitor can help to titrate the level of sedation so that less drugs are used to maintain the desired level. The trend toward an earlier return of motor function in BIS-monitored patients warrants further investigation. Copyright 2001 American Association of Oral and Maxillofacial Surgeons.

Comparison of sedation strategies for critically ill patients: a protocol for a systematic review incorporating network meta-analyses.

PubMed

Hutton, Brian; Burry, Lisa D; Kanji, Salmaan; Mehta, Sangeeta; Guenette, Melanie; Martin, Claudio M; Fergusson, Dean A; Adhikari, Neill K; Egerod, Ingrid; Williamson, David; Straus, Sharon; Moher, David; Ely, E Wesley; Rose, Louise

2016-09-20

Sedatives and analgesics are administered to provide sedation and manage agitation and pain in most critically ill mechanically ventilated patients. Various sedation administration strategies including protocolized sedation and daily sedation interruption are used to mitigate drug pharmacokinetic limitations and minimize oversedation, thereby shortening the duration of mechanical ventilation. At present, it is unclear which strategy is most effective, as few have been directly compared. Our review will use network meta-analysis (NMA) to compare and rank sedation strategies to determine their efficacy and safety for mechanically ventilated patients. We will search the following from 1980 to March 2016: Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science. We will also search the Cochrane Library, gray literature, and the International Clinical Trials Registry Platform. We will use a validated randomized control trial search filter to identify studies evaluating any strategy to optimize sedation in mechanically ventilated adult patients. Authors will independently extract data from eligible studies in duplicate and complete the Cochrane Risk of Bias tool. Our outcomes of interest include duration of mechanical ventilation, time to first extubation, ICU and hospital length of stay, re-intubation, tracheostomy, mortality, total sedative and opioid exposure, health-related quality of life, and adverse events. To inform our NMA, we will first conduct conventional pair-wise meta-analyses using random-effects models. Where appropriate, we will perform Bayesian NMA using WinBUGS software. There are multiple strategies to optimize sedation for mechanically ventilated patients. Current ICU guidelines recommend protocolized sedation or daily sedation interruption. Our systematic review incorporating NMA will provide a unified analysis of all sedation strategies to determine the relative efficacy and safety of interventions that may not have been compared directly. We will provide knowledge users, decision makers, and professional societies with ranking of multiple sedation strategies to inform future sedation guidelines. PROSPERO CRD42016037480.

Sedation practice in Nordic and non-Nordic ICUs: a European survey.

PubMed

Egerod, Ingrid; Albarran, John W; Ring, Mette; Blackwood, Bronagh

2013-07-01

A trend towards lighter sedation has been evident in many intensive care units (ICUs). The aims of the survey were to describe sedation practice in European ICUs and to compare sedation practice in Nordic and non-Nordic countries. A cross-sectional survey of ICU nurses attending the fourth European federation of Critical Care Nursing associations (EfCCNa) in Denmark, 2011. Data included use of protocols; sedation, pain and delirium assessment tools; collaborative decision-making; sedation and analgesic medications; and educational preparation related to sedation. Response rate was 42% (n = 291) from 22 countries where 53% (n = 148) used sedation protocols. Nordic nurses reported greater use of sedation (91% versus 67%, p < 0·01) and pain (91% versus 69%, p < 0·01) assessment tools than non-Nordic nurses. Decision-making on sedation was more inter-professionally collaborative in Nordic ICUs (83% versus 61%, p < 0·01), units were smaller (10 versus 15 beds, p < 0·01) and nurse-patient ratio was higher (1:1, 75% versus 26%, p < 0·01). Nordic nurses reported greater consistency in maintaining circadian rhythm (66% versus 49%, p < 0·01), less use of physical restraints (14% versus 36%, p < 0·01), less use of neuromuscular blocking agents (3% versus 16%, p < 0·01), and received more sedation education (92% versus 76%, p < 0·01). Delirium assessment was not performed systematically in most settings. Organizational and contextual factors, such as ICU size, staffing ratio and inter-professional collaboration, are contributing factors to sedation management in European ICUs. The Nordic context might be more germane to the goal of lighter sedation and better pain management. Our study raises awareness of current sedation practice, paving the way towards optimized ICU sedation management. © 2013 The Authors. Nursing in Critical Care © 2013 British Association of Critical Care Nurses.

Global inhibition and stimulus competition in the owl optic tectum

PubMed Central

Mysore, Shreesh P.; Asadollahi, Ali; Knudsen, Eric I.

2010-01-01

Stimulus selection for gaze and spatial attention involves competition among stimuli across sensory modalities and across all of space. We demonstrate that such cross-modal, global competition takes place in the intermediate and deep layers of the optic tectum, a structure known to be involved in gaze control and attention. A variety of either visual or auditory stimuli located anywhere outside of a neuron's receptive field (RF) were shown to suppress or completely eliminate responses to a visual stimulus located inside the RF in nitrous oxide sedated owls. The essential mechanism underlying this stimulus competition is global, divisive inhibition. Unlike the effect of the classical inhibitory surround, which decreases with distance from the RF center and shapes neuronal responses to individual stimuli, global inhibition acts across the entirety of space and modulates responses primarily in the context of multiple stimuli. Whereas the source of this global inhibition is as yet unknown, our data indicate that different networks mediate the classical surround and global inhibition. We hypothesize that this global, cross-modal inhibition, which acts automatically in a bottom-up fashion even in sedated animals, is critical to the creation of a map of stimulus salience in the optic tectum. PMID:20130182

Sedation and Monitoring in the Pediatric Patient during Gastrointestinal Endoscopy.

PubMed

Chung, Hyun Kee; Lightdale, Jenifer R

2016-07-01

Sedation is a fundamental component of pediatric gastrointestinal procedures. The 2 main types of sedation for pediatric endoscopy remain general anesthesia and procedural sedation. Although anesthesiologist-administered sedation protocols are more common, there is no ideal regimen for endoscopy in children. This article discusses specific levels of sedation for endoscopy as well as various regimens that can be used to achieve each. Risks and considerations that may be specific to performing gastrointestinal procedures in children are reviewed. Finally, potential future directions for sedation and monitoring that may change the practice of pediatric gastroenterology and ultimately patient outcomes are examined. Copyright © 2016 Elsevier Inc. All rights reserved.

Amnesia for electric dental pulp stimulation and picture recall test under different levels of propofol or midazolam sedation.

PubMed

Matsuki, Y; Ichinohe, T; Kaneko, Y

2007-01-01

To compare the amnesic effect of propofol and midazolam to electric dental pulp stimulation (invasive) and picture recall test (non-invasive) at two sedation levels with the aid of bispectral index (BIS) monitoring. The subjects were 10 male volunteers (24-34 years) classified as ASA physical status I. Propofol was administered to achieve a sedation score of three with a target-controlled infusion technique; it was then regulated to give a sedation score of two (P group). Midazolam was administered by a titration dosage to achieve a sedation score of three (M group). It then gradually decreased to give a sedation score of two. The BIS score, sedation score, plasma/serum concentration of propofol and midazolam, blood pressure, pulse rate, respiratory rate, end-tidal CO(2) tension and arterial oxygen saturation were observed at each sedation level in both groups. Amnesic effects were evaluated using a picture recall test and electric dental pulp stimulation. No difference was observed in the amnesic effect evaluated by picture recall test at the two sedation levels. Likewise, there was no difference at a sedation score of three when the amnesic effect was evaluated by electric dental pulp stimulation. In contrast, a significant difference was observed at a sedation score of two; midazolam produced amnesia in more subjects than did propofol. Propofol and midazolam did not show any significant difference in amnesic effects to non-invasive stimuli. For invasive stimuli, midazolam showed a stronger amnesic effect at the moderate sedation level, but not at the deeper sedation level.

Palliative sedation in end-of-life care and survival: a systematic review.

PubMed

Maltoni, Marco; Scarpi, Emanuela; Rosati, Marta; Derni, Stefania; Fabbri, Laura; Martini, Francesca; Amadori, Dino; Nanni, Oriana

2012-04-20

Palliative sedation is a clinical procedure aimed at relieving refractory symptoms in patients with advanced cancer. It has been suggested that sedative drugs may shorten life, but few studies exist comparing the survival of sedated and nonsedated patients. We present a systematic review of literature on the clinical practice of palliative sedation to assess the effect, if any, on survival. A systematic review of literature published between January 1980 and December 2010 was performed using MEDLINE and EMBASE databases. Search terms included palliative sedation, terminal sedation, refractory symptoms, cancer, neoplasm, palliative care, terminally ill, end-of-life care, and survival. A manual search of the bibliographies of electronically identified articles was also performed. Eleven published articles were identified describing 1,807 consecutive patients in 10 retrospective or prospective nonrandomized studies, 621 (34.4%) of whom were sedated. One case-control study was excluded from prevalence analysis. The most frequent reason for sedation was delirium in the terminal stages of illness (median, 57.1%; range, 13.8% to 91.3%). Benzodiazepines were the most common drug category prescribed. Comparing survival of sedated and nonsedated patients, the sedation approach was not shown to be associated with worse survival. Even if there is no direct evidence from randomized clinical trials, palliative sedation, when appropriately indicated and correctly used to relieve unbearable suffering, does not seem to have any detrimental effect on survival of patients with terminal cancer. In this setting, palliative sedation is a medical intervention that must be considered as part of a continuum of palliative care.

Paediatric conscious sedation: views and experience of specialists in paediatric dentistry.

PubMed

Woolley, S M; Hingston, E J; Shah, J; Chadwick, B L

2009-09-26

The objectives were three-fold: to investigate the level of conscious sedation training received prior to and during specialist training in paediatric dentistry; to establish the use of conscious sedation during and following specialisation; and to determine the attitudes of specialists in paediatric dentistry to conscious sedation. A self-administered postal questionnaire was sent to all specialists in paediatric dentistry registered with the General Dental Council in January 2008. Non-responders were contacted again after a four-week period. A response rate of 60% was achieved. Of the 122 respondents, 67 (55%) had received sedation training as an undergraduate; 89 (75%) had been trained during specialisation. All respondents performed dental treatment under sedation as a trainee and the majority used nitrous oxide inhalation sedation (NOIS). Over 90% of respondents felt that NOIS should be available to all children, both in appropriate primary care settings and in hospitals. One hundred and twenty-one (99%) respondents thought that all trainees in paediatric dentistry should have sedation training. The most popular form of sedation amongst specialists in paediatric dentistry was NOIS. However, some of the respondents felt that children should have access to other forms of sedation in both the primary care and hospital settings. Additional research on other forms of sedation is required to evaluate their effectiveness and safety.

Analgesia and Sedation Requirements in Mechanically Ventilated Trauma Patients With Acute, Preinjury Use of Cocaine and/or Amphetamines.

PubMed

Kram, Bridgette; Kram, Shawn J; Sharpe, Michelle L; James, Michael L; Kuchibhatla, Maragatha; Shapiro, Mark L

2017-03-01

The purpose of this study was to determine whether mechanically ventilated trauma patients with a positive urine drug screen (UDS) for cocaine and/or amphetamines have different opioid analgesic and sedative requirements compared with similar patients with a negative drug screen for these stimulants. This retrospective, single-center cohort study at a tertiary care, academic medical and level 1 trauma center in the United States included patients ≥16 years of age who were admitted to an adult intensive care unit with a diagnosis of trauma between 2009 and 2013 with a UDS documented within 24 hours of admission, and were mechanically ventilated for >24 hours. The primary end point was the daily dose of opioid received during mechanical ventilation, expressed as morphine equivalents, for patients presenting with a positive UDS for cocaine and/or amphetamines compared with patients with a negative UDS for these stimulants. Secondary end points included the daily benzodiazepine dose and median infusion rates of propofol and dexmedetomidine received during mechanical ventilation, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality. Analgesic and sedative goals were similar for the duration of the study period, and both intermittent and continuous infusions of opioids and sedatives were administered to achieve these targets, although a standardized approach was not used. A multivariate logistic regression analysis and a propensity-adjusted model evaluated patient characteristics predictive of a higher median opioid requirement. A total of 150 patients were included in the final analysis. In a univariate analysis, opioid and sedative requirements were similar for patients presenting with a positive UDS for cocaine and/or amphetamines compared with patients with a negative UDS for these stimulants. In the multivariate regression analysis, increasing age and Abbreviated Injury Scale (head and neck) were associated with decreased daily opioid requirements (odds ratio [OR], .95, 95% confidence interval [CI], .93-.97 and OR, .71, 95% CI, .65-.77, respectively), whereas preinjury stimulant use was not predictive of opioid requirements (OR, .88, 95% CI, .40-1.90). In a propensity score--adjusted model, preinjury stimulant use was similarly not predictive of opioid requirements during mechanical ventilation (OR, .97, 95% CI, .44-2.11). For trauma patients presenting with acute, preinjury use of cocaine and/or amphetamines, analgesic and sedative requirements are variables and may not be greater than those patients presenting with a stimulant-negative UDS to achieve desirable pain control and depth of sedation, although this observation should be interpreted cautiously in light of the wide CI observed in the propensity score--adjusted model. Although unexpected, these findings indicate that empirically increasing analgesic and sedative doses based on positive UDS results for these stimulants may not be necessary.

Effect of dexmedetomidine on preventing agitation and delirium after microvascular free flap surgery: a randomized, double-blind, control study.

PubMed

Yang, Xudong; Li, Zhenzhen; Gao, Chunyan; Liu, Ruichang

2015-06-01

To determine whether dexmedetomidine sedation in the postanesthesia care unit (PACU) could decrease agitation and delirium after free flap surgery. Eighty patients were randomly divided into 2 groups. In the experimental group, dexmedetomidine was given at an hourly infusion rate of 0.5 μg/kg for 1 hour before the operation was completed and continued in the PACU at 0.2 to 0.7 μg/kg continuously until the next morning. In the control group, normal saline was given during the same periods. Patients in the 2 groups received sufentanil and midazolam for sedation and pain relief when necessary. Agitation was monitored with the Riker Sedation-Agitation Scale in the PACU and delirium was monitored with the Confusion Assessment Method for the Intensive Care Unit for 5 days postoperatively. The overall incidence of agitation was similar between the 2 groups. However, when the influence of patient shifting was excluded, the incidence of agitation in the dexmedetomidine group was apparently lower than that in the control group (10.3 vs 30%; P = .029). No difference was found in the occurrence of delirium between the experimental and control groups (5.1 vs 12.5%; P = .432). Dexmedetomidine does not change the overall incidence of agitation after free flap surgery; however, it does decrease agitation after PACU admission. It does not prevent delirium within 5 days postoperatively. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Assessment of patients' awareness and factors influencing patients' demands for sedation in endodontics.

PubMed

Huh, Yoo Kyeom; Montagnese, Thomas A; Harding, Jarrod; Aminoshariae, Anita; Mickel, Andre

2015-02-01

Endodontic therapy is perceived by many as a procedure to be feared. Many studies have reported that fear and anxiety are major deterrents to seeking dental care in general, but only a few deal with the use of sedation in endodontic therapies. The purpose of this study was to assess patients' awareness of and factors influencing the potential demand for sedation in endodontics. We hypothesized that there is an association between demographic factors and the demand for sedation in endodontics. A survey consisting of 24 questions was given to patients 18 years and older who presented to the graduate endodontic clinic. Results were collected and statistically analyzed. Thirty-six percent of patients reported that their perception of sedation was being put to sleep, and 27% perceived it as related to or reducing pain. Concerns associated with endodontic therapy were the fear of pain (35%), fear of needles (16%), difficulty getting numb (10%), and anxiety (7%). The 2 major demographic factors that influenced the demand for sedation were cost and the level of anxiety (P < .05). Fifty-one percent showed a positive interest in sedation for endodontic therapy if the option of sedation was available. The demand for sedation in endodontics is high. Patients' understanding of sedation varies. More patients would consider having endodontic procedures if sedation was available. The provision of sedation by endodontists could result in more patients accepting endodontic therapies. Copyright © 2015 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk

PubMed Central

Cobb, Benjamin; Liu, Renyu; Valentine, Elizabeth; Onuoha, Onyi

2015-01-01

Brief Summary Doctors, nurses, and midwives often inform mothers to “pump and dump” their breast milk for 24 hours after receiving anesthesia to avoid passing medications to the infant. This advice, though cautious, is probably outdated. This review highlights the more recent literature regarding common anesthesia medications, their passage into breast milk, and medication effects observed in breastfed infants. We suggest continuing breastfeeding after anesthesia when the mother is awake, alert, and able to hold her infant. We recommend multiple types of medications for pain relief while minimizing sedating medications. Few medications can have sedating effects to the infant, but those medications are specifically outlined. For additional safety, anesthesia providers and patients may screen medications using the National Institute of Health’ LactMed database. PMID:26413558

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk.

PubMed

Cobb, Benjamin; Liu, Renyu; Valentine, Elizabeth; Onuoha, Onyi

Doctors, nurses, and midwives often inform mothers to "pump and dump" their breast milk for 24 hours after receiving anesthesia to avoid passing medications to the infant. This advice, though cautious, is probably outdated. This review highlights the more recent literature regarding common anesthesia medications, their passage into breast milk, and medication effects observed in breastfed infants. We suggest continuing breastfeeding after anesthesia when the mother is awake, alert, and able to hold her infant. We recommend multiple types of medications for pain relief while minimizing sedating medications. Few medications can have sedating effects to the infant, but those medications are specifically outlined. For additional safety, anesthesia providers and patients may screen medications using the National Institute of Health' LactMed database.

Evaluation of volatile components from spikenard: valerena-4,7(11)-diene is a highly active sedative compound.

PubMed

Takemoto, Hiroaki; Yagura, Toru; Ito, Michiho

2009-10-01

Valerena-4,7(11)-diene and beta-maaliene were isolated from spikenard for the first time, and the effects of inhaling these compounds were investigated. Both compounds reduced the locomotor activity of mice dose-dependently, even at a low dose. Valerena-4,7(11)-diene had a particularly profound effect, with the strongest sedative activity observed at a dose of 0.06%. Caffeine-treated mice that showed an area under the curve (AUC) for locomotor activity that was double that of controls were calmed to normal levels by administration of valerena-4,7(11)-diene. The continuous sleep time of pentobarbital-treated mice was prolonged by about 2.7 times with valerena-4,7(11)-diene, an effect similar to that of chlorpromazine administered orally.

Propofol. An overview of its pharmacology and a review of its clinical efficacy in intensive care sedation.

PubMed

Fulton, B; Sorkin, E M

1995-10-01

Propofol is a phenolic derivative that is structurally unrelated to other sedative hypnotic agents. It has been used extensively as an anaesthetic agent, particularly in procedures of short duration. More recently it has been investigated as a sedative in the intensive care unit (ICU) where it produces sedation and hypnosis in a dose-dependent manner. Propofol also provides control of stress responses and has anticonvulsant and amnesic properties. Importantly, its pharmacokinetic properties are characterised by a rapid onset and short duration of action. Noncomparative and comparative trials have evaluated the use of propofol for the sedation of mechanically ventilated patients in the ICU (postsurgical, general medical, trauma). Overall, propofol provides satisfactory sedation and is associated with good haemodynamic stability. It produces results similar to or better than those seen with midazolam or other comparator agents when the quality of sedation and/or the amount of time that patients were at adequate levels of sedation are measured. Patients sedated with propofol also tend to have a faster recovery (time to spontaneous ventilation or extubation) than patients sedated with midazolam. Although most studies did not measure time to discharge from the ICU, propofol tended to be superior to midazolam in this respect. In a few small trials in patients with head trauma or following neurosurgery, propofol was associated with adequate sedation and control of cerebral haemodynamics. The rapid recovery of patients after stopping propofol makes it an attractive option in the ICU, particularly for patients requiring only short term sedation. In short term sedation, propofol, despite its generally higher acquisition costs, has the potential to reduce overall medical costs if patients are able to be extubated and discharged from the ICU sooner. Because of the potential for hyperlipidaemia and the development of tolerance to its sedative effects, and because of the reduced need for rapid reversal of drug effects in long term sedation, the usefulness of propofol in long term situations is less well established. While experience with propofol for the sedation of patients in the ICU is extensive, there are still areas requiring further investigation. These include studies in children, trials examining cerebral and haemodynamic outcomes following long term administration and in patients with head trauma and, importantly, pharmacoeconomic investigations to determine those situations where propofol is cost effective. In the meantime, propofol is a well established treatment native to benzodiazepines and/or other hypnotics or analgesics when sedation of patients in the ICU is required. In particular, propofol possesses unique advantages over these agents in patients requiring only short term sedation.

Transient central diabetes insipidus induced by ketamine infusion.

PubMed

Hatab, Sarah Z; Singh, Arun; Felner, Eric I; Kamat, Pradip

2014-12-01

Report a case of central diabetes insipidus (DI) associated with ketamine infusion. A 2-year-old girl with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency and stable hypertrophic cardiomyopathy was admitted to the pediatric intensive care with pneumonia. She subsequently developed respiratory failure and required intubation. Continuous ketamine infusion was used for the sedation and facilitation of mechanical ventilation. Shortly after infusion of ketamine, the patient developed DI and responded appropriately to vasopressin. The Naranjo adverse drug reaction probability scale indicated a probable relationship between the development of central DI and ketamine. The most likely mechanism involves ketamine's antagonist action on N-methyl-d-aspartate receptors, resulting in inhibition of glutamate-stimulated arginine vasopressin release from the neurohypophysis. This is the second case report of ketamine-induced central DI and the only report in children. Clinicians who sedate children with continuous ketamine infusions should monitor patients for developing signs and symptoms of DI by measuring serum sodium and urine output prior to, during, and after ketamine infusion in order to make a timely diagnosis of this potentially serious complication. © The Author(s) 2014.

Effect of vigabatrin on sedation and cognitive function in patients with refractory epilepsy.

PubMed Central

Gillham, R A; Blacklaw, J; McKee, P J; Brodie, M J

1993-01-01

Twenty-four patients with refractory epilepsy on one or more antiepileptic drugs were given additional vigabatrin (1 g twice daily for six weeks, followed by 1.5 g twice daily for a further six weeks) and matched placebo in a double blind, randomised, crossover study. A battery of neuropsychological tests was administered at baseline and at weeks two, six and 12 of both treatment periods. No significant differences were found between vigabatrin and placebo at any time point for any of the objective tests of cognitive function. Patients, however, reported a greater degree of sedation after two and six weeks on vigabatrin than during the equivalent placebo phase (p < 0.01), although no such difference was apparent at 12 weeks. Follow up over a mean of 14.75 months in 12 responders, who continued on vigabatrin, revealed a significant improvement (all p < 0.01) on each of three composite scales (three psychomotor tests, four memory tests, three self rating scales) compared with their scores during the double blind trial. Vigabatrin did not cause cognitive impairment either acutely or in the long term. Phased introduction, however, seems a prudent policy to allow tolerance to early subjective sedation. PMID:8270925

Dexmedetomidine: a novel sedative-analgesic agent

PubMed Central

2001-01-01

Since the first report of clonidine, an α2-adrenoceptor agonist, the indications for this class of drugs have continued to expand. In December 1999, dexmedetomidine was approved as the most recent agent in this group and was introduced into clinical practice as a short-term sedative (<24 hours). α2-Adrenoceptor agonists have several beneficial actions during the perioperative period. They decrease sympathetic tone, with attenuation of the neuroendocrine and hemodynamic responses to anesthesia and surgery; reduce anesthetic and opioid requirements; and cause sedation and analgesia. They allow psychomotoric function to be preserved while letting the patient rest comfortably. With this combination of effects, α2-adrenoceptor agonists may offer benefits in the prophylaxis and adjuvant treatment of perioperative myocardial ischemia. Furthermore, their role in pain management and regional anesthesia is expanding. Side effects consist of mild to moderate cardiovascular depression, with slight decreases in blood pressure and heart rate. The development of new, more selective α2-adrenoceptor agonists with improved side effect profiles may provide a new concept for the administration of perioperative anesthesia and analgesia. This review aims to give background information to improve understanding of the properties and applications of the novel α2-adrenoceptor agonist, dexmedetomidine. PMID:16369581

A Questionnaire of Parental Perceptions of Conscious Sedation in Pediatric Dentistry.

PubMed

White, Jason; Wells, Martha; Arheart, Kristopher L; Donaldson, Martin; Woods, Marjorie A

2016-01-01

The purpose of this study was to determine the opinions of parents about oral sedation in pediatric dentistry. A 21-question questionnaire, administered to parents of children presenting for care in four pediatric dental practices, collected demographic information, media exposure to sedation, and parental knowledge/opinions regarding sedation procedures, such as NPO (nothing by mouth) guidelines, need for restraint, parental presence, and parental acceptance of treatment scenarios. Among 256 questionnaires completed, 235 were usable. Fifty-eight percent of respondents reported using public insurance. Parents agreed/strongly agreed (75 percent) that protective stabilization should not be necessary during sedation, and 87 percent preferred to stay with their child during the appointment. No parents perceived sedation as unsafe. Seventy-three percent of parents were unaware of media coverage of sedation; 82 percent reported it was acceptable for their child to sleep through a sedation appointment, while only 18 percent found it acceptable for the child to be highly reactive. Parents prefer to remain with their child, believe that sedation is safe and restraint should not be necessary, and are more accepting of the child sleeping during treatment. Most parents are unaware of media coverage of dental sedation for children.

[Survey of pediatric sedation in Japan--results of questionnaire to universities of dentistry].

PubMed

Takeuchi, Lisa; Kuratani, Norifumi; Hoshijima, Hiroshi; Kikuchi, Hirosato

2010-12-01

Despite widespread use of sedation for stress management during dental treatment in adults, its prevalence of use for pediatric in patients Japan has not been clarified. We investigated here, the present situation of pediatric sedation by the questionnaire sent to the dental anesthesia departments of university hospitals in Japan. Postal survey was conducted of the dental anesthesia departments of university hospitals (29 institutions) throughout the country. Information was requested on hospital policy of indication and technique of pediatric sedation for dental treatment. The causes for avoiding pediatric sedation were also investigated. The response rate was 86.2% (25/29 institutions). Of these respondents, 16 institutions (64%, 16/25 institutions) employ sedation for pediatric dental treatment stress management. The cases performed were around 1-5 cases every month. However, the criteria for employment of pediatric sedation during dental treatment varied among institutes. They preferred to provide general endotracheal anesthesia for pediatric dental procedures, and tended to avoid sedation without airway security for children. The present survey suggests that pediatric sedation for stress management during dental treatment are employed in more than half of the dental university hospitals. However, there was little consensus regarding pediatric sedation during dental treatment among dental anesthesiologists in Japan.

Palliative sedation, not slow euthanasia: a prospective, longitudinal study of sedation in Flemish palliative care units.

PubMed

Claessens, Patricia; Menten, Johan; Schotsmans, Paul; Broeckaert, Bert

2011-01-01

Palliative sedation remains a much debated and controversial issue. The limited literature on the topic often fails to answer ethical questions concerning this practice. The aim of this study was to describe the characteristics of patients who are being sedated for refractory symptoms in palliative care units (PCUs) from the time of admission until the day of death. A prospective, longitudinal, descriptive design was used to assess data in eight PCUs. The total sample consisted of 266 patients. Information on demographics, medication, food and fluid intake, decision making, level of consciousness, and symptom experience were gathered by nurses and researchers three times a week. If patients received palliative sedation, extra information was gathered. Of all included patients (n=266), 7.5% received palliative sedation. Sedation started, on average, 2.5 days before death and for half of these patients, the form of sedation changed over time. At the start of sedation, patients were in the end stage of their illness and needed total care. Patients were fully conscious and had very limited oral food or fluid intake. Only three patients received artificial fluids at the start of sedation. Patients reported, on average, two refractory symptoms, the most important ones being pain, fatigue, depression, drowsiness, and loss of feeling of well-being. In all cases, the patient gave consent to start palliative sedation because of increased suffering. This study revealed that palliative sedation is only administered in exceptional cases where refractory suffering is evident and for those patients who are close to the ends of their lives. Moreover, this study supports the argument that palliative sedation has no life-shortening effect. Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Comparison of dexmedetomidine and chloral hydrate sedation for transthoracic echocardiography in infants and toddlers: a randomized clinical trial.

PubMed

Miller, Jeff; Xue, Bin; Hossain, Md; Zhang, Ma-Zhong; Loepke, Andreas; Kurth, Dean

2016-03-01

Procedural sedation using chloral hydrate is used in many institutions to improve the quality of transthoracic echocardiograms (TTE) in infants and young children. Chloral hydrate has limited availability in some countries, creating the need for alternative effective sedatives. The aim of our study was to compare the effectiveness of two doses of intranasal dexmedetomidine vs oral chloral hydrate sedation for transthoracic echocardiography. This is a randomized, prospective study of 150 children under the age of 3 years with known or suspected congenital heart disease scheduled for transthoracic echocardiography with sedation. Group CH received oral chloral hydrate 70 mg · kg(-1), group DEX2 received 2 μg · kg(-1) intranasal dexmedetomidine, and group DEX3 received 3 μg · kg(-1) intranasal dexmedetomidine. Acceptance of drug administration, sedation onset and duration, heart rate, and oxygen saturation, sonographer and parent satisfaction were recorded. All patients were successfully sedated for TTE. A second sedative dose (rescue) for failed single-dose sedation was required for 4% of patients after CH, none of the patients after DEX2, and 4% of patients after DEX3. Patients in group CH had an average heart rate decline of 22% during sedation, while group DEX2 decreased 27%, and group DEX3 23% (P = 0.2180). Mean time from administration of the sedative to final patient discharge was 96 min after CH, 83 min after DEX2, and 94 min after DEX3 (P = 0.1826). Intranasal dexmedetomidine 2 and 3 μg · kg(-1) were found to be as effective for TTE sedation as oral chloral hydrate with similar sedation onset and recovery time and heart rate changes in this study population. © 2015 John Wiley & Sons Ltd.

Sedation with detomidine and acepromazine influences the endoscopic evaluation of laryngeal function in horses.

PubMed

Lindegaard, C; Husted, L; Ullum, H; Fjeldborg, J

2007-11-01

Endoscopy of the upper airways of horses is used as a diagnostic tool and at purchase examinations. On some occasions it is necessary to use sedation during the procedure and it is often speculated that the result of the examination might be influenced due to the muscle-relaxing properties of the most commonly used sedatives. To evaluate the effect of detomidine (0.01 mg/kg bwt) and acepromazine (0.05 mg/kg bwt) on the appearance of symmetry of rima glottidis, ability to abduct maximally the arytenoid cartilages and the effect on recurrent laryngeal neuropathy (RLN) grade. Forty-two apparently normal horses underwent endoscopic examination of the upper airways on 3 different occasions, under the influence of 3 different treatments: no sedation (control), sedation with detomidine and sedation with acepromazine. All examinations were performed with a minimum of one week apart. The study was performed as an observer-blind cross-over study. Sedation with detomidine had a significant effect on the RLN grading (OR = 2.91) and ability maximally to abduct the left arytenoid cartilages (OR = 2.91). Sedation with acepromazine resulted in OR = 2.43 for the RLN grading and OR = 2.22 for the ability to abduct maximally. The ability to abduct maximally the right arytenoid cartilage was not altered. Sedating apparently healthy horses with detomidine or acepromazine significantly impairs these horses' ability to abduct fully the left but not the right arytenoid cartilage. This resulted in different diagnosis with respect to RLN when comparing sedation to no sedation. Since the ability to abduct the right arytenoid cartilage fully is not altered by sedation, it is speculated that horses changing from normal to abnormal laryngeal function when sedated, might be horses in an early stage of the disease. To confirm or reject these speculations, further studies are needed. Until then sedation during endoscopy should be used with care.

The Use of Office-Based Sedation and General Anesthesia by Board Certified Pediatric Dentists Practicing in the United States

PubMed Central

Olabi, Nassim F.; Jones, James E.; Saxen, Mark A.; Sanders, Brian J.; Walker, LaQuia A.; Weddell, James A.; Schrader, Stuart M.; Tomlin, Angela M.

2012-01-01

The purpose of this study is to explore the use of office-based sedation by board-certified pediatric dentists practicing in the United States. Pediatric dentists have traditionally relied upon self-administered sedation techniques to provide office-based sedation. The use of dentist anesthesiologists to provide office-based sedation is an emerging trend. This study examines and compares these two models of office-based sedations. A survey evaluating office-based sedation of diplomates of the American Board of Pediatric Dentistry (ABPD) based on gender, age, years in practice, practice types, regions, and years as a diplomate of the ABPD was completed by 494 active members. The results were summarized using frequencies and percentages. Relationships of dentist age, gender, and number of years in practice with the use of intravenous (IV) sedation was completed using two-way contingency tables and Mantel-Haenszel tests for ordered categorical data. Relationships of office-based sedation use and the type of one's practice were examined using Pearson chi-square tests. Of the 1917 surveys e-mailed, 494 completed the survey for a response rate of 26%. Over 70% of board-certified US pediatric dentists use some form of sedation in their offices. Less than 20% administer IV sedation, 20 to 40% use a dentist anesthesiologist, and 60 to 70% would use dentist anesthesiologists if one were available. PMID:22428969

The use of office-based sedation and general anesthesia by board certified pediatric dentists practicing in the United States.

PubMed

Olabi, Nassim F; Jones, James E; Saxen, Mark A; Sanders, Brian J; Walker, Laquia A; Weddell, James A; Schrader, Stuart M; Tomlin, Angela M

2012-01-01

The purpose of this study is to explore the use of office-based sedation by board-certified pediatric dentists practicing in the United States. Pediatric dentists have traditionally relied upon self-administered sedation techniques to provide office-based sedation. The use of dentist anesthesiologists to provide office-based sedation is an emerging trend. This study examines and compares these two models of office-based sedations. A survey evaluating office-based sedation of diplomates of the American Board of Pediatric Dentistry (ABPD) based on gender, age, years in practice, practice types, regions, and years as a diplomate of the ABPD was completed by 494 active members. The results were summarized using frequencies and percentages. Relationships of dentist age, gender, and number of years in practice with the use of intravenous (IV) sedation was completed using two-way contingency tables and Mantel-Haenszel tests for ordered categorical data. Relationships of office-based sedation use and the type of one's practice were examined using Pearson chi-square tests. Of the 1917 surveys e-mailed, 494 completed the survey for a response rate of 26%. Over 70% of board-certified US pediatric dentists use some form of sedation in their offices. Less than 20% administer IV sedation, 20 to 40% use a dentist anesthesiologist, and 60 to 70% would use dentist anesthesiologists if one were available.

Sedation versus no sedation: Are there differences in relatives' satisfaction with the Intensive Care Unit? A survey study based on data from a randomised controlled trial.

PubMed

Laerkner, Eva; Stroem, Thomas; Toft, Palle

2017-04-01

Currently there is a trend towards less or no use of sedation of mechanically ventilated patients. Still, little is known about how different sedation strategies affect relatives' satisfaction with the Intensive Care Unit (ICU). To explore if there was a difference in relatives' personal reactions and the degree of satisfaction with information, communication, surroundings, care and treatment in the ICU between relatives of patients who receive no sedation compared with relatives of patients receiving sedation during mechanical ventilation in the ICU. A survey study using a questionnaire with 39 questions was distributed to relatives of mechanically ventilated patients, who had been randomised to either sedation with daily wake up or no sedation. Forty-nine questionnaires were sent out and 36 relatives answered. The response rate was 73%. We found no differences in relatives' personal reactions or in the degree of satisfaction with information, communication, care and treatment in the ICU between relatives of patients in the two groups. Relatives of patients treated with no sedation felt more bothered by disturbances in the surroundings compared with relatives of patients who were sedated (p=0.03). Treating the patient during mechanical ventilation with no sedation does not affect relatives' satisfaction adversely. Copyright © 2016 Elsevier Ltd. All rights reserved.

Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit.

PubMed

Blamoun, John; Alfakir, Maria; Rella, Marie E; Wojcik, Janice M; Solis, Roberto A; Anees Khan, M; DeBari, Vincent A

2009-03-01

The ventilator bundle (VB) includes a group of clinical maneuvers (head-of-bed elevation, "sedation vacation," deep vein thrombosis prophylaxis, and peptic ulcer disease prophylaxis) to improve outcomes in patients undergoing mechanical ventilation. We modified the standard VB in our medical intensive care unit to include a group of respiratory therapist-driven protocols and, postimplementation, observed a statistically significant (P = .0006) reduction in ventilator-associated pneumonia (VAP), from a median of 14.1 cases/10(3) ventilator-days (interquartile range [IQR] = 12.1 to 20.6) to 0 cases/10(3) ventilator-days (IQR = 0 to 1.1).

L'Equin du Pied dans un Contexte de Brulure Grave - Interet du Bilan Photographique

PubMed Central

Girbon, J.P.; Maligot, B.; Coiffier, E.; Gonzalez-Gutierrez, L.; Gaussorgues, C.; Lacroix, P.; Braye, F.

2008-01-01

Summary The incorrect position of the foot in talipes equinus is common in the framework of prolonged confinement to bed in a patient in deep sedation. In the context of severe burns, this incorrect position is difficult to prevent and its fixation by cutaneous shrinkage, which is often associated with a musculotendinous fibrosis, constitutes an important functional after-effect. The onset of talipes equinus is insidious and progressive, and it is therefore important to be watchful both in detection and in prevention. Regular photographic assessment makes it possible to predict its appearance and to take appropriate preventive or curative action. PMID:21991119

Ipsi- and Contralateral Motor Response Using Ultrasound-induced Neurostimulation in Deeply Anesthetized Mice

NASA Astrophysics Data System (ADS)

Kamimura, Hermes; Wang, Shutao; Chen, Hong; Wang, Qi; Aurup, Christian; Fan, Kathtleen; Carneiro, Antonio; Konofagou, Elisa

Ultrasound neurostimulation has been proven capable of eliciting motor responses. However, the studies in sedated rodents presented problems with target specificity due to the use of low ultrasound frequencies (<700 kHz). Here, we show that focused ultrasound (FUS) in mega-Hz range was able to evoke motor responses in mice under deep anesthesia. Contralateral movements of the hind limbs were observed when sonications were carried out at +2 mm of Lambda and ±2 mm lateral of midline in three mice. Moreover, stimulating other regions of the somatosensory and cerebellum induced trunk and ipsilateral limb movements in all six mice.

Palliative sedation in nursing anesthesia.

PubMed

Wolf, Michael T

2013-04-01

Palliative sedation is a technique of providing a sedative for end-of-life care to patients with intractable pain. The literature discusses the techniques and use of palliative sedation. Numerous articles have been written regarding the issues surrounding its use, but no literature has discussed the prescription or administration of palliative sedation by a nurse anesthetist. By understanding the concept and ethics involved in its use and providing nursing care that is theory based, the author argues that the involvement of nursing anesthesia is appropriate and within the scope of practice. Few other healthcare disciplines can provide the patient care and empirical knowledge that is imperative in the care of the dying patient. This article discusses the concept and ethics of palliative sedation and presents a case of providing palliative sedation to a terminally ill patient by an experienced nurse anesthetist. Palliative sedation should be understood, embraced, and utilized as an area of expertise suited for nursing anesthesia.

[General practitioner and palliative sedation].

PubMed

Schweitzer, Bart

2014-01-01

Recent publications in Dutch national newspapers on palliative sedation have raised concerns about its use in general practice. There is now evidence that there is no significant increase in the incidence of palliative sedation. Euthanasia requests were pending in 20.8% of the cases in which palliative sedation was performed, but the general practitioners could clearly justify why they made this choice. This is important because it indicates that they are aware of a sharp distinction between euthanasia and palliative sedation. Although the decision to perform palliative sedation was discussed with almost all cancer patients, patient involvement was less present in non-cancer conditions. This may be related to different disease trajectories, but it also indicates that attention should be devoted to earlier identification of patients in need of palliative care. The findings confirm that the practice of palliative sedation by general practitioners largely reflects the recommendations of the Dutch National Guideline on Palliative Sedation.

Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS): Standardized Quality Improvement and Research Tools from the International Committee for the Advancement of Procedural Sedation.

PubMed

Roback, M G; Green, S M; Andolfatto, G; Leroy, P L; Mason, K P

2018-01-01

Many hospitals, and medical and dental clinics and offices, routinely monitor their procedural-sedation practices-tracking adverse events, outcomes, and efficacy in order to optimize the sedation delivery and practice. Currently, there exist substantial differences between settings in the content, collection, definition, and interpretation of such sedation outcomes, with resulting widespread reporting variation. With the objective of reducing such disparities, the International Committee for the Advancement of Procedural Sedation has herein developed a multidisciplinary, consensus-based, standardized tool intended to be applicable for all types of sedation providers in all locations worldwide. This tool is amenable for inclusion in either a paper or an electronic medical record. An additional, parallel research tool is presented to promote consistency and standardized data collection for procedural-sedation investigations. Copyright © 2017. Published by Elsevier Ltd.

[Hospital Doctors Should Receive Lecture for Sedation According to Joint Commission International].

PubMed

Ueshima, Hironobu; Komasawa, Nobuyasu; Kitamura, Akira

2015-08-01

At our hospital, intending to obtaining an approval from the Joint Commission International (JCI), we conducted a workshop on sedation for all staff physicians. A sedation instructor authorized by the Japanese Association for Medical Simulation gave a lecture using the "practice guidelines for sedation and administration of analgesics for non-anesthesiologists", revised in 2002 by the American Society of Anesthesiologists, following which, a test using 10 true-false questions was conducted, while before and after the lecture a questionnaire survey on the sedation lecture was carried out Among 191 physicians attending the lecture, except for one person, 7 or more questions were answered correctly. From the questionnaires, the sedation lectures were also generally accepted favourably. In the test of understanding, the mistakes were mostly in the sections on "sedation evaluation" "intraoperative monitoring" "pharmaceutical knowledge" and "airway management methods". The sedation lecture in the hospital was effective.

Resting-state Network-specific Breakdown of Functional Connectivity during Ketamine Alteration of Consciousness in Volunteers.

PubMed

Bonhomme, Vincent; Vanhaudenhuyse, Audrey; Demertzi, Athena; Bruno, Marie-Aurélie; Jaquet, Oceane; Bahri, Mohamed Ali; Plenevaux, Alain; Boly, Melanie; Boveroux, Pierre; Soddu, Andrea; Brichant, Jean François; Maquet, Pierre; Laureys, Steven

2016-11-01

Consciousness-altering anesthetic agents disturb connectivity between brain regions composing the resting-state consciousness networks (RSNs). The default mode network (DMn), executive control network, salience network (SALn), auditory network, sensorimotor network (SMn), and visual network sustain mentation. Ketamine modifies consciousness differently from other agents, producing psychedelic dreaming and no apparent interaction with the environment. The authors used functional magnetic resonance imaging to explore ketamine-induced changes in RSNs connectivity. Fourteen healthy volunteers received stepwise intravenous infusions of ketamine up to loss of responsiveness. Because of agitation, data from six subjects were excluded from analysis. RSNs connectivity was compared between absence of ketamine (wake state [W1]), light ketamine sedation, and ketamine-induced unresponsiveness (deep sedation [S2]). Increasing the depth of ketamine sedation from W1 to S2 altered DMn and SALn connectivity and suppressed the anticorrelated activity between DMn and other brain regions. During S2, DMn connectivity, particularly between the medial prefrontal cortex and the remaining network (effect size β [95% CI]: W1 = 0.20 [0.18 to 0.22]; S2 = 0.07 [0.04 to 0.09]), and DMn anticorrelated activity (e.g., right sensory cortex: W1 = -0.07 [-0.09 to -0.04]; S2 = 0.04 [0.01 to 0.06]) were broken down. SALn connectivity was nonuniformly suppressed (e.g., left parietal operculum: W1 = 0.08 [0.06 to 0.09]; S2 = 0.05 [0.02 to 0.07]). Executive control networks, auditory network, SMn, and visual network were minimally affected. Ketamine induces specific changes in connectivity within and between RSNs. Breakdown of frontoparietal DMn connectivity and DMn anticorrelation and sensory and SMn connectivity preservation are common to ketamine and propofol-induced alterations of consciousness.

Optimum Drug Combinations for the Sedation of Growing Boars Prior to Castration

PubMed Central

Lehmann, Heidi S.; Blache, Dominique; Drynan, Eleanor; Tshewang, Pema; Blignaut, David J. C.; Musk, Gabrielle C.

2017-01-01

Simple Summary Pigs are notoriously challenging patients. They are difficult to handle so the use of predictable and safe sedation techniques is required for husbandry and surgical procedures. Various combinations of sedative and analgesic drugs have been previously investigated in this species, though the combination of midazolam and detomidine with either butorphanol or morphine has not been reported for sedation in pigs. The use of these combinations was investigated in the context of adequate sedation to allow castration of boars with the aid of local anaesthetic infiltration. The combination of midazolam, detomidine with butorphanol provided a more reliable sedation combination than that including morphine. It is proposed that this combination of drugs would be useful for sedation during painful husbandry procedures in pigs. Abstract Juvenile male pigs were sedated for castration. Eight five-month old boars were sedated twice (two weeks apart) with a combination of detomidine (0.1 mg/kg), midazolam (0.2 mg/kg) and either butorphanol (0.2 mg/kg) (Group MDB, n = 8) or morphine (0.2 mg/kg) (Group MDM, n = 8) intramuscularly. The boars were positioned in lateral recumbency and lidocaine (200 mg total) was injected into the testicle and scrotal skin. Castration of a single testicle was performed on two occasions. Sedation and reaction (to positioning and surgery) scores, pulse rate, respiratory rate, haemoglobin oxygen saturation, body temperature, arterial blood gas parameters and the times to immobility and then recovery were recorded. Atipamezole was administered if spontaneous recovery was not evident within 60 min of sedative administration. Data were compared with either a paired-sample t-test or a Wilcoxon-Signed Rank Test. There was no difference in sedation score, body temperature, respiratory rate and haemoglobin oxygen saturation between MDB and MDM. Mild hypoxaemia was noted in both groups. There was less reaction to castration after MDB. The pulse rate was higher after MDM sedation. The times to immobility and then recovery were similar. The combination of MDB provided more reliable sedation than MDM. MDB may be useful for sedation for short procedures in pigs, though oxygen supplementation is recommended to avoid hypoxaemia. PMID:28796153

Drugs Used for Parenteral Sedation in Dental Practice

PubMed Central

Dionne, Raymond A.; Gift, Helen C.

1988-01-01

The relative efficacy and safety of drugs and combinations used clinically in dentistry as premedicants to alleviate patient apprehension are largely unsubstantiated. To evaluate the efficacy and safety of agents used for parenteral sedation through controlled clinical trials, it is first necessary to identify which drugs, doses, and routes of administration are actually used in practice. A survey instrument was developed to characterize the drugs used clinically for anesthesia and sedation by dentists with advanced training in pain control. A random sample of 500 dentists who frequently use anesthesia and sedation in practice was selected from the Fellows of the American Dental Society of Anesthesiology. The first mailing was followed by a second mailing to nonrespondents after 30 days. The respondents report a variety of parenteral sedation techniques in combination with local anesthesia (the response categories are not mutually exclusive): nitrous oxide (64%), intravenous conscious sedation (59%), intravenous “deep” sedation (47%), and outpatient general anesthesia (27%). Drugs most commonly reported for intravenous sedation include diazepam, methohexital, midazolam, and combinations of these drugs with narcotics. A total of 82 distinct drugs and combinations was reported for intravenous sedation and anesthesia. Oral premedication and intramuscular sedation are rarely used by this group. Most general anesthesia reported is done on an outpatient basis in private practice. These results indicate that a wide variety of drugs is employed for parenteral sedation in dental practice, but the most common practice among dentists with advanced training in anesthesia is local anesthesia supplemented with intravenous sedation consisting of a benzodiazepine and an opioid or a barbiturate. PMID:3250279

The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: a systematic review.

PubMed

Brinkkemper, Tijn; van Norel, Arjanne M; Szadek, Karolina M; Loer, Stephan A; Zuurmond, Wouter W A; Perez, Roberto S G M

2013-01-01

Palliative sedation is the intentional lowering of consciousness of a patient in the last phase of life to relieve suffering from refractory symptoms such as pain, delirium and dyspnoea. In this systematic review, we evaluated the use of monitoring scales to assess the degree of control of refractory symptoms and/or the depth of the sedation. A database search of PubMed and Embase was performed up to January 2010 using the search terms 'palliative sedation' OR 'terminal sedation'. Retro- and prospective studies as well as reviews and guidelines containing information about monitoring of palliative sedation, written in the English, German or Dutch language were included. The search yielded 264 articles of which 30 were considered relevant. Most studies focused on monitoring refractory symptoms (pain, fatigue or delirium) or the level of awareness to control the level of sedation. Four prospective and one retrospective study used scales validated in other settings: the Numeric Pain Rating Scale, the Visual Analogue Scale, the Memorial Delirium Assessment Scale, the Communication Capacity Scale and Agitation Distress Scale. Only the Community Capacity Scale was partially validated for use in a palliative sedation setting. One guideline described the use of a scale validated in another setting. A minority of studies reported the use of observational scales to monitor the effect of palliative sedation. Future studies should be focused on establishing proper instruments, most adequate frequency and timing of assessment, and interdisciplinary evaluation of sedation depth and symptom control for palliative sedation.

Sedative load and salivary secretion and xerostomia in community-dwelling older people.

PubMed

Tiisanoja, Antti; Syrjälä, Anna-Maija; Komulainen, Kaija; Hartikainen, Sirpa; Taipale, Heidi; Knuuttila, Matti; Ylöstalo, Pekka

2016-06-01

The aim was to investigate how sedative load and the total number of drugs used are related to hyposalivation and xerostomia among 75-year-old or older dentate, non-smoking, community-dwelling people. The study population consisted of 152 older people from the Oral Health GeMS study. The data were collected by interviews and clinical examinations during 2004-2005. Sedative load, which measures the cumulative effect of taking multiple drugs with sedative properties, was calculated using the Sedative Load Model. The results showed that participants with a sedative load of either 1-2 or ≥3 had an increased likelihood of having low stimulated salivary flow (<0.7 ml/min; OR: 2.4; CI: 0.6-8.6 and OR: 11; CI: 2.2-59; respectively) and low unstimulated salivary flow (<0.1 ml/min; OR: 2.7, CI: 1.0-7.4 and OR: 4.5, CI: 1.0-20, respectively) compared with participants without a sedative load. Participants with a sedative load ≥3 had an increased likelihood of having xerostomia (OR: 2.5, CI: 0.5-12) compared with participants without a sedative load. The results showed that the association between the total number of drugs and hyposalivation was weaker than the association between sedative load and hyposalivation. Sedative load is strongly related to hyposalivation and to a lesser extent with xerostomia. The adverse effects of drugs on saliva secretion are specifically related to drugs with sedative properties. © 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd.

Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) - a novel assessment tool.

PubMed

Coulthard, P; Bridgman, C M; Gough, L; Longman, L; Pretty, I A; Jenner, T

2011-09-09

While the control of pain and anxiety is fundamental to the practice of dentistry, the use of conscious sedation in dentistry is very variable among dentists. The need for conscious sedation could be considered by assessing and ranking a combination of information on patient anxiety, medical history and the complexity of the anticipated clinical treatment. By undertaking this systemtic assessment an indication of sedation need may be developed which would act as an aide to decision making and, potentially, referral management. Such a tool could also be used by commissioners who need to identify patients who need conscious sedation for dental treatment in order to plan, commission and deliver appropriate sedation services.

Safe sedation practices among gastroenterology registrars: do we need more training?

PubMed Central

Mohanaruban, Aruchuna; Bryce, Kathleen; Radhakrishnan, Archchana; Gallaher, Joseph; Johnson, Gavin

2015-01-01

Endoscopy training is a central component of gastroenterology training for the vast majority of UK trainees, and integral to this is the practice of safe sedation. The majority of endoscopic procedures are performed with the patient under conscious sedation with a benzodiazepine, often combined with an opioid. Little data exists on the practice of sedation among gastroenterology trainees, including their degree of knowledge of the common sedation agents used and their actions. Using both an online and paper-based questionnaire, we surveyed current gastroenterology speciality trainees (ST) in the UK and received 78 responses giving a response rate of 10%. Fifty-one per cent of the trainees did not receive structured training in safe sedation, despite national guidelines advising this to be an essential part of the training programme, and 92% felt a structured sedation course would be beneficial. We also identified some gaps in trainees’ knowledge of the action of sedation agents. We propose that a formal training session in sedation or an e-learning module could be incorporated as part of a deanery or trust induction for gastroenterology trainees and kept under regular review. PMID:28839813

Palliative Sedation in Patients With Cancer.

PubMed

Maltoni, Marco; Setola, Elisabetta

2015-10-01

Palliative sedation involves the use of sedative medication to relieve refractory symptoms in patients by reducing their level of consciousness. Although it is considered an acceptable clinical practice from most ethical points of view, palliative sedation is still a widely debated procedure and merits better understanding. The relevant medical literature pertaining to palliative sedation was analyzed and reviewed from various technical, relational, and bioethical perspectives. Proportionate palliative sedation is considered to be the most clinically appropriate modality for performing palliative sedation. However, guidelines must be followed to ensure that it is performed correctly. Benzodiazepines represent the first therapeutic option and careful monitoring of dosages is essential to avoid oversedation or undersedation. Proportionate palliative sedation is used to manage and relieve refractory symptoms in patients with cancer during their last days or hours of life. Evidence suggests that its use has no detrimental effect on survival. A different decision-making process is used to manage the withdrawal of hydration than the process used to determine whether proportionate palliative sedation is appropriate. Communication between patients, their relatives, and the health care staff is important during this medical intervention.

Propofol dose and incidence of dreaming during sedation.

PubMed

Eer, Audrey Singyi; Padmanabhan, Usha; Leslie, Kate

2009-10-01

Dreaming is commonly reported after propofol-based sedation. We measured the incidence of dreaming and bispectral index (BIS) values in colonoscopy patients sedated with combinations of propofol, midazolam and fentanyl. Two hundred patients presenting for elective outpatient colonoscopy were sedated with combinations of propofol, midazolam and fentanyl. BIS was monitored throughout the procedure. Patients were interviewed immediately after they emerged from sedation. The primary end point was a report of dreaming during sedation. Ninety-seven patients were administered propofol alone, 44 were administered propofol and fentanyl, 16 were administered propofol and midazolam and 43 were administered propofol, midazolam and fentanyl. Dreaming was reported by 19% of patients. Dreamers received higher doses of propofol and had lower BIS values during sedation. Age of 50 years or less, preoperative quality of recovery score of less than 14, higher home dream recall, propofol dose of more than 300 mg and time to Observers' Assessment of Alertness/Sedation score equalling 5 of 8 min or less were independent predictors of dreaming. Dreaming during sedation is associated with higher propofol dose and lower BIS values.

Safety of propofol sedation for pediatric outpatient procedures.

PubMed

Larsen, Reagan; Galloway, David; Wadera, Sheetal; Kjar, Dean; Hardy, David; Mirkes, Curtis; Wick, Lori; Pohl, John F

2009-10-01

Propofol sedation is used more frequently in pediatric procedures because of its ability to provide varying sedation levels. The authors evaluated all outpatient pediatric procedures using propofol sedation over a 6-year period. All sedation was provided by pediatric intensivists at a single institution. In all, 4716 procedures were recorded during the study period; 15% of procedures were associated with minor complications, whereas only 0.1% of procedures were associated with major complications. Significantly more major complications associated with propofol occurred during bronchoscopy (P = .001). Propofol administered by a pediatric intensivist is a safe sedation technique in the pediatric outpatient setting.

Relieving existential suffering through palliative sedation: discussion of an uneasy practice.

PubMed

Bruce, Anne; Boston, Patricia

2011-12-01

This article presents a discussion of the use of palliative sedation in response to intractable (not responsive to treatment) existential suffering. Patients suffering from a terminal illness are often faced with severe symptoms at the end of life. Although palliative sedation is sometimes used when no other options are effective in relieving unbearable pain or suffering, its use in response to intractable existential suffering in terminal illness remains controversial. A literature search was conducted for published articles addressing the use of palliative sedation between 1996 and 2009 using established databases. Palliative sedation remains an uneasy practice. The debates have centred on ethical issues surrounding decisions to use sedation and on separating the intent of palliative sedation (relief of intolerable symptoms) from the intent of euthanasia (hastening death). There is lack of consensus in defining existential suffering. Consequently, there is limited understanding of how decisions are being made when using palliative sedation to treat intractable existential suffering. Given the confusion and uncertainty about ethical and clinical justifications for palliative sedation in treating existential suffering, we argue that a better understanding of the controversies and decision-making process is needed. Greater understanding is required to prevent palliative sedation from becoming a substitute for intensive treatment of this kind of suffering. © 2011 Blackwell Publishing Ltd.

Smart syringe pumps for drug infusion during dental intravenous sedation

PubMed Central

Lee, Kiyoung

2016-01-01

Dentists often sedate patients in order to reduce their dental phobia and stress during dental treatment. Sedatives are administered through various routes such as oral, inhalation, and intravenous routes. Intravenous administration has the advantage of rapid onset of action, predictable duration of action, and easy titration. Typically, midazolam, propofol or dexmedetomidine are used as intravenous sedatives. Administration of these sedatives via infusion by using a syringe pump is more effective and successful than infusing them as a bolus. However, during intravenous infusion of sedatives or opioids using a syringe pump, fatal accidents may occur due to the clinician's carelessness. To prevent such risks, smart syringe pumps have been introduced clinically. They allow clinicians to perform effective sedation by using a computer to control the dose of the drug being infused. To ensure patient safety, various alarm features along with a drug library, which provides drug information and prevents excessive infusion by limiting the dose, have been added to smart pumps. In addition, programmed infusion systems and target-controlled infusion systems have also been developed to enable effective administration of sedatives. Patient-controlled infusion, which allows a patient to control his/her level of sedation through self-infusion, has also been developed. Safer and more successful sedation may be achieved by fully utilizing these new features of the smart pump. PMID:28884149

Balanced conscious sedation with intravenous induction and inhalational maintenance for patients requiring endoscopic and/or surgical procedures.

PubMed

Lahoud, G Y; Hopkins, P M

2007-02-01

The use of inhalation sedation with sub-anaesthetic concentrations of sevoflurane and nitrous oxide mixture is expected to reduce amounts of intravenous sedative drugs needed to produce a balanced sedation with the benefits of having reduced side-effects. Eighty-two patients requiring endoscopic and/or surgical procedures under conscious sedation and local anaesthesia were recruited for this pilot study. Conscious sedation was induced with a titrated dose of midazolam and propofol given intravenously until the clinical end-point of conscious sedation was achieved. Subsequently, during the procedure, the patient was asked to breathe sevoflurane 0.1-0.3% and a fixed ratio of 40% nitrous oxide in oxygen given through a face mask. In 78 patients (95.1%), the treatment was completed successfully. Patients were discharged back to the wards within 4-16 min (10.1) without significant side-effects. Treatment was satisfactorily accepted by 38 patients (48.7%) and considered excellent by 40 patients (51.3%). The use of titrated doses of intravenous sedative drugs for induction of conscious sedation followed by the use of low concentrations (0.1-0.3%) of sevoflurane combined with 40% nitrous oxide for maintenance of conscious sedation in patients requiring endoscopic and/or surgical procedures under local anaesthesia, has the potential advantages of reducing amounts of intravenous sedative drugs, less likelihood of problems from drug side-effects and fast recovery and discharge time. Further investigations to establish the technique are currently in progress.

Low-dose propofol-induced amnesia is not due to a failure of encoding: left inferior prefrontal cortex is still active.

PubMed

Veselis, Robert A; Pryor, Kane O; Reinsel, Ruth A; Mehta, Meghana; Pan, Hong; Johnson, Ray

2008-08-01

Propofol may produce amnesia by affecting encoding. The hypothesis that propofol weakens encoding was tested by measuring regional cerebral blood flow during verbal encoding. Seventeen volunteer participants (12 men; aged 30.4 +/- 6.5 yr) had regional cerebral blood flow measured using H2O positron emission tomography during complex and simple encoding tasks (deep vs. shallow level of processing) to identify a region of interest in the left inferior prefrontal cortex (LIPFC). The effect of either propofol (n = 6, 0.9 microg/ml target concentration), placebo with a divided attention task (n = 5), or thiopental at sedative doses (n = 6, 3 microg/ml) on regional cerebral blood flow activation in the LIPFC was tested. The divided attention task was expected to decrease activation in the LIPFC. Propofol did not impair encoding performance or reaction times, but impaired recognition memory of deeply encoded words 4 h later (median recognition of 35% [interquartile range, 17-54%] of words presented during propofol vs. 65% [38-91%] before drug; P < 0.05). Statistical parametric mapping analysis identified a region of interest of 6.6 cm in the LIPFC (T = 7.44, P = 0.014). Regional cerebral blood flow response to deep encoding was present in this region of interest in each group before drug (T > 4.41, P < 0.04). During drug infusion, only the propofol group continued to have borderline significant activation in this region (T = 4.00, P = 0.063). If the amnesic effect of propofol were solely due to effects on encoding, activation in the LIPFC should be minimal. Because LIPFC activation was not totally eliminated by propofol, the amnesic action of propofol must be present in other brain regions and/or affect other memory processes.

Sedation in the neurologic intensive care unit.

PubMed

Keegan, Mark T

2008-03-01

Providing adequate sedation in the neurologic intensive care unit (ICU) depends on determination of proper goals for sedation, adequate assessment of the level of sedation, and appropriate choice of drug based on the patient's physiology. The management of sedation in the ICU will influence long-term outcome. Delirium, anxiety, and pain must be identified and treated separately. The use of protocols can improve compliance with published evidence-based recommendations. Propofol and dexmedetomidine may be used for rapidly titratable sedation, benzodiazepines for anxiolysis, neuroleptics for treatment of delirium, and opiates for analgesia. Unique aspects of patients with acute brain disease, such as elevated intracranial pressure or status epilepticus, require adaptation of sedative regimens. Processed EEG monitoring and volatile anesthetic agents have not yet proven beneficial or practical for use in the ICU.

Electroencephalography for children with autistic spectrum disorder: a sedation protocol.

PubMed

Keidan, Ilan; Ben-Menachem, Erez; Tzadok, Michal; Ben-Zeev, Bruria; Berkenstadt, Haim

2015-02-01

To report the effectiveness and efficiency of a predetermined sedation protocol for providing sedation for electroencephalograph (EEG) studies in children with autism. Sleep EEG has been advocated for the majority of children with autism spectrum disorder. In most cases, sedation is required to allow adequate studies. Most sedation drugs have negative effects on the EEG pattern. The sedation protocol we adopted included chloral hydrate, dexmedetomidine, and ketamine and was evaluated prospectively for 2 years. One hundred and eighty-three children with autistic spectrum disorder were sedated with the described drug protocol that was efficient, provided adequate EEG readings, and was not associated with serious adverse events. Our protocol kept costs to a minimum but provided appropriate escalation in care when required. © 2014 John Wiley & Sons Ltd.

Critical care nurses' decision making: sedation assessment and management in intensive care.

PubMed

Aitken, Leanne M; Marshall, Andrea P; Elliott, Rosalind; McKinley, Sharon

2009-01-01

This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients' sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Observational study. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.

Prescription of Sedative Drugs During Hospital Stay: A Swiss Prospective Study.

PubMed

Schumacher, Laurence; Dobrinas, Maria; Tagan, Damien; Sautebin, Annelore; Blanc, Anne-Laure; Widmer, Nicolas

2017-12-01

In recent years, the number of prescriptions for sedative drugs has increased significantly, as has their long-term use. Moreover, sedative use is frequently initiated during hospital stays. This study aimed to describe new prescriptions of sedative drugs during hospital stays and evaluate their maintenance as discharge medication. This observational prospective study took place in an internal medicine ward of a Swiss hospital over a period of 3 months in 2014. Demographic (age, sex, diagnosis, comorbidities) and medication data [long-term use of sedative drugs, new regular or pro re nata ('as needed') prescriptions of sedative drugs, drug-related problems] were collected. Sedative medications included: benzodiazepines, Z-drugs, antihistamines, antidepressants, neuroleptics, herbal drugs, and clomethiazole. McNemar's test was used for comparison. Of 290 patients included, 212 (73%) were over 65 years old and 169 (58%) were women; 34% (n = 98) were using sedative drugs long term before their hospital stay, and 44% (n = 128) had a prescription for sedative drugs at discharge-a 10% increase (p < 0.05). Sedative drugs were newly prescribed to 37% (n = 108) of patients during their stay. Among these, 37% (n = 40) received a repeat prescription at discharge. Over half of the sedative drugs were prescribed within 24 h of admission. Drug-related problems were detected in 76% of new prescriptions, of which 90% were drug-drug interactions. This study showed that hospital stays increased the proportion of patients who were prescribed a sedative drug at discharge by 10% (absolute increase). These prescriptions may generate long-term use and expose patients to drug-related problems. Promoting alternative approaches for managing insomnia are recommended.

Association of Opioids and Sedatives with Increased Risk of In-Hospital Cardiopulmonary Arrest from an Administrative Database

PubMed Central

Overdyk, Frank J.; Dowling, Oonagh; Marino, Joseph; Qiu, Jiejing; Chien, Hung-Lun; Erslon, Mary; Morrison, Neil; Harrison, Brooke; Dahan, Albert; Gan, Tong J.

2016-01-01

Background While opioid use confers a known risk for respiratory depression, the incremental risk of in-hospital cardiopulmonary arrest, respiratory arrest, or cardiopulmonary resuscitation (CPRA) has not been studied. Our aim was to investigate the prevalence, outcomes, and risk profile of in-hospital CPRA for patients receiving opioids and medications with central nervous system sedating side effects (sedatives). Methods A retrospective analysis of adult inpatient discharges from 2008–2012 reported in the Premier Database. Patients were grouped into four mutually exclusive categories: (1) opioids and sedatives, (2) opioids only, (3) sedatives only, and (4) neither opioids nor sedatives. Results Among 21,276,691 inpatient discharges, 53% received opioids with or without sedatives. A total of 96,554 patients suffered CPRA (0.92 per 1000 hospital bed-days). Patients who received opioids and sedatives had an adjusted odds ratio for CPRA of 3.47 (95% CI: 3.40–3.54; p<0.0001) compared with patients not receiving opioids or sedatives. Opioids alone and sedatives alone were associated with a 1.81-fold and a 1.82-fold (p<0.0001 for both) increase in the odds of CPRA, respectively. In opioid patients, locations of CPRA were intensive care (54%), general care floor (25%), and stepdown units (15%). Only 42% of patients survived CPRA and only 22% were discharged home. Opioid patients with CPRA had mean increased hospital lengths of stay of 7.57 days and mean increased total hospital costs of $27,569. Conclusions Opioids and sedatives are independent and additive risk factors for in-hospital CPRA. The impact of opioid sparing analgesia, reduced sedative use, and better monitoring on CPRA incidence deserves further study. PMID:26913753

Short-Term Health-Related Quality of Life of Critically Ill Children Following Daily Sedation Interruption.

PubMed

Vet, Nienke J; de Wildt, Saskia N; Verlaat, Carin W M; Mooij, Miriam G; Tibboel, Dick; de Hoog, Matthijs; Buysse, Corinne M P

2016-11-01

Our earlier pediatric daily sedation interruption trial showed that daily sedation interruption in addition to protocolized sedation in critically ill children does not reduce duration of mechanical ventilation, length of stay, or amounts of sedative drugs administered when compared with protocolized sedation only, but undersedation was more frequent in the daily sedation interruption + protocolized sedation group. We now report the preplanned analysis comparing short-term health-related quality of life and posttraumatic stress symptoms between the two groups. Preplanned prospective part of a randomized controlled trial. Two tertiary medical-surgical PICUs in the Netherlands. Critically ill children requiring mechanical ventilation. None. Eight weeks after a child's discharge from the PICU, health-related quality of life was assessed with the validated Child Health Questionnaire and, only for children above 4 years old, posttraumatic stress was assessed with the Dutch Children's Responses to Trauma Inventory. Additionally, health-related quality of life of all study patients was compared with Dutch normative data. Of the 113 patients from two participating centers in the original study, 96 patients were eligible for follow-up and 64 patients were included (response rate, 67%). No difference was found with respect to health-related quality of life between the two study groups. None of the eight children more than 4 years old showed posttraumatic stress symptoms. Daily sedation interruption in addition to protocolized sedation for critically ill children did not seem to have an effect on short-term health-related quality of life. Also in view of the earlier found absence of effect on clinical outcome, we cannot recommend the use of daily sedation interruption + protocolized sedation.

Pediatric dental sedation: challenges and opportunities

PubMed Central

Nelson, Travis M; Xu, Zheng

2015-01-01

High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques. PMID:26345425

Pediatric dental sedation: challenges and opportunities.

PubMed

Nelson, Travis M; Xu, Zheng

2015-01-01

High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques.

Retrospective evaluation of unexpected events during collection of blood donations performed with and without sedation in cats (2010-2013).

PubMed

Doolin, Kerry S; Chan, Daniel L; Adamantos, Sophie; Humm, Karen

2017-09-01

Describe unexpected events (UEs) that occurred during blood donation in cats with and without sedation. Retrospective observational study (2010-2013). University teaching hospital. Client-owned healthy cats enrolled in a blood donation program. None. Blood collection for transfusion was performed 115 times from 32 cats. Seventy donation events were in unsedated cats and 45 in sedated cats. For each collection, the anticipated blood volume to be collected, actual blood volume collected, sedation protocol, and any UE in the peridonation period were recorded. There were 6 categories of UEs: movement during donation, donor anxiety, inadequate collected blood volume, jugular vessel related UEs, additional sedation requirement, and cardiorespiratory distress. Fisher's exact test was used to compare the frequency of UEs between sedated and unsedated cats. UEs were recorded in 54 of 115 collections. In the donor population, movement was reported as an UE in 0 cats that donated under sedation and 24/70 (34.3%) cats that donated without sedation (P < 0.001). Donor anxiety occurred in 2/45 (4.4%) cats that donated under sedation and 14/70 (20.0%) cats that donated unsedated (P = 0.014). Unsedated donation did not increase the likelihood of inadequate donation volume, jugular vessel related UEs, or cardiorespiratory distress. Eight of 45 (17.8%) sedated donations required additional sedation. Movement during donation and signs of donor anxiety were more frequent in unsedated cats. These were considered minor issues, expected in unsedated cats being gently restrained. Blood collection from unsedated feline donors is a viable alternative to sedated donation. © Veterinary Emergency and Critical Care Society 2017.

[Sedation with midazolam for ambulatory pediatric dentistry].

PubMed

Shavlokhova, E A; Ostreĭkov, I F; Korolenkova, M V

2014-01-01

To improve the quality of dental treatment in children by using combined anaesthesia technique including local anaesthesia and conscious sedation, and to assess the effectiveness of conscious sedation for younger children undergoing dental treatment. The study included 208 children aged 14-88 months who received dental treatment for tooth decay and its complication under combined anaesthesia. Midazolam was used as sedative medication. Sedation level was assessed by visual scale and BIS-monitoring. ANI-monitoring was also used for pain sensitiveness evaluation. Results All 208 children were successfully treated under combined anaesthesia which showed satisfactory sedation rates both by visual scale and and BIS-monitoring values. While mean patient age was 39 months 20.6% were younger than 24 months. These data are extremely valuable as according to literature review conscious sedation in early infancy remains controversial. Our results proved conscious sedation to be effective in younger children undergoing dental treatment thus representing important alternative for general anaesthesia and providing a basis for later behavior management.

The indicator of sedation need (IOSN).

PubMed

Coulthard, Paul

2013-01-01

Conscious sedation in dentistry is usually indicated because a patient's anxiety can prohibit the necessary dental treatment being undertaken. It may also be indicated because of unpleasant or lengthy treatment or to prevent exacerbation of a patient's medical or behavioural condition by anxiety. The indicator of sedation need (IOSN) tool has been developed to help support dentists in their clinical decision-making and uses information about a patient's anxiety, medical and behavioural status and treatment complexity. The IOSN has been used to measure sedation need and has shown that 5.1% of patients attending general dental practices have a high need of conscious sedation. IOSN has also been used to investigate the need for conscious sedation in the general population among dental practice attenders and those who don't attend. The proportion was found to be 6.7%. Some patients require conscious sedation in order to access dental care. The indicator of sedation need (IOSN) tool helps in the decision-making process.

Comparison of entropy and bispectral index during propofol and fentanyl sedation in monitored anaesthesia care.

PubMed

Balci, Canan; Karabekir, H S; Kahraman, F; Sivaci, R G

2009-01-01

Comparison of entropy (state entropy [SE] and response entropy [RE]) with the bispectral index (BIS) during propofol sedation in monitored anaesthesia care (MAC) was carried out in patients undergoing hand surgery. Thirty candidates for elective hand surgery were pre-medicated with midazolam 0.06 mg/kg and atropine 0.01 mg/kg. Sedation was induced with intravenous propofol and fentanyl was also administered. The Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) was used to determine sedation level and pain was maintained at < 4 on a 0 - 10 verbal rating scale. The BIS, entropy, MOAA/S and pain values were recorded before initiation of sedation (control), during initiation of sedation, during surgery, and for 30 min after the end of surgery and anaesthesia. On initiation of sedation, entropy decreased more rapidly than BIS. At 10 min after initiation of sedation, the mean +/- SD values for MOAA/S, BIS, RE and SE were 3.00 +/- 0.36, 85.45 +/- 0.15, 74.00 +/- 0.60 and 72.02 +/- 0.12, respectively. During recovery, BIS and RE and SE increased in parallel with MOAA/S. It is concluded that entropy monitoring is as reliable as BIS monitoring in MAC.

A Clinical Audit of Escorts' Awareness And Patients' Safety Following Intravenous Sedation In Adult Oral Surgery.

PubMed

Licheri, Luca; Erriu, Matteo; Bryant, Vincenzo; Piras, Vincenzo

2016-01-01

To evaluate current level of safety under the care of an escort following intravenous sedation, post-sedation arrangements and to identify potential risk levels. Information and post-sedation arrangements are important to patients'safety following surgery but although there is a general consensus over what is recommended for patients and their escorts, there is little, if any, literature on the escorts' awareness of sedation and accordance to post-sedation arrangement and recommendations. Escorts of 113 consecutive patients treated in oral surgery under sedation (midazolam) completed a questionnaire composed of 27 questions divided into seven sections including demographics, awareness of sedation, source of information and post-operative arrangement. From the data collected, two scores were calculated representative of the escorts' Safety and Reliability. Data were then analysed by ANOVA. Safety scores were statistically correlated with instruction source while Reliability correlated to a wider variety of parameters including gender, age as well as information source. Provision of clear written information to escorts is recommended as likely to improve patients' safety. Assessment of escorts' Safety and Reliability could provide a means for improving quality and safety of sedation service.

[Use of sedation in the palliative care situation by respiratory physicians].

PubMed

Grijol-Cariou, A-L; Goupil, F; Hubault, P; Jouanneau, J

2014-01-01

The prognosis of advanced stage chronic lung disease, including lung cancer, is often poor and associated with uncomfortable symptoms for the patient, especially in the end of life phase. In the case of intolerable symptoms, refractory to maximal treatment, sedation may then be considered. This is sometimes a source of confusion and difficulty for clinicians who need to know the official guidelines. The purpose of this study was to investigate the use of sedation by respiratory physicians, in order to understand their difficulties in these complex situations. The study was conducted using semi-structured, anonymous interviews of volunteers. The topics discussed included their definition of sedation, its indications, their possible difficulties or reluctance in using it, the information given to the patient and the traceability of the sedation prescription. All respiratory physicians agreed to participate in the study, indicating a major interest in this topic. No sedation decision is taken without careful consideration. The majority of physicians understand the difference between anxiolysis and sedation, most defining the latter as using a drug to sedate a patient faced with uncontrollable symptoms. All doctors refused to link sedation to euthanasia, although half expressed a feeling of causality between sedation and the patient's death - knowing that few consider the possibility of transient sedation. The main reluctance among doctors is in chronic respiratory insufficiency. Any decision concerning sedation should be discussed beforehand with the care team and the resident in charge of the patient, but not necessarily with another colleague. There is rarely evidence of this discussion in the medical records or of the information given to the patient and his family, thus increasing the difficulties of decision-making, especially at nights or weekends. The decision to start sedation is seen as difficult because it presupposes that a life-threatening short-term prognosis has been already been given to the patient. In this medical population, already aware of palliative care issues, the majority of respiratory physicians know the definition, the indications for sedation and the principles of collective decision, but few are aware of the need of regular reappraisal of the sedation, to record it, and of its potential reversibility. There is, therefore, a clear need for regular and further training of clinicians to improve their professional practice. Copyright © 2013 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Chloral hydrate enteral infusion for sedation in ventilated children: the CHOSEN pilot study.

PubMed

Joffe, Ari R; Hogan, Jessica; Sheppard, Cathy; Tawfik, Gerda; Duff, Jonathan P; Garcia Guerra, Gonzalo

2017-11-26

We aimed to test a novel method of delivery of chloral hydrate (CH) sedation in ventilated critically ill young children. Children < 12 years old, within 72 hours of admission, who were ventilated, receiving enteral tube-feeds, with intermittent CH ordered were enrolled after signed consent. Patients received a CH loading-dose of 10 mg/kg enterally, then a syringe-pump enteral infusion at 5 mg/kg/hour, increasing to a maximum of 9 mg/kg/hour. Cases were compared to historical controls matched for age group and Pediatric Risk of Mortality score (PRISM) category, using Fisher's exact test and the t test. The primary outcome was feasibility, defined as the use of an enteral CH continuous infusion without discontinuation attributable to a pre-specified potential harm. There were 21 patients enrolled, at age 11.4 (12.1) months, with bronchiolitis in 10 (48%), a mean Pediatric Logistic Organ Dysfunction (PELOD) score of 6.2 (5.2), and having received enteral CH continuous infusion for 4.5 (2.2) days. Infusion of CH was feasible in 20/21 (95%; 95% CI 76-99%) patients, with one (5%) adverse event of duodenal ulcer perforation on day 3 in a patient with croup receiving regular ibuprofen and dexamethasone. The CH infusion dose (mg/kg/h) on day 2 (n = 20) was 8.9 (IQR 5.9, 9), and on day 4 (n = 11) was 8.8 (IQR 7, 9). Days to titration of adequate sedation (defined as ≤ 3 PRN doses/shift) was 1 (IQR 0.5, 2.5), and hours to awakening for extubation was 5 (IQR 2, 9). Cases (versus controls) had less positive fluid balance at 48 h (-2 (45) vs. 26 (46) ml/kg, p = 0.051), and a decrease in number of PRN sedation doses from 12 h pre to 12 hours post starting CH (4.7 (3.3) to 2.6 (2.8), p = 0.009 versus 2.9 (3.9) to 3.4 (5), p = 0.74). There were no statistically significant differences between cases and controls in inotrope scores, signs or treatment of withdrawal, or PICU days. Delivering CH by continuous enteral infusion is feasible, effective, and may be associated with less positive fluid balance. Whether there is a risk of duodenal perforation requires further study.

[Rational use of psychotropic medications and sedative load in older adults with and without dementia].

PubMed

Rattagan, María L; Lisei, Darío; Rojas, Galeno J; Persi, Gabriel G; Parisi, Virginia L; López Vicchi, Martín; Da Prat de Magalhaes, Gustavo; Bres Bullrich, María; Gatto, Emilia M

2016-09-01

Sedative drugs use has been associated with more cognitive impairment and increased mortality. Sedative load refers to cumulative exposure to multiple drugs with sedative properties. Describe the use of psychotropic drugs and sedative load in older adults with and without dementia. We conducted a cross-sectional study from 2014-2015 (Sanatorio Trinidad Mitre), in hospitalized patients older than 65 years old. Drugs were classified according to the WHO ATC system. The sedative load of drugs was calculated using the Linjakumpu model. 152 PsD and 35 PcD patients were registered, mean age 80.8±8.42. Polypharmacy was present in 44.39% being higher in patients with dementia than without dementia (62.80% vs 40.13%, p=0.0147). In 40.64% at least one psychotropic/sedative medication was used, greater in PcD (60% vs 36.18%, p=0.0097). The CS was: 1.32±1.59; 2.14 in PcD and 1.13 in PsD (p<0.001). Atypical antipsychotics and benzodiazepines were the most common (51.43 and 40% respectively) in patients without dementias. we evidenced a high level of prescription psychotropic or sedative drugs, mostly in patients with dementia. In those, the sedative load was greater. This finding highlights the importance of implementing strategies to optimize sedative drug use among older people.

Susceptibility-Weighted Phase Imaging and Oxygen Extraction Fraction Measurement during Sedation and Sedation Recovery using 7T MRI.

PubMed

Goodwin, Jonathan A; Kudo, Kohsuke; Shinohe, Yutaka; Higuchi, Satomi; Uwano, Ikuko; Yamashita, Fumio; Sasaki, Makoto

2015-01-01

In this work, we demonstrate oxygen extraction fraction (OEF) measurement using 7T MRI with susceptibility-weighted imaging (SWI), in sedated and nonsedated adults. Ten healthy subjects (30.3 ± 4.5 years, 9 men, 1 woman) formed control (n = 5) and sedation groups (n = 5). Midazolam and propofol injection was administered to the same sedation group subjects during 2 different scanning sessions. Two-dimensional SPGR imaging was performed before, during, and twice after (propofol, +10, +30 minutes; midazolam, +10, +40 minutes) conscious sedation. The equivalent procedure was performed with the control group without sedation. After SWI analysis, change in OEF between scans was quantified, and parcelated ΔOEF maps were generated with 77 gray matter (GM)-containing volumes-of-interest (VOIs). Significant decreases in OEF were shown in 14 GM VOIs during sedation relative to the control group, most notably during midazolam sedation (P < .05). In contrast, no significant decrease was observed after 10 minutes and in only 4 VOIs after 40 minutes recovery. Significant change in ΔOEF during conscious sedation using midazolam and propofol could be measured using SWI at 7T in vivo. This may be a potentially useful approach for the noninvasive assessment of OEF in the brain on a clinical basis. Copyright © 2014 by the American Society of Neuroimaging.

Registered nurse-administered sedation for gastrointestinal endoscopic procedure

PubMed Central

Amornyotin, Somchai

2015-01-01

The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient’s safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures. PMID:26191341

The role of alternative (advanced) conscious sedation techniques in dentistry for adult patients: a series of cases.

PubMed

Robb, N

2014-03-01

The basic techniques of conscious sedation have been found to be safe and effective for the management of anxiety in adult dental patients requiring sedation to allow them to undergo dental treatment. There remains great debate within the profession as to the role of the so called advanced sedation techniques. This paper presents a series of nine patients who were managed with advanced sedation techniques where the basic techniques were either inappropriate or had previously failed to provide adequate relief of anxiety. In these cases, had there not been the availability of advanced sedation techniques, the most likely recourse would have been general anaesthesia--a treatment modality that current guidance indicates should not be used where there is an appropriate alternative. The sedation techniques used have provided that appropriate alternative management strategy.

Speed of recovery and side-effect profile of sevoflurane sedation compared with midazolam.

PubMed

Ibrahim, A E; Ghoneim, M M; Kharasch, E D; Epstein, R H; Groudine, S B; Ebert, T J; Binstock, W B; Philip, B K

2001-01-01

Sedation for surgical procedures performed with regional or local anesthesia has usually been achieved with intravenous medications, whereas the use of volatile anesthetics has been limited. The use of sevoflurane for sedation has been suggested because of its characteristics of nonpungency, rapid induction, and quick elimination. The purpose of this investigation was to assess the quality, recovery, and side effects of sevoflurane sedation compared with midazolam. One hundred seventy-three patients undergoing surgery with local or regional anesthesia were enrolled in a multicenter, open-label, randomized investigation comparing sedation with sevoflurane versus midazolam. Sedation level was titrated to an Observer's Assessment of Alertness--Sedation score of 3 (responds slowly to voice). Recovery was assessed objectively by Observer's Assessment of Alertness--Sedation, Digit Symbol Substitution Test (DSST), and memory scores, and subjectively by visual analog scales. Significantly more patients in the sevoflurane group had to be converted to general anesthesia because of excessive movement (18 sevoflurane and 2 midazolam; P = 0.043). Of remaining patients, 141 were assessable for efficacy and recovery data (93 sevoflurane and 48 midazolam). Sevoflurane and midazolam produced dose-related sedation. Sevoflurane patients had higher DSST and memory scores during recovery. Seventy-six percent (sevoflurane) compared with 35% (midazolam) returned to baseline DSST at 30 min postoperatively (P < 0.05). More frequent excitement-disinhibition was observed with sevoflurane (15 [16%] vs. midazolam; P = 0.008). Sevoflurane for sedation produces faster recovery of cognitive function as measured by DSST and memory scores compared with midazolam. However, sevoflurane for sedation is complicated by a high incidence of intraoperative excitement.

Quality of care in palliative sedation: audit and compliance monitoring of a clinical protocol.

PubMed

Benitez-Rosario, Miguel Angel; Castillo-Padrós, Manuel; Garrido-Bernet, Belén; Ascanio-León, Belen

2012-10-01

The European Association for Palliative Care and the U.S. National Hospice and Palliative Care Organization have published statements that recommend an audit of palliative sedation practices. The aim was to assess the feasibility of a quality care project in palliative sedation. We carried out an audit of adherence to a guideline regarding palliative sedation, undertaken as a yearly assessment during two years, of a sample of patient charts. With an audit tool, the charts were evaluated as to the presence of the ethical sedation checklist, information that justified palliative sedation, patient and/or family agreement, and the appropriateness of treatment in concordance with the clinical protocol. An educational program and result feedback meetings were used as the implementation strategy. Roughly 25% of the medical charts of patients who died in the palliative care unit were evaluated, 94 in 2007 and 110 in 2008. In 2007 and 2008, 63% and 57% of the patients, respectively, whose median age was 65 years, were sedated, with a median length of two days. The main reason for sedation was agitation concomitant with respiratory failure in roughly 60% and 75% of the cases in 2007 and 2008, respectively. Agreement of the patient/family about sedation was collected from 100% of the cases. The concordance of procedures with the sedation guideline was 100% in both years. Our quality-of-care strategy was shown to obtain a higher level of compliance with the palliative sedation guideline for at least two years. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Opinions of the Dutch public on palliative sedation: a mixed-methods approach.

PubMed

van der Kallen, Hilde T H; Raijmakers, Natasja J H; Rietjens, Judith A C; van der Male, Alex A; Bueving, Herman J; van Delden, Johannes J M; van der Heide, Agnes

2013-10-01

Palliative sedation is defined as deliberately lowering a patient's consciousness, to relieve intolerable suffering from refractory symptoms at the end of life. Palliative sedation is considered a last resort intervention in end-of-life care that should not be confused with euthanasia. To inform healthcare professionals about attitudes of the general public regarding palliative sedation. design and setting: A cross-sectional survey among members of the Dutch general public followed by qualitative interviews. One thousand nine hundred and sixty members of the general public completed the questionnaire, which included a vignette describing palliative sedation (response rate 78%); 16 participants were interviewed. In total, 22% of the responders indicated knowing the term 'palliative sedation'. Qualitative data showed a variety of interpretations of the term. Eighty-one per cent of the responders agreed with the provision of sedatives as described in a vignette of a patient with untreatable pain and a life expectancy of <1 week who received sedatives to alleviate his suffering. This percentage was somewhat lower for a patient with a life expectancy of <1 month (74%, P = 0.007) and comparable in the case where the physician gave sedatives with the aim of ending the patient's life (79%, P = 0.54). Most of the general public accept the use of palliative sedation at the end of life, regardless of a potential life-shortening effect. However, confusion exists about what palliative sedation represents. This should be taken into account by healthcare professionals when communicating with patients and their relatives on end-of-life care options.

Consultation with specialist palliative care services in palliative sedation: considerations of Dutch physicians.

PubMed

Koper, Ian; van der Heide, Agnes; Janssens, Rien; Swart, Siebe; Perez, Roberto; Rietjens, Judith

2014-01-01

Palliative sedation is considered a normal medical practice by the Royal Dutch Medical Association. Therefore, consultation of an expert is not considered mandatory. The European Association of Palliative Care (EAPC) framework for palliative sedation, however, is more stringent: it considers the use of palliative sedation without consulting an expert as injudicious and insists on input from a multi-professional palliative care team. This study investigates the considerations of Dutch physicians concerning consultation about palliative sedation with specialist palliative care services. Fifty-four physicians were interviewed on their most recent case of palliative sedation. Reasons to consult were a lack of expertise and the view that consultation was generally supportive. Reasons not to consult were sufficient expertise, the view that palliative sedation is a normal medical procedure, time pressure, fear of disagreement with the service and regarding consultation as having little added value. Arguments in favour of mandatory consultation were that many physicians lack expertise and that palliative sedation is an exceptional intervention. Arguments against mandatory consultation were practical obstacles that may preclude fulfilling such an obligation (i.e. lack of time), palliative sedation being a standard medical procedure, corroding a physician's responsibility and deterring physicians from applying palliative sedation. Consultation about palliative sedation with specialist palliative care services is regarded as supportive and helpful when physicians lack expertise. However, Dutch physicians have both practical and theoretical objections against mandatory consultation. Based on the findings in this study, there seems to be little support among Dutch physicians for the EAPC recommendations on obligatory consultation.

Block-Dependent Sedation during Epidural Anaesthesia is Associated with Delayed Brainstem Conduction

PubMed Central

Wadhwa, Anupama; Shah, Yunus M.; Lin, Chum-Ming; Haugh, Gilbert S.; Sessler, Daniel I.

2005-01-01

Neuraxial anaesthesia produces a sedative and anesthetic-sparing effect. Recent evidence suggests that spinal cord anaesthesia modifies reticulo-thalamo-cortical arousal by decreasing afferent sensory transmission. We hypothesized that epidural anaesthesia produces sensory deafferentation-dependent sedation that is associated with impairment of brainstem transmission. We used brainstem auditory evoked potentials (BAEP) to evaluate reticular function in 11 volunteers. Epidural anaesthesia was induced with 2% 2-chloroprocaine. Hemodynamic and respiratory responses, sensory block level, sedation depth and BAEP were assessed throughout induction and resolution of epidural anaesthesia. Sedation was evaluated using verbal rating score (VRS), observer's assessment alertness/sedation (OAA/S) score, and bispectral index (BIS). Prediction probability (PK) was used to associate sensory block with sedation, as well as BIS with other sedation measures. Spearman rank order correlation was used to associate block level and sedation with the absolute and interpeak BAEP latencies. Sensory block level significantly predicted VRS (PK = 0.747), OAA/S score (PK = 0.748) and BIS. Bispectral index predicted VRS and OAA/S score (PK = 0.728). The latency of wave III of BAEP significantly correlated with sedation level (rho = 0.335, P < 0.01) and sensory block (rho = 0.394, P < 0.01). The other BAEP parameters did not change during epidural anaesthesia. Hemodynamic and respiratory responses remained stable throughout the study. Sedation during epidural anaesthesia depends on sensory block level and is associated with detectable block-dependent alterations in the brainstem auditory evoked responses. Sensory deafferentation may reduce CNS alertness through mechanisms related to brainstem neural activity. PMID:15220178

Practice and documentation of palliative sedation: a quality improvement initiative

PubMed Central

McKinnon, M.; Azevedo, C.; Bush, S.H.; Lawlor, P.; Pereira, J.

2014-01-01

Background Palliative sedation (ps), the continuous use of sedating doses of medication to intentionally reduce consciousness and relieve refractory symptoms at end of life, is ethically acceptable if administered according to standards of best practice. Procedural guidelines outlining the appropriate use of ps and the need for rigorous documentation have been developed. As a quality improvement strategy, we audited the practice and documentation of ps on our palliative care unit (pcu). Methods A pharmacy database search of admissions in 2008 identified, for a subsequent chart review, patients who had received either a continuous infusion of midazolam (≥10 mg/24 h), regular parenteral dosing of methotrimeprazine (≥75 mg daily), or regular phenobarbital. Documentation of the decision-making process, consent, and medication use was collected using a data extraction form based on current international ps standards. Results Interpretation and comparison of data were difficult because of an apparent lack of a consistent operational definition of ps. Patient records had no specific documentation in relation to ps initiation, to clearly identified refractory symptoms, and to informed consent in 60 (64.5%), 43 (46.2%), and 38 (40.9%) charts respectively. Variation in the medications used was marked: 54 patients (58%) were started on a single agent and 39 (42%), on multiple agents. The 40 patients (43%) started on midazolam alone received a mean daily dose of 21.4 mg (standard deviation: 24.6 mg). Conclusions The lack of documentation and standardized practice of ps on our pcu has resulted in a quality improvement program to address those gaps. They also highlight the importance of conducting research and developing clinical guidelines in this area. PMID:24764700

Advancing Novel Anesthetics: Pharmacodynamic and Pharmacokinetic Studies of Cyclopropyl-Methoxycarbonyl Metomidate in Dogs

PubMed Central

Campagna, Jason A.; Pojasek, Kevin; Grayzel, David; Randle, John; Raines, Douglas E.

2014-01-01

Background Cyclopropyl-methoxycarbonyl metomidate (CPMM, also known as ABP-700) is a second-generation “soft” (i.e., metabolically-labile) etomidate analogue. The purpose of these studies was to characterize CPMM's pharmacology in beagle dogs in preparation for potential first in human phase 1 clinical trials. Methods CPMM's and etomidate's hypnotic activity and duration of action were assessed using loss of righting reflex and anesthesia score assays in three or four dogs. Their pharmacokinetics were defined after single bolus administration and single bolus followed by 2-h infusion. Adrenocortical recovery times after single bolus followed by 2-h infusion of CPMM, propofol, etomidate, and vehicle were measured using an adrenocorticotropic hormone stimulation test. Results Compared to etomidate, CPMM was half as potent as a hypnotic (ED50 ~ 0.8 mg/kg), more rapidly metabolized, and had a shorter duration of sedative-hypnotic action. Recovery times after CPMM administration were also independent of infusion duration. After hypnotic infusion, adrenocorticotropic hormone-stimulated plasma cortisol concentrations were 4- to 27-fold higher in dogs that received CPMM versus etomidate. Adrenocortical recovery was faster in dogs after CPMM infusion versus etomidate infusion (half-time: 215 min vs. 1623 min, respectively). Adrenocortical responsiveness assessed 90 min after CPMM infusion was not significantly different from that after propofol infusion. Conclusion Our studies in dogs confirm that CPMM has hypnotic and adrenocortical recovery profiles that are superior than those of etomidate, supporting the continued development of CPMM as a clinical sedative-hypnotic to be used as a single bolus and by continuous infusion to induce and maintain general anesthesia or procedural sedation. PMID:25170571

[Sedation with nitrous oxide in daily practice].

PubMed

Martens, Luc C; Marks, Luc A

2003-01-01

Conscious sedation is recommended, together with behaviour management techniques, to facilitate treatment of dental fear or dental phobia patients. In this article the authors focus on inhalation sedation by means of nitrous oxide. The procedures and indications are explained and illustrated with clinical cases. On the strength of the literature and their own experience the authors reach the conclusion that Inhalation sedation is a kind of pharmacological behaviour management and an important additional tool to increase patient cooperation. Inhalation sedation can only be performed by trained practitioners under internationally accepted safety conditions. Inhalation sedation has a future in Belgium providing the appropriate law is adapted. This technique deserves a place in the dental curriculum.

The interpersonal work of dental conscious sedation: A qualitative analysis.

PubMed

Woolley, Stephen M; Chadwick, Barbara; Pugsley, Lesley

2017-08-01

Whilst there is a considerable body of literature examining the pharmacology of conscious sedation, the social tasks required to successfully provide conscious sedation have not been reported. This paper discusses data regarding the interpersonal work integral to effective conscious sedation provision, from a larger qualitative study exploring how patients and clinicians engage with secondary care conscious sedation provided within the UK. Semi-structured interviews were conducted with 13 conscious sedation providers and nine patients within UK-based secondary care sedation settings. Digital audio-recordings were transcribed verbatim and subsequently analysed using a constant comparative method within NVivo Data Analysis Software. Four main themes of interpersonal work were reported by participants: displaying care, containing emotions, demonstrating competence and maximizing the effect. This study shows that performing conscious sedation requires more than technical delivery, and involves the projection of attributes in a literal "performance." The importance of managing outward emotional appearance reflects previous dental research. The need to manage outward appearance, and the emotional impact this has, is of relevance to all clinicians. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Palliative sedation for intolerable suffering.

PubMed

Maltoni, Marco; Scarpi, Emanuela; Nanni, Oriana

2014-07-01

The purpose of this review is to provide an update on palliative sedation in palliative and end-of-life care. Palliative sedation is the medical procedure used to deal with refractory symptoms in advanced cancer patients when all other specific approaches have failed. Palliative sedation, in the strictest sense of the term, is a proportionate (proportionate palliative sedation, PPS) and intrinsically variable procedure used on an individual basis to relieve refractory symptoms in terminally ill patients, without the intention of hastening death. Completely separate from any other end-of-life decision and not intended to hasten death, palliative sedation has been shown not to have a detrimental impact on survival. To maintain palliative sedation as a legitimate clinical procedure from any ethical or clinical point of view, it must be limited to the restricted area for which it was conceived, that is, relief from refractory suffering as deemed necessary by a patient and by an experienced palliative care team. In this way, there is no risk of associating palliative sedation with other end-of-life decisions. Close collaboration is needed between oncologists and palliative care physicians for this clinical procedure.

Determinants of receiving intravenous sedation in a sample of dentally-fearful patients in the USA

PubMed Central

Coolidge, Trilby; Irwin, Scott P.; Leyster, Kimberly A.; Milgrom, Peter

2012-01-01

Dental fear may be the most common reason for referral for intravenous sedation. Intravenous sedation offers many patients an opportunity to obtain needed dental care. However, intravenous sedation also has costs and may not help patients overcome their fear. Given a sample of 518 dentally-fearful patients in the USA presenting for dental care, this study examined the variables which predicted receiving intravenous sedation or not. About one-fifth of the patients received intravenous sedation, while the others received only cognitive behavioural therapy. Having more carious teeth, higher dental fear, more negative beliefs about dentists, lifetime diagnoses of panic disorder and/or generalized anxiety disorder, fewer existing coping skills, and a lower desire to cope with the dental situation were each predictive of having intravenous sedation. When the variables were considered simultaneously, only lower desire to cope contributed uniquely to the prediction. In a setting where psychological treatment for dental fear is available, patients’ desire to cope with their fear was the most important factor in determining whether they received intravenous sedation or not. PMID:23264704

Sedative Drug Use among King Saud University Medical Students: A Cross-Sectional Sampling Study.

PubMed

Al-Sayed, Ahmed A; Al-Rashoudi, Abdualltef H; Al-Eisa, Abdulrhman A; Addar, Abdullah M; Al-Hargan, Abdullah H; Al-Jerian, Albaraa A; Al-Omair, Abdullah A; Al-Sheddi, Ahmed I; Al-Nowaiser, Hussam I; Al-Kathiri, Omar A; Al-Hassan, Abdullah H

2014-01-01

Introduction. Medical students experience significant psychological stress and are therefore at higher risk of using sedatives. There are currently no studies describing the prevalence of sedative drug use among medical students in Saudi Arabia. The aim of this study was to evaluate the prevalence and factors associated with sedative drug use among medical students in Saudi Arabia. Materials and Methods. A cross-sectional convenience sampling study gathered data by anonymous questionnaire from students enrolled at the King Saud University College of Medicine in 2011. The questionnaires collected data regarding social and demographic variables, sleep patterns, and the use of stimulant and sedative drugs since enrollment. Sedatives were defined as any pharmaceutical preparations that induce sleep. Results and Discussion. Of the 729 students who returned questionnaires, 17.0% reported sedative drug use at some time since enrollment. Higher academic year, lower grade point average, regular exercise, fewer hours of sleep per day, poorer quality of sleep, and the presence of sleeping disorders were found to be significantly associated with sedative drug use. Conclusions. Further study is required to increase our understanding of sedative drug use patterns in this relatively high-risk group, as such understanding will help in the development of early intervention programs.

Sedative Drug Use among King Saud University Medical Students: A Cross-Sectional Sampling Study

PubMed Central

Al-Sayed, Ahmed A.; Al-Rashoudi, Abdualltef H.; Al-Eisa, Abdulrhman A.; Addar, Abdullah M.; Al-Hargan, Abdullah H.; Al-Jerian, Albaraa A.; Al-Omair, Abdullah A.; Al-Sheddi, Ahmed I.; Al-Nowaiser, Hussam I.; Al-Kathiri, Omar A.; Al-Hassan, Abdullah H.

2014-01-01

Introduction. Medical students experience significant psychological stress and are therefore at higher risk of using sedatives. There are currently no studies describing the prevalence of sedative drug use among medical students in Saudi Arabia. The aim of this study was to evaluate the prevalence and factors associated with sedative drug use among medical students in Saudi Arabia. Materials and Methods. A cross-sectional convenience sampling study gathered data by anonymous questionnaire from students enrolled at the King Saud University College of Medicine in 2011. The questionnaires collected data regarding social and demographic variables, sleep patterns, and the use of stimulant and sedative drugs since enrollment. Sedatives were defined as any pharmaceutical preparations that induce sleep. Results and Discussion. Of the 729 students who returned questionnaires, 17.0% reported sedative drug use at some time since enrollment. Higher academic year, lower grade point average, regular exercise, fewer hours of sleep per day, poorer quality of sleep, and the presence of sleeping disorders were found to be significantly associated with sedative drug use. Conclusions. Further study is required to increase our understanding of sedative drug use patterns in this relatively high-risk group, as such understanding will help in the development of early intervention programs. PMID:24551449

Volume-dependent hemodynamic effects of blood collection in canine donors - evaluation of 13% and 15% of total blood volume depletion.

PubMed

Ferreira, Rui R F; Gopegui, Rafael R; De Matos, Augusto J F

2015-03-01

There is no consensus regarding the blood volume that could be safely donated by dogs, ranging from 11 to 25% of its total blood volume (TBV). No previous studies evaluated sedated donors. To evaluate the hemodynamic effects of blood collection from sedated and non-sedated dogs and to understand if such effects were volume-dependent. Fifty three donations of 13% of TBV and 20 donations of 15% TBV were performed in dogs sedated with diazepam and ketamine. Additionally, a total of 30 collections of 13% TBV and 20 collections of 15% TBV were performed in non-sedated dogs. Non-invasive arterial blood pressures and pulse rates were registered before and 15 min after donation. Post-donation pulse rates increased significantly in both sedated groups, with higher differences in the 15% TBV collections. Systolic arterial pressures decreased significantly in these groups, while diastolic pressures increased significantly in 13% TBV donations. Non-sedated groups revealed a slight, but significant, SBP decrease. No clinical signs related to donations were registered. These results suggest that the collection of 15% TBV in sedated donors induces hemodynamic variations that may compromise the harmlessness of the procedure, while it seems to be a safe procedure in non-sedated dogs.

Palliative sedation: a focus group study on the experiences of relatives.

PubMed

Bruinsma, Sophie; Rietjens, Judith; van der Heide, Agnes

2013-04-01

Most studies that have investigated the practice of palliative sedation have focused on physicians' practices and attitudes. The aim of this study was to explore relatives' experiences with palliative sedation and to gain more insight in positive and negative elements in their evaluation of palliative sedation. Focus groups and individual interviews. Various care settings in the Netherlands. A total of 14 relatives of patients who received palliative sedation until death participated. Most relatives evaluated the provision of palliative sedation of their dying family member positively. Positive experiences were related to: the beneficial impact of palliative sedation on the patient's suffering, the opportunity that was offered to prepare for the patient's death, their involvement in the decision-making and care for the patient, and the pleasant care environment. However, the majority of the relatives were unsatisfied with one or more aspects of how information was being provided for. Some relatives were frustrated about the fact that nurses were not authorized to make decisions about the care for the patient and about the absence of physicians during weekends. None of the relatives mentioned the loss of the ability to communicate with the patient during the sedation and the possibility of "hastening death" as disadvantages of palliative sedation. Relatives tend to evaluate the provision of palliative sedation to their severely suffering family member positively because it contributes to a peaceful dying process. However, relatives indicated discontent with how information was being provided and with the communication in general.

Level of consciousness in dying patients. The role of palliative sedation: a longitudinal prospective study.

PubMed

Claessens, Patricia; Menten, Johan; Schotsmans, Paul; Broeckaert, Bert

2012-05-01

Patients suffering from a terminal illness often are confronted with severe symptoms during the last phase of their lives. Palliative sedation, although one of the options of last resort, remains a much debated and controversial issue and is often referred to as a form of slow euthanasia or euthanasia in disguise. A prospective longitudinal and descriptive design was used. Each patient admitted in one of the 8 participating units was included if they met the inclusion criteria and gave written informed consent. 266 patients were included. The incidence of palliative sedation was 7;5%. For the group of sedated patients results show that 90% entered the palliative care unit being fully conscious. Two patients were comatose upon arrival. 90% of the patients remained fully conscious up to the day palliative sedation was started. When looking at the effect of palliative sedation on the level of consciousness the analysis strongly suggest that the palliative sedation - as expected- has an impact on the GCS score. Irrespective of the dichotomization of the score the probability of having a lower GCS increases substantially once sedation is initiated. Additionally, results show that once palliative sedation is administered, the level of consciousness gradually goes down up until the day of death. Palliative sedation is nor slow euthanasia nor an ambivalent practice. It is an intentional medical treatment which is administered in a proportional way when refractory suffering occurs. It occurs in extraordinary situations and at the very end of the dying process.

Muslim physicians and palliative care: attitudes towards the use of palliative sedation.

PubMed

Muishout, George; van Laarhoven, Hanneke W M; Wiegers, Gerard; Popp-Baier, Ulrike

2018-05-08

Muslim norms concerning palliative sedation can differ from secular and non-Muslim perceptions. Muslim physicians working in a Western environment are expected to administer palliative sedation when medically indicated. Therefore, they can experience tension between religious and medical norms. To gain insight into the professional experiences of Muslim physicians with palliative sedation in terms of religious and professional norms. Interpretative phenomenological study using semi-structured interviews to take a closer look at the experiences of Muslim physicians with palliative sedation. Data were recorded, transcribed and analysed by means of interpretative phenomenological analysis (IPA). Ten Muslim physicians, working in the Netherlands, with professional experience of palliative sedation. Two main themes were identified: professional self-concept and attitudes towards death and dying. Participants emphasized their professional responsibility when making treatment decisions, even when these contravened the prevalent views of Islamic scholars. Almost all of them expressed the moral obligation to fight their patients' pain in the final stage of life. Absence of acceleration of death was considered a prerequisite for using palliative sedation by most participants. Although the application of palliative sedation caused friction with their personal religious conceptions on a good death, participants followed a comfort-oriented care approach corresponding to professional medical standards. All of them adopted efficient strategies for handling of palliative sedation morally and professionally. The results of this research can contribute to and provide a basis for the emergence of new, applied Islamic ethics regarding palliative sedation.

Acute severe asthma: new approaches to assessment and treatment.

PubMed

Papiris, Spyros A; Manali, Effrosyni D; Kolilekas, Likurgos; Triantafillidou, Christina; Tsangaris, Iraklis

2009-01-01

The precise definition of a severe asthmatic exacerbation is an issue that presents difficulties. The term 'status asthmaticus' relates severity to outcome and has been used to define a severe asthmatic exacerbation that does not respond to and/or perilously delays the repetitive or continuous administration of short-acting inhaled beta(2)-adrenergic receptor agonists (SABA) in the emergency setting. However, a number of limitations exist concerning the quantification of unresponsiveness. Therefore, the term 'acute severe asthma' is widely used, relating severity mostly to a combination of the presenting signs and symptoms and the severity of the cardiorespiratory abnormalities observed, although it is well known that presentation does not foretell outcome. In an acute severe asthma episode, close observation plus aggressive administration of bronchodilators (SABAs plus ipratropium bromide via a nebulizer driven by oxygen) and oral or intravenous corticosteroids are necessary to arrest the progression to severe hypercapnic respiratory failure leading to a decrease in consciousness that requires intensive care unit (ICU) admission and, eventually, ventilatory support. Adjunctive therapies (intravenous magnesium sulfate and/or others) should be considered in order to avoid intubation. Management after admission to the hospital ward because of an incomplete response is similar. The decision to intubate is essentially based on clinical judgement. Although cardiac or respiratory arrest represents an absolute indication for intubation, the usual picture is that of a conscious patient struggling to breathe. Factors associated with the increased likelihood of intubation include exhaustion and fatigue despite maximal therapy, deteriorating mental status, refractory hypoxaemia, increasing hypercapnia, haemodynamic instability and impending coma or apnoea. To intubate, sedation is indicated in order to improve comfort, safety and patient-ventilator synchrony, while at the same time decrease oxygen consumption and carbon dioxide production. Benzodiazepines can be safely used for sedation of the asthmatic patient, but time to awakening after discontinuation is prolonged and difficult to predict. The most common alternative is propofol, which is attractive in patients with sudden-onset (near-fatal) asthma who may be eligible for extubation within a few hours, because it can be titrated rapidly to a deep sedation level and has rapid reversal after discontinuation; in addition, it possesses bronchodilatory properties. The addition of an opioid (fentanyl or remifentanil) administered by continuous infusion to benzodiazepines or propofol is often desirable in order to provide amnesia, sedation, analgesia and respiratory drive suppression. Acute severe asthma is characterized by severe pulmonary hyperinflation due to marked limitation of the expiratory flow. Therefore, the main objective of the initial ventilator management is 2-fold: to ensure adequate gas exchange and to prevent further hyperinflation and ventilator-associated lung injury. This may require hypoventilation of the patient and higher arterial carbon dioxide (PaCO(2)) levels and a more acidic pH. This does not apply to asthmatic patients intubated for cardiac or respiratory arrest. In this setting the post-anoxic brain oedema might demand more careful management of PaCO(2) levels to prevent further elevation of intracranial pressure and subsequent complications. Monitoring lung mechanics is of paramount importance for the safe ventilation of patients with status asthmaticus. The first line of specific pharmacological therapy in ventilated asthmatic patients remains bronchodilation with a SABA, typically salbutamol (albuterol). Administration techniques include nebulizers or metered-dose inhalers with spacers. Systemic corticosteroids are critical components of therapy and should be administered to all ventilated patients, although the dose of systemic corticosteroids in mechanically ventilated asthmatic patients remains controversial. Anticholinergics, inhaled corticosteroids, leukotriene receptor antagonists and methylxanthines offer little benefit, and clinical data favouring their use are lacking. In conclusion, expertise, perseverance, judicious decisions and practice of evidence-based medicine are of paramount importance for successful outcomes for patients with acute severe asthma.

Psychological impact of unexpected explicit recall of events occurring during surgery performed under sedation, regional anaesthesia, and general anaesthesia: data from the Anesthesia Awareness Registry.

PubMed

Kent, C D; Mashour, G A; Metzger, N A; Posner, K L; Domino, K B

2013-03-01

Anaesthetic awareness is a recognized complication of general anaesthesia (GA) and is associated with post-traumatic stress disorder (PTSD). Although complete amnesia for intraprocedural events during sedation and regional anaesthesia (RA) may occur, explicit recall is expected by anaesthesia providers. Consequently, the possibility that there could be psychological consequences associated with unexpected explicit recall of events during sedation and RA has not been investigated. This study investigated the psychological sequelae of unexpected explicit recall of events during sedation/RA that was reported to the Anesthesia Awareness Registry. The Registry recruited subjects who self-identified as having had anaesthetic awareness. Inclusion criteria were a patient-reported awareness experience in 1990 or later and availability of medical records. The sensations experienced by the subjects during their procedure and the acute and persistent psychological sequelae attributed to this explicit recall were assessed for patients receiving sedation/RA and those receiving GA. Among the patients fulfilling the inclusion criteria, medical record review identified 27 sedation/RA and 50 GA cases. Most patients experienced distress (78% of sedation/RA vs 94% of GA). Approximately 40% of patients with sedation/RA had persistent psychological sequelae, similar to GA patients. Some sedation/RA patients reported an adverse impact on their job performance (15%), family relationships (11%), and friendships (11%), and 15% reported being diagnosed with PTSD. Patients who self-reported to the Registry unexpected explicit recall of events during sedation/RA experienced distress and persistent psychological sequelae comparable with those who had reported anaesthetic awareness during GA. Further study is warranted to determine if patients reporting distress with explicit recall after sedation/RA require psychiatric follow-up.

Palliative sedation versus euthanasia: an ethical assessment.

PubMed

ten Have, Henk; Welie, Jos V M

2014-01-01

The aim of this article was to review the ethical debate concerning palliative sedation. Although recent guidelines articulate the differences between palliative sedation and euthanasia, the ethical controversies remain. The dominant view is that euthanasia and palliative sedation are morally distinct practices. However, ambiguous moral experiences and considerable practice variation call this view into question. When heterogeneous sedative practices are all labeled as palliative sedation, there is the risk that palliative sedation is expanded to include practices that are actually intended to bring about the patients' death. This troublesome expansion is fostered by an expansive use of the concept of intention such that this decisive ethical concept is no longer restricted to signify the aim in guiding the action. In this article, it is argued that intention should be used in a restricted way. The significance of intention is related to other ethical parameters to demarcate the practice of palliative sedation: terminality, refractory symptoms, proportionality, and separation from other end-of-life decisions. These additional parameters, although not without ethical and practical problems, together formulate a framework to ethically distinguish a more narrowly defined practice of palliative sedation from practices that are tantamount to euthanasia. Finally, the article raises the question as to what impact palliative sedation might have on the practice of palliative care itself. The increasing interest in palliative sedation may reemphasize characteristics of health care that initially encouraged the emergence of palliative care in the first place: the focus on therapy rather than care, the physical dimension rather than the whole person, the individual rather than the community, and the primacy of intervention rather than receptiveness and presence. Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Propofol sedation in children: sleep trumps amnesia.

PubMed

Veselis, Robert; Kelhoffer, Eric; Mehta, Meghana; Root, James C; Robinson, Fay; Mason, Keira P

Detailed assessments of the effects of propofol on memory in children are lacking. We assessed the feasibility of measuring memory during propofol infusion, as commonly performed in sedation for MRI scanning. In addition, we determined the onset of memory loss in relation to the onset of sedation measured by verbal responsiveness. Children scheduled for sedation for MRI received a 10-min infusion of propofol (3 mg/kg) as they viewed and named 100 simple line drawings, one shown every five seconds, until they were no longer responsive (encoding). A control group receiving no sedation for MRI underwent similar tasks. Sedation was measured as any verbal response, regardless of correctness. After recovery from sedation, recognition memory was tested, with correct yes/no recognitions matched to sedation responses during encoding (subsequent memory paradigm). Of the 48 children who received propofol, 30 could complete all study tasks (6.2 ± 1.6 years, 16 males). Individual responses could be modeled in all 30 children. On average, there was a 50% probability of no verbal response 3.1 min after the start of infusion, with 50% memory loss at 2.7 min. Children receiving propofol recognized 65 ± 16% of the pictures seen, whereas the control group recognized 93 ± 5%. Measurement of memory and sedation is possible in verbal children receiving propofol by infusion in a clinical setting. Despite propofol being an amnestic agent, there was little or no amnestic effect of propofol while the child was verbally responsive. It is important for sedation providers to realize that propofol sedation does not always produce amnesia while the child is responsive. CLINICALTRIALS. NCT02278003. Copyright © 2016. Published by Elsevier B.V.

Comparison of butorphanol-detomidine versus butorphanol-azaperone for the standing sedation of captive greater one-horned rhinoceroses (Rhinoceros unicornis).

PubMed

Bapodra, Priya; Cracknell, Jonathan; Wolfe, Barbara A

2014-03-01

Three adult and two subadult greater one-horned rhinoceroses (Rhinoceros unicornis) were sedated a total of nine times using two different intramuscular sedative combinations in order to compare the effectiveness of these combinations in inducing consistent standing sedation in this species. The sedation protocols compared were butorphanol tartrate (50-60 mg) and detomidine hydrochloride (20-30 mg; BD) versus butorphanol tartrate (80-120 mg) and azaperone (80-120 mg; BA). Specific doses were adjusted according to age and sex class, and based on previous experience. Parameters compared included time to achieve defined levels of sedation, time to recovery following antagonism, physiological parameters including heart rate, respiratory rate, indirect arterial blood pressure, and venous blood gas values. A hydraulic restraint chute was utilized to mechanically restrain animals during the procedures, and blood collection and ophthalmic examinations were conducted on all animals. Both protocols resulted in standing sedation for > or = 22.3 +/- 2.9 min or until antagonists were administered. The BD protocol resulted in deeper and more consistent sedation, compared to the BA protocol. Naltrexone hydrochloride (250-300 mg) and tolazoline hydrochloride (1,500-2,000 mg) were administered intramuscularly to antagonize protocol BD, whereas naltrexone alone (200-500 mg) was used to antagonize BA. Time to full antagonism, defined as normal mentation and ambulation following administration of antagonists, was prolonged in the BD protocol (132.3 +/- 17.2 min) compared with the BA protocol (7.5 +/- 2.5 min). Venous blood gas analysis did not reveal any significant blood gas deviations during sedation when compared with either conscious equine or white rhinoceros (Ceratotherium simum) venous reference ranges. In summary, both combinations resulted in adequate standing sedation for minimally invasive procedures, although BD resulted in more profound and consistent sedation.

Feeding response of sport fish after electrical immobilization, chemical sedation, or both

USGS Publications Warehouse

Meinertz, Jeffery R.; Fredricks, Kim T.; Ambrose, Ryan D.; Jackan, Leanna M.; Wise, Jeremy K.

2012-01-01

Fishery managers frequently capture wild fish for a variety of fishery management activities. Though some activities can be accomplished without immobilizing the fish, others are accomplished more readily, humanely, and safely (for both the handler and the fish) when fish are immobilized by physical (e.g., electrical immobilization) or chemical sedation. A concern regarding the use of chemical sedatives is that chemical residues may remain in the fillet tissue after the fish recovers from sedation. If those residues are harmful to humans, there is some risk that a postsedated fish released to public waters may be caught and consumed by an angler. To characterize this risk, a series of four trials were conducted. Three trials assessed feeding activity after hatchery-reared fish were electrically immobilized, chemically sedated, or both, and one trial assessed the likelihood of an angler catching a wild fish that had been electrically immobilized and chemically sedated. Results from the first trial indicated that the feeding activity of laboratory habituated fish was variable among and within species after electrical immobilization, chemical sedation, or both. Results from the second trial indicated that the resumption of feeding activity was rapid after being mildly sedated for 45 min. Results from the third trial indicated that the feeding activity of outdoor, hatchery-reared fish was relatively aggressive after fish had been chemically sedated. Results from the fourth trial indicated that the probability of capturing wild fish in a more natural environment by angling after fish had been electrically immobilized and chemically sedated is not likely, i.e., in a group of five fish caught, 3 out of 100 times one would be a fish that had been sedated.

The experiences of relatives with the practice of palliative sedation: a systematic review.

PubMed

Bruinsma, Sophie M; Rietjens, Judith A C; Seymour, Jane E; Anquinet, Livia; van der Heide, Agnes

2012-09-01

Guidelines about palliative sedation typically include recommendations to protect the well-being of relatives. The aim of this study was to systematically review evidence on the experiences of relatives with the practice of palliative sedation. PubMed, Embase, Web of Science, PsycINFO, and CINAHL were searched for empirical studies on relatives' experiences with palliative sedation. We investigated relatives' involvement in the decision-making and sedation processes, whether they received adequate information and support, and relatives' emotions. Of the 564 studies identified, 39 were included. The studies (30 quantitative, six qualitative, and three mixed methods) were conducted in 16 countries; three studies were based on relatives' reports, 26 on physicians' and nurses' proxy reports, seven on medical records, and three combined different sources. The 39 studies yielded a combined total of 8791 respondents or studied cases. Caregivers involved relatives in the decision making in 69%-100% of all cases (19 quantitative studies), and in 60%-100% of all cases, relatives were reported to have received adequate information (five quantitative studies). Only two quantitative studies reported on relatives' involvement in the provision of sedation. Despite the fact that the majority of relatives were reported to be comfortable with the use of palliative sedation (seven quantitative studies, four qualitative studies), several studies found that relatives were distressed by the use of sedation (five quantitative studies, five qualitative studies). No studies reported specifically about the support provided to the relatives. Relatives' experiences with palliative sedation are mainly studied from the perspective of proxies, mostly professional caregivers. The majority of relatives seems to be comfortable with the use of palliative sedation; however, they may experience substantial distress by the use of sedation. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

The use of anaesthetic agents to provide anxiolysis and sedation in dentistry and oral surgery.

PubMed

O'Halloran, Michael

2013-12-31

Throughout the world there is considerable variation in the techniques used to manage anxious dental patients requiring treatment. Traditionally anxious or phobic dental patients may have been sent for general anaesthesia to allow dental treatment be undertaken. While this is still the case for the more invasive oral surgical procedures, such as wisdom teeth extraction, sedation in general dentistry is becoming more popular. Various sedation techniques using many different anaesthetic agents have gained considerable popularity over the past 30 years. While the practice of sedating patients for dental procedures is invaluable in the management of suitably assessed patients, patient safety must always be the primary concern. Medical, dental and psychosocial considerations must be taken into account when evaluating the patient need and the patient suitability for sedation or general anaesthesia. The regulations that govern the practice of dental sedation vary throughout the world, in particular regarding the techniques used and the training necessary for dental practitioners to sedate patients. It is necessary for medical and dental practitioners to be up to date on current practice to ensure standards of practice, competence and safety throughout our profession. This article, the first in a two-part series, will provide information to practitioners on the practice of sedation in dentistry, the circumstances where it may be appropriate instead of general anaesthesia and the risks involved with sedation. It will also discuss the specific training and qualifications required for dental practitioners to provide sedation. The second article in this series will outline the different techniques used to administer inhalation, oral and intravenous sedation in dentistry and will focus on specific methods that are practiced.

Comparison of rescue techniques for failed chloral hydrate sedation for magnetic resonance imaging scans--additional chloral hydrate vs intranasal dexmedetomidine.

PubMed

Zhang, Wenhua; Wang, Zixin; Song, Xingrong; Fan, Yanting; Tian, Hang; Li, Bilian

2016-03-01

Chloral hydrate, a commonly used sedative in children during noninvasive diagnostic procedures, is associated with side effects like prolonged sedation, paradoxical excitement, delirium, and unpleasant taste. Dexmedetomidine, a highly selective α-2 agonist, has better pharmacokinetic properties than chloral hydrate. We conducted this prospective, double-blind, randomized controlled trial to evaluate efficacy of intranasal dexmedetomidine with that of a second oral dose of chloral hydrate for rescue sedation during magnetic resonance imaging (MRI) studies in infants. One hundred and fifty infants (age group: 1-6 months), who were not adequately sedated after initial oral dose of 50 mg · kg(-1) chloral hydrate, were randomly divided into three groups with the following protocol for each group. Group C: second oral dose chloral hydrate 25 mg · kg(-1); Group L and Group H: intranasal dexmedetomidine in a dosage of 1 and 2 mcg · kg(-1), respectively. Status of sedation, induction time, time to wake up, vital signs, oxygen saturation, and recovery characteristics were recorded. Successful rescue sedation in Groups C, L, and H were achieved in 40 (80%), 47 (94%), and 49 (98%) of infants, respectively, on an intention to treat analysis, and the proportion of infants successfully sedated in Group H was more than that of Group L (P ˂ 0.01). There were no significant differences in sedation induction time; however, the time to wake up was significantly shorter in Group L as compared to that in Group C or H (P < 0.01). No significant adverse hemodynamic or hypoxemic effects were observed in the study. Intranasal dexmedetomidine induced satisfactory rescue sedation in 1- to 6-month-old infants during MRI study, and appears to cause sedation in a dose-dependent manner. © 2015 John Wiley & Sons Ltd.

Spatio-temporal dynamics of multimodal EEG-fNIRS signals in the loss and recovery of consciousness under sedation using midazolam and propofol

PubMed Central

Won, Dong-Ok; Chi, Seong In; Seo, Kwang-Suk; Kim, Hyun Jeong; Müller, Klaus-Robert; Lee, Seong-Whan

2017-01-01

On sedation motivated by the clinical needs for safety and reliability, recent studies have attempted to identify brain-specific signatures for tracking patient transition into and out of consciousness, but the differences in neurophysiological effects between 1) the sedative types and 2) the presence/absence of surgical stimulations still remain unclear. Here we used multimodal electroencephalography–functional near-infrared spectroscopy (EEG–fNIRS) measurements to observe electrical and hemodynamic responses during sedation simultaneously. Forty healthy volunteers were instructed to push the button to administer sedatives in response to auditory stimuli every 9–11 s. To generally illustrate brain activity at repetitive transition points at the loss of consciousness (LOC) and the recovery of consciousness (ROC), patient-controlled sedation was performed using two different sedatives (midazolam (MDZ) and propofol (PPF)) under two surgical conditions. Once consciousness was lost via sedatives, we observed gradually increasing EEG power at lower frequencies (<15 Hz) and decreasing power at higher frequencies (>15 Hz), as well as spatially increased EEG powers in the delta and lower alpha bands, and particularly also in the upper alpha rhythm, at the frontal and parieto-occipital areas over time. During ROC from unconsciousness, these spatio-temporal changes were reversed. Interestingly, the level of consciousness was switched on/off at significantly higher effect-site concentrations of sedatives in the brain according to the use of surgical stimuli, but the spatio-temporal EEG patterns were similar, regardless of the sedative used. We also observed sudden phase shifts in fronto-parietal connectivity at the LOC and the ROC as critical points. fNIRS measurement also revealed mild hemodynamic fluctuations. Compared with general anesthesia, our results provide insights into critical hallmarks of sedative-induced (un)consciousness, which have similar spatio-temporal EEG-fNIRS patterns regardless of the stage and the sedative used. PMID:29121108

Spatio-temporal dynamics of multimodal EEG-fNIRS signals in the loss and recovery of consciousness under sedation using midazolam and propofol.

PubMed

Yeom, Seul-Ki; Won, Dong-Ok; Chi, Seong In; Seo, Kwang-Suk; Kim, Hyun Jeong; Müller, Klaus-Robert; Lee, Seong-Whan

2017-01-01

On sedation motivated by the clinical needs for safety and reliability, recent studies have attempted to identify brain-specific signatures for tracking patient transition into and out of consciousness, but the differences in neurophysiological effects between 1) the sedative types and 2) the presence/absence of surgical stimulations still remain unclear. Here we used multimodal electroencephalography-functional near-infrared spectroscopy (EEG-fNIRS) measurements to observe electrical and hemodynamic responses during sedation simultaneously. Forty healthy volunteers were instructed to push the button to administer sedatives in response to auditory stimuli every 9-11 s. To generally illustrate brain activity at repetitive transition points at the loss of consciousness (LOC) and the recovery of consciousness (ROC), patient-controlled sedation was performed using two different sedatives (midazolam (MDZ) and propofol (PPF)) under two surgical conditions. Once consciousness was lost via sedatives, we observed gradually increasing EEG power at lower frequencies (<15 Hz) and decreasing power at higher frequencies (>15 Hz), as well as spatially increased EEG powers in the delta and lower alpha bands, and particularly also in the upper alpha rhythm, at the frontal and parieto-occipital areas over time. During ROC from unconsciousness, these spatio-temporal changes were reversed. Interestingly, the level of consciousness was switched on/off at significantly higher effect-site concentrations of sedatives in the brain according to the use of surgical stimuli, but the spatio-temporal EEG patterns were similar, regardless of the sedative used. We also observed sudden phase shifts in fronto-parietal connectivity at the LOC and the ROC as critical points. fNIRS measurement also revealed mild hemodynamic fluctuations. Compared with general anesthesia, our results provide insights into critical hallmarks of sedative-induced (un)consciousness, which have similar spatio-temporal EEG-fNIRS patterns regardless of the stage and the sedative used.

Utility of intranasal Ketamine and Midazolam to perform gastric aspirates in children: a double-blind, placebo controlled, randomized study

PubMed Central

2014-01-01

Background We performed a prospective, randomized, placebo-controlled study aimed to evaluate the efficacy and safety of a sedation protocol based on intranasal Ketamine and Midazolam (INKM) administered by a mucosal atomizer device in uncooperative children undergoing gastric aspirates for suspected tuberculosis. Primary outcome: evaluation of Modified Objective Pain Score (MOPS) reduction in children undergoing INKM compared to the placebo group. Secondary outcomes: evaluation of safety of INKM protocol, start time sedation effect, duration of sedation and evaluation of parents and doctors’ satisfaction about the procedure. Methods In the sedation group, 19 children, mean age 41.5 months, received intranasal Midazolam (0.5 mg/kg) and Ketamine (2 mg/kg). In the placebo group, 17 children received normal saline solution twice in each nostril. The child’s degree of sedation was scored using the MOPS. A questionnaire was designed to evaluate the parents’ and doctors’ opinions on the procedures of both groups. Results Fifty-seven gastric washings were performed in the sedation-group, while in the placebo-group we performed 51 gastric aspirates. The degree of sedation achieved by INMK enabled all procedures to be completed without additional drugs. The mean duration of sedation was 71.5 min. Mean MOPS was 3.5 (range 1-8) in the sedation-group, 7.2 (range 4-9) in the placebo-group (p <0.0001). The questionnaire revealed high levels of satisfaction by both doctors and parents in the sedation-group compared to the placebo-group. The only side effect registered was post-sedation agitation in 6 procedures in the sedation group (10.5%). Conclusions Our experience suggests that atomized INKM makes gastric aspirates more acceptable and easy to perform in children. Trial registration Unique trial Number: UMIN000010623; Receipt Number: R000012422. PMID:24598046

Implants in disabled patients: A review and update

PubMed Central

Romero-Pérez, María J.; Mang-de la Rosa, María R.; López-Jimenez, Julián; Fernández-Feijoo, Javier

2014-01-01

The range of indications for dental implants has broadened enormously owing to their predictability and the improvement of patient satisfaction in terms of stability, comfort, aesthetics and functionality. The aim of this article is to review those indications in patients with mental or physical disabilities as the difficulty to cope with oral hygiene often leads to teeth extraction, adding edentulousness to the impairments already present. Following that goal, available literature in Pubmed database, Scopus, Web of Knowledge and The Cochrane Library database about dental implants placement in these patients has been reviewed, assessing the variables of each study: number of patients, sex, average age, oral hygiene, parafunctional habits, impairment, bone quality, protocol of implant surgery, necessity of deep intravenous sedation or general anesthesia, follow-up period and number of failures. The comparison with studies involving other patient populations without mental or physical impediments did not show statistically significant differences in terms of the failure rate recorded. Although there is not much literature available, the results of this review seem to suggest that osseointegrated oral implants could be a therapeutic option in patients who suffer from any physical or psychological impairment. The success of an oral rehabilitation depends mainly on an adequate selection of the patients. Key words:Implants, disabled, sedation. PMID:24608221

Update on bispectral index monitoring.

PubMed

Johansen, Jay W

2006-03-01

Since 1997, bispectral index (BIS; Aspect Medical Systems Inc., Natick, MA) has been in clinical practice and a wealth of experimental research has accumulated on its use. Originally, the device was approved only for monitoring hypnosis and has now received an indication for reducing the incidence of intraoperative awareness during anesthesia. Numerous studies have documented the ability of BIS to reduce intermediate outcomes such as hypnotic drug administration, extubation time, postoperative nausea and shortened recovery room discharge. Two recent large-scale outcome studies using BIS (one randomized controlled trial and one prospective, nonrandomized historical cohort study) identified an approximately 80% reduction in the incidence of recall after anesthesia. BIS provides clinicians with unique information that can be used to tailor hypnotic drug doses to individual patient requirements. BIS does not predict movement or hemodynamic response to stimulation, nor will it predict the exact moment consciousness returns. This review will also discuss other BIS applications including use in pediatrics, intensive care and for procedural sedation. Some limitations exist to the use of BIS and it is not useful for some individual hypnotic agents (ketamine, dexmedetomidine, nitrous oxide, xenon, opioids). BIS technology is moving out of the operating room and into diverse environments where conscious and deep sedation are provided. Anesthesiologists need to be actively involved in promoting patient safety and helping transition this technology into broader use.

Capsule endoscopy in pediatrics: a 10-years journey.

PubMed

Oliva, Salvatore; Cohen, Stanley A; Di Nardo, Giovanni; Gualdi, Gianfranco; Cucchiara, Salvatore; Casciani, Emanuele

2014-11-28

Video capsule endoscopy (CE) for evaluation the esophagus (ECE), small bowel (SBCE) and the colon (CCE) is particularly useful in pediatrics, because this imaging modality does not require ionizing radiation, deep sedation or general anesthesia. The risk of capsule retention appears to be dependent on indication rather than age and parallels the adult experience by indication, making SBCE a relatively safe procedure with a significant diagnostic yield. The newest indication, assessment of mucosal change, greatly enhances and expands its potential benefit. The diagnostic role of CE extends beyond the SB. The use of ECE also may enhance our knowledge of esophageal disease and assist patient care. Colon CCE is a novel minimally invasive and painless endoscopic technique allowing exploration of the colon without need for sedation, rectal intubation and gas insufflation. The limited data on ECE and CCE in pediatrics does not yet allow the same conclusions regarding efficacy; however, both appear to provide safe methods to assess and monitor mucosal change in their respective areas with little discomfort. Moreover, although experience has been limited, the patency capsule may help lessen the potential of capsule retention; and newly researched protocols for bowel cleaning may further enhance CE's diagnostic yield. However, further research is needed to optimize the use of the various CE procedures in pediatric populations.

Postoperative nausea and vomiting (PONV) in outpatient repair of inguinal hernia.

PubMed

Palumbo, Piergaspare; Usai, Sofia; Amatucci, Chiara; Pulli, Valentina Taurisano; Illuminati, Giulio; Vietri, Francesco; Tellan, Guglielmo

2018-01-01

Nausea and vomiting are among the most frequent complications following anesthesia and surgery. Due to anesthesia seems to be primarily responsible for post operative nausea and vomiting (PONV) in Day Surgery facilities, the aim of the study is to evaluate how different methods of anesthesia could modify the onset of postoperative nausea and vomiting in a population of patients undergoing inguinal hernia repair. Ninehundredten patients, aged between 18 and 87 years, underwent open inguinal hernia repair. The PONV risk has been assessed according to Apfel Score. Local anesthetic infiltration, performed by the surgeon in any cases, has been supported by and analgo-sedation with Remifentanil in 740 patients; Fentanyl was used in 96 cases and the last 74 underwent deep sedation with Propofol . Among the 910 patients who underwent inguinal hernia repair, PONV occurred in 68 patients (7.5%). Among patients presenting PONV, 29 received Remifentanil, whereas 39 received Fentanyl. In the group of patients receiving Propofol, no one presented PONV. This difference is statistically significant (p < .01). Moreover, only 50 patients of the total sample received antiemetic prophylaxis, and amongst these, PONV occurred in 3 subjects. Compared to Remifentanil, Fentanyl has a major influence in causing PONV. Nonetheless, an appropriate antiemetic prophylaxis can significantly reduce this undesirable complication. Key words: Day Surgery, Fentanyl, Inguinal, Hernia repair, Nausea, Vomiting.

Anesthetic activity and bio-guided fractionation of the essential oil of Aloysia gratissima (Gillies & Hook.) Tronc. in silver catfish Rhamdia quelen.

PubMed

Benovit, Simone C; Silva, Lenise L; Salbego, Joseânia; Loro, Vania L; Mallmann, Carlos A; Baldisserotto, Bernardo; Flores, Erico M M; Heinzmann, Berta M

2015-09-01

This work aimed to determine the efficacy of the essential oil of A. gratissima as anesthetic for silver catfish, and to perform the bio-guided fractionation of essential oil aiming to isolate compounds responsible for the noted effects. Fish were submitted to anesthesia bath with essential oil, its fractions and isolated compounds to determine time of anesthetic induction and recovery. Eugenol (50 mg L(-1)) was used as positive control. Essential oil of A. gratissima was effective as an anesthetic at concentrations of 300 to 900 mg L(-1). Fish presented involuntary muscle contractions during induction and recovery. The bio-guided fractionation of essential oil furnished E-(-)-pinocamphone, (-)-caryophyllene oxide, (-)-guaiol and (+)-spathulenol. E-(-)-pinocamphone caused the same side effects observed for essential oil. (-)-Caryophyllene oxide, (-)-guaiol and (+)-spathulenol showed only sedative effects at proportional concentrations to those of the constituents in essential oil. (+)-Spathulenol (51.2 mg L(-1)) promoted deep anesthesia without side effects. A higher concentration of (+)-spathulenol, and lower or absent amounts ofE-(-)-pinocamphone could contribute to increase the activity and safety of the essential oil of A. gratissima. (+)-Spathulenol showed potent sedative and anesthetic activities in silver catfish, and could be considered as a viable compound for the development of a new anesthetic.

The safety and efficacy of using a concentrated intranasal midazolam formulation for paediatric dental sedation.

PubMed

Wood, Michael

2011-01-01

To add to the evidence base for safe and effective paediatric conscious sedation techniques in primary dental care. To consider the safety and effectiveness of an alternative sedation technique for facilitating dental treatment in anxious children, thereby avoiding dental general anaesthetic. Leagrave Dental Sedation Clinic. A primary care-based general and referral clinic for anxious patients, special care dentistry and oral surgery. This is a prospective service evaluation of 114 selected anxious children requiring invasive dental treatment. Each child was administered 0.25 mg/kg intranasal midazolam using a concentrated 40 mg/ml midazolam (INM) in 2% lignocaine solution. Successful completion of intended dental treatment with a child who is co-operative and who meets the UK accepted definition of conscious sedation. 57% of the children found the administration of the new formulation acceptable. Of the 114 patients who received INM, 104 completed the treatment (91%). The 10 children who could not complete the treatment with INM were converted to intravenous sedation and treatment was completed successfully at the same appointment. During treatment there was no desaturation and only one patient desaturated briefly in the recovery area. Parents rated the technique acceptable in 76% of cases and would have the procedure repeated in 83% of cases. Parents rated this technique as having 8.3 out of 10 with only 5 parents awarding a score of less than 7 out of 10. Side effects included blurred vision, sneezing, headaches, restlessness with one patient having post-operative nausea and vomiting. In selected cases intranasal sedation provides a safe and effective alternative for dental GA in short invasive procedures limited to one or two quadrants in children. Other techniques, e.g., oral and intravenous sedation, appear to have a much higher acceptability of administration. This technique may be useful if inhalation sedation, oral sedation or intravenous sedation is considered and the child is still unco-operative, either as a technique on its own or to facilitate cannulation for intravenous sedation. It is recommended that this technique should only be used by dentists skilled in intravenous paediatric sedation with midazolam with the appropriate staff training and equipment at their disposal.

Dexmedetomidine: a review of its use for sedation in mechanically ventilated patients in an intensive care setting and for procedural sedation.

PubMed

Hoy, Sheridan M; Keating, Gillian M

2011-07-30

Dexmedetomidine (Precedex®), a pharmacologically active dextroisomer of medetomidine, is a selective α(2)-adrenergic receptor agonist. It is indicated in the US for the sedation of mechanically ventilated adult patients in an intensive care setting and in non-intubated adult patients prior to and/or during surgical and other procedures. This article reviews the pharmacological properties, therapeutic efficacy and tolerability of dexmedetomidine in randomized, double-blind, placebo-controlled, multicentre studies in these indications. Post-surgical patients in an intensive care setting receiving dexmedetomidine required less rescue sedation with intravenous propofol or intravenous midazolam to achieve and/or maintain optimal sedation during the assisted ventilation period than placebo recipients, according to two randomized, double-blind, multinational studies. Moreover, significantly more dexmedetomidine than placebo recipients acquired and/or maintained optimal sedation without rescue sedation. Sedation with dexmedetomidine was also effective in terms of the total dose of morphine administered, with dexmedetomidine recipients requiring less morphine than placebo recipients; with regard to patient management, dexmedetomidine recipients were calmer and easier to arouse and manage than placebo recipients. Intravenous dexmedetomidine was effective as a primary sedative in two randomized, double-blind, placebo-controlled, multicentre studies in adult patients undergoing awake fibre-optic intubation or a variety of diagnostic or surgical procedures requiring monitored anaesthesia care. In one study, significantly fewer dexmedetomidine than placebo recipients required rescue sedation with intravenous midazolam to achieve and/or maintain optimal sedation; conversely, in another study, rescue sedation with intravenous midazolam was not required by significantly more dexmedetomidine than placebo recipients. Primary sedation with intravenous dexmedetomidine was also effective in terms of the secondary efficacy endpoints, including the mean total dose of midazolam and fentanyl administered and the percentage of patients requiring further sedation (in addition to dexmedetomidine or placebo and midazolam), with, for the most part, significant between-group differences observed in favour of dexmedetomidine over placebo. In general, no significant differences were observed between the dexmedetomidine and placebo treatment groups in the anaesthesiologists' assessment of ease of intubation, haemodynamic stability, patient cooperation and/or respiratory stability. Intravenous dexmedetomidine is generally well tolerated when utilized in mechanically ventilated patients in an intensive care setting and for procedural sedation in non-intubated patients. Dexmedetomidine is associated with a lower rate of postoperative delirium than midazolam or propofol; it is not associated with respiratory depression. While dexmedetomidine is associated with hypotension and bradycardia, both usually resolve without intervention. Thus, intravenous dexmedetomidine provides a further option as a short-term (<24 hours) primary sedative in mechanically ventilated adult patients in an intensive care setting and in non-intubated adult patients prior to and/or during surgical and other procedures.

Palliative pharmacological sedation for terminally ill adults.

PubMed

Beller, Elaine M; van Driel, Mieke L; McGregor, Leanne; Truong, Shani; Mitchell, Geoffrey

2015-01-02

Terminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain, vomiting, and psychological and physical distress. In the terminal phase of life, these symptoms may become refractory, and unable to be controlled by supportive and palliative therapies specifically targeted to these symptoms. Palliative sedation therapy is one potential solution to providing relief from these refractory symptoms. Sedation in terminally ill people is intended to provide relief from refractory symptoms that are not controlled by other methods. Sedative drugs such as benzodiazepines are titrated to achieve the desired level of sedation; the level of sedation can be easily maintained and the effect is reversible. To assess the evidence for the benefit of palliative pharmacological sedation on quality of life, survival, and specific refractory symptoms in terminally ill adults during their last few days of life. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 11), MEDLINE (1946 to November 2014), and EMBASE (1974 to December 2014), using search terms representing the sedative drug names and classes, disease stage, and study designs. We included randomised controlled trials (RCTs), quasi-RCTs, non-RCTs, and observational studies (e.g. before-and-after, interrupted-time-series) with quantitative outcomes. We excluded studies with only qualitative outcomes or that had no comparison (i.e. no control group or no within-group comparison) (e.g. single arm case series). Two review authors independently screened titles and abstracts of citations, and full text of potentially eligible studies. Two review authors independently carried out data extraction using standard data extraction forms. A third review author acted as arbiter for both stages. We carried out no meta-analyses due to insufficient data for pooling on any outcome; therefore, we reported outcomes narratively. The searches resulted in 14 included studies, involving 4167 adults, of whom 1137 received palliative sedation. More than 95% of people had cancer. No studies were randomised or quasi-randomised. All were consecutive case series, with only three having prospective data collection. Risk of bias was high, due to lack of randomisation. No studies measured quality of life or participant well-being, which was the primary outcome of the review. Five studies measured symptom control, using four different methods, so pooling was not possible. The results demonstrated that despite sedation, delirium and dyspnoea were still troublesome symptoms in these people in the last few days of life. Control of other symptoms appeared to be similar in sedated and non-sedated people. Only one study measured unintended adverse effects of sedative drugs and found no major events; however, four of 70 participants appeared to have drug-induced delirium. The study noticed no respiratory suppression. Thirteen of the 14 studies measured survival time from admission or referral to death, and all demonstrated no statistically significant difference between sedated and non-sedated groups. There was insufficient evidence about the efficacy of palliative sedation in terms of a person's quality of life or symptom control. There was evidence that palliative sedation did not hasten death, which has been a concern of physicians and families in prescribing this treatment. However, this evidence comes from low quality studies, so should be interpreted with caution. Further studies that specifically measure the efficacy and quality of life in sedated people, compared with non-sedated people, and quantify adverse effects are required.

Oral dexmedetomidine for preoperative sedation in an adult uncooperative autistic patient.

PubMed

Konia, Mojca Remskar

2016-11-01

We describe preoperative sedation with oral dexmedetomidine 5 mcg/kg in an uncooperative adult with autism and developmental delay. The sedation with oral dexmedetomidine achieved good sedation level (Ramsey 4-5), allowing for calm transfer of the patient to the operating room and uneventful induction of anesthesia. Copyright © 2016 Elsevier Inc. All rights reserved.

Antiemetics With Concomitant Sedative Use in Civil Aviation Pilot Fatalities: From 2000 to 2006

DTIC Science & Technology

2007-10-01

Unclassified Unclassified 13 Form DOT F 1700.7 (8-72) Reproduction of completed page authorized iii CONTENTS INTRODUCTION...sedative hypnotics , and ethanol. Antiemetics and drugs with antiemetic properties such as metoclopramide, diphenhydramine (a sedating...antihistamines, ethanol, barbiturates, serotonin modulators, and/or sedative- hypnotics . Antihistamines such as diphenhydramine are commonly used. The

The proportionate value of proportionality in palliative sedation.

PubMed

Berger, Jeffrey T

2014-01-01

Proportionality, as it pertains to palliative sedation, is the notion that sedation should be induced at the lowest degree effective for symptom control, so that the patient's consciousness may be preserved. The pursuit of proportionality in palliative sedation is a widely accepted imperative advocated in position statements and guidelines on this treatment. The priority assigned to the pursuit of proportionality, and the extent to which it is relevant for patients who qualify for palliative sedation, have been overstated. Copyright 2014 The Journal of Clinical Ethics. All rights reserved.

A continuous quality improvement approach to improving clinical practice in the areas of sedation, analgesia, and neuromuscular blockade.

PubMed

Arbour, Richard

2003-01-01

Practice concerns associated with the medical prescription and nurses' administration and monitoring of sedatives, analgesics, and neuromuscular blocking agents were identified by the clinical nurse specialist within a surgical intensive care unit of a large, tertiary-care referral center. These concerns were identified using a variety of needs assessment strategies. Results of the needs assessment were used to develop a program of care, including a teaching initiative, specific to these practice areas. The teaching initiative incorporated principles of andragogy, the theory of adult learning. Educational techniques included inservice education, bedside instruction using "teaching moments," competency-based education modules, and integration of instruction into critical care orientation. Content and approach were based on the background and level of experience of participants. Educational program outcomes included increased consistency in monitoring neuromuscular blockade by clinical assessment and peripheral nerve stimulation. A second outcome was more accurate patient assessment leading to the provision of drug therapy specific to the patients' clinical states, including anxiety or pain. The continuous quality improvement approach offers a model for improving patient care using individualized needs assessment, focused educational interventions, and program evaluation strategies.

Challenges in paediatric procedural sedation: political, economic, and clinical aspects.

PubMed

Mason, K P

2014-12-01

Paediatric sedation has expanded in volume and demand over the past decade. In parallel with the increasing demand for and delivery of sedation by multi-specialty providers, conflicting political agendas have surfaced. With a limited selection of sedatives and few new sedatives to market over the past decade, some providers utilize agents that formerly were considered exclusive for administration by anaesthesiologists. This review highlights the important contributions to paediatric sedation over the past century. Considerations include the barriers and politics that impede progress and also future advances and contributions that may lie ahead. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effects of different doses of tramadol added to levobupivacaine in continuous wound infusion for postoperative pain treatment following cesarean section.

PubMed

Ekmekçi, Perihan; Çağlar, Gamze S; Yilmaz, Hakan; Kazbek, Baturay K; Gursoy, Asli Yarci; Kiseli, Mine; Tüzüner, Filiz

2017-02-01

The aim of this study was to compare the effects of two different doses of tramadol added to levobupivacaine as continuous wound infusion, on VAS scores following cesarean section. The study was conducted in an University Hospital and was approved by the Local Ethical Committee. Sixty-five ASA I-II parturients, between 18 and 45 years were enrolled. The participants were randomized to three groups. Group T1 (n = 21) was given the study solution consisting of levobupivacaine 0.25% + tramadol 1 mg/kg. Group T2 (n = 21) was given levobupivacaine 0.25% + tramadol 2 mg/kg and Group L (n = 21) was given levobupivacaine 0.25%, subcutaneously, alone. Each patient who delivered by cesarean section was applied a triple orifice epidural catheter above rectus fascia for continious wound infiltration. VAS at rest and with 20 degrees leg lift, time to first additional analgesic, total additional analgesic consumption, side effects, and sedation scores were recorded. There were no statistically significant differences among groups, concerning VAS scores at rest and VAS scores at leg lift. Total amount of additional analgesics and sedation scores were also similar for three groups. Different doses of tramadol as adjunct to local anesthetics in continuous wound infiltration following cesarean section do not seem to provide superior analgesia.

Asleep versus awake: does it matter?: Pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network.

PubMed

Taenzer, Andreas H; Walker, Benjamin J; Bosenberg, Adrian T; Martin, Lynn; Suresh, Santhanam; Polaner, David M; Wolf, Christie; Krane, Elliot J

2014-01-01

The impact of the patient state at time of placement of regional blocks on the risk of complications is unknown. Current opinion is based almost entirely on case reports, despite considerable interest in the question. Analyzing more than 50,000 pediatric regional anesthesia blocks from an observational prospective database, we determined the rate of adverse events in relation to the patient's state at the time of block placement. Primary outcomes considered were postoperative neurologic symptoms (PONSs) and local anesthetic systemic toxicity (LAST). Secondary outcome was extended hospital stay due to a block complication. The Pediatric Regional Anesthesia Network is a multi-institutional research consortium that was created with an emphasis on rigorous, prospective, and complete data collection including a data validation and audit process. For the purpose of the analysis, blocks were divided in major groups by single injection versus continuous and by block location. Rates were determined in aggregate for these groups and classified further based on the patient's state (general anesthesia [GA] without neuromuscular blockade [NMB], GA with NMB, sedated, and awake) at the time of block placement. Postoperative neurological symptoms occurred at a rate of 0.93/1000 (confidence interval [CI], 0.7-1.2) under GA and 6.82/1000 (CI, 4.2-10.5) in sedated and awake patients. The only occurrence of PONSs lasting longer than 6 months (PONSs-L) was a small sensory deficit in a sedated patient (0.019/1000 [CI, 0-0.1] for all, 0.48/1000 [CI, 0.1-2.7] for sedated patients). There were no cases of paralysis. There were 5 cases of LAST or 0.09/1000 (CI, 0.03-0.21). The incidence of LAST in patients under GA (both with and without NMB) was 0.08/1000 (CI, 0.02-0.2) and 0.34/1000 (CI, 0-1.9) in awake/sedated patients. Extended hospital stays were described 18 times (0.33/1000 [CI, 0.2-0.53]). The rate for patients under GA without NMB was 0.29/1000 (CI, 0.13-0.48); GA with NMB, 0.29/1000 (CI, 0.06-0.84); sedated, 1.47/1000 (CI, 0.3-4.3); and awake, 1.15/1000 (CI, 0.02-6.4). The placement of regional anesthetic blocks in pediatric patients under GA is as safe as placement in sedated and awake children. Our results provide the first prospective evidence for the pediatric anesthesia community that the practice of placing blocks in anesthetized patients should be considered safe and should remain the prevailing standard of care. Prohibitive recommendations based on anecdote and case reports cannot be supported.

[Palliative sedation in a university hospital: experience after introducing a specific protocol].

PubMed

Boceta Osuna, J; Nabal Vicuña, M; Martínez Peñalver, F; Blanco Picabia, A; Aguayo Canela, M; Royo Aguado, J L

2013-01-01

A descriptive prospective study of palliative sedation (PS) records during a one year period after starting the PS protocol. Patients included in the PS protocol and those who had completed the "data registry form". Registry forms included in the PS protocol as Annex 5 (included as Annex 1 in this study). Personal data, data regarding basal disease, prognosis, level of information. Refractory symptoms: type, time of evolution and treatments employed. Involvement of the patient and/or representatives in decision making. Type of sedation, continuity, depth, employed, duration and results, and readjustment of other therapeutic measures. The SPSS 14.0 was used. For qualitative variables we studied absolute frequencies and proportions. For quantitative variables with normal distribution, we used means and standard deviations, and for non-normal distribution, medians and ranges. In the study period 90 cases of PS were counted. This represented 27.6% of the patients treated in the hospital palliative care support team (PCST), and 7.03% of the total deceased patients in our hospital. Mean age of patients undergoing PS was 59.22 years old, range between 40.86 and 77.58 years, and 68.1% were men. All patients were in an advanced or terminal stage of their condition, and 49.5% in an agonal phase. In 90.4% of the cases, the main pathology was oncological. Regarding PS indication, this was jointly made between the PCST physician and the patient's usual doctor in 60 cases (66.6%). Symptoms leading to sedation were mainly dyspnea, delirium and pain. The Ethics committee was consulted in five cases. Mean time under sedation was 134.02 hours (5.5 days). In 90% of the cases, duration ranged from 50 to 218.04 hours (2-9 days). Depth of PS after induction was registered in 88.8% of the cases. Informed consent (IC) was explicit in 11.2% of the cases,and given prior to the appearance of refractory symptoms and/or agonal phase. In 88.8% of sedation cases, the IC was given by a representative. Midazolam was the most used drug of choice in 87.8% of the cases, and levomepromazine in 10.2%. Up to 15% of sedations required drug changes or combinations. 1) The application of a PS Protocol and the availability of a hospital PCST and an Ethical Care Committee favored a safe (correct) use of PS in a hospital lacking a palliative care unit (PCU), and a homogeneous data registry for their analysis, with quality criteria similar to those offered by a PCU. 2) We have detected areas of improvement that will be applied in the second version of our protocol. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.

Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome.

PubMed

Kuyrukluyıldız, Ufuk; Binici, Orhan; Onk, Didem; Ayhan Celik, Serap; Torun, Mumtaz Taner; Unver, Edhem; Ozcicek, Adalet; Alagol, Aysin

2015-01-01

Backround: Surgical operations are alternative treatments in persons with Obstructive Sleep Apnea Syndrome who cannot tolerate continuous positive airway pressure therapy. Drug-Induced Sleep Endoscopy is a method with which somnolence is pharmacologically induced and collapse is evaluated through nasal endoscopy in patients with Obstructive Sleep Apnea Syndrome. We aimed to evaluate efficiency of dexmedetomidine or propofol used for sedation in patients undergoing drug-induced sleep endoscopy. A total of 40 patients aged between 18 and 65 years old in the ASA STATUS I-II group were included in the study. After premedicatıon wıth midazolam 0.05 mg/kg intravenously, patients were randomly divided into two groups and administered intravenous (iv) propofol with the loading dose of 0.7 mg/kg for 10 minutes, followed 0.5 mg/kg/h infusion (Group P); or dexmedetomidine with the loading dose of 1 mcg/kg for 10 minutes, followed by 0.3 mcg/kg/h infusion (Group D). Haemodynamic and respiratuary parameters, Bispectral index score, Ramsey sedation score, time to achieve sufficient sedation, surgeon's and patients' satisfaction, postoperative Aldrete score and side effects were recorded. Time to achieve sufficient sedation, Bispectral index scores at 5, 10 and 15th. minutes intraoperatively, first Aldrete score in the recovery room, SpO2 values and respiratory rates all over the surgical procedure and in the recovery room were found lower in Group P (P<0.05). Bispectral index scores, mean arterial pressure and heart rate in the recovery room were significantly lower in Group D (P<0.05). Dexmedetomidine may be preferred as a safer agent with respecting to respiratory function compared with propofol in obstructive sleep apnea patients who known to be susceptible to hypoxia and hypercarbia.

Randomised clinical trial: a 'nudge' strategy to modify endoscopic sedation practice.

PubMed

Harewood, G C; Clancy, K; Engela, J; Abdulrahim, M; Lohan, K; O'Reilly, C

2011-07-01

In behavioural economics, a 'nudge' describes configuration of a choice to encourage a certain action without taking away freedom of choice. To determine the impact of a 'nudge' strategy - prefilling either 3mL or 5mL syringes with midazolam - on endoscopic sedation practice. Consecutive patients undergoing sedation for EGD or colonoscopy were enrolled. On alternate weeks, midazolam was prefilled in either 3mL or 5mL syringes. Preprocedure sedation was administered by the endoscopist to achieve moderate conscious sedation; dosages were at the discretion of the endoscopist. Meperidine was not prefilled. Overall, 120 patients received sedation for EGD [59 (5mL), 61 (3mL)] and 86 patients were sedated for colonoscopy [38 (5mL), 48 (3mL)]. For EGDs, average midazolam dose was significantly higher in the 5-mL group (5.2mg) vs. 3-mL group (3.3mg), (P<0.0001); for colonoscopies, average midazolam dose was also significantly higher in the 5-mL group (5.1mg) vs. 3-mL group (3.3mg), (P<0.0001). There was no significant difference in mean meperidine dose (42.1mg vs. 42.8mg, P=0.9) administered to both colonoscopy groups. No adverse sedation-related events occurred; no patient required reversal of sedation. These findings demonstrate that 'nudge' strategies may hold promise in modifying endoscopic sedation practice. Further research is required to explore the utility of 'nudges' in impacting other aspects of endoscopic practice. © 2011 Blackwell Publishing Ltd.

Opinions of the Dutch public on palliative sedation: a mixed-methods approach

PubMed Central

van der Kallen, Hilde TH; Raijmakers, Natasja JH; Rietjens, Judith AC; van der Male, Alex A; Bueving, Herman J; van Delden, Johannes JM; van der Heide, Agnes

2013-01-01

Background Palliative sedation is defined as deliberately lowering a patient’s consciousness, to relieve intolerable suffering from refractory symptoms at the end of life. Palliative sedation is considered a last resort intervention in end-of-life care that should not be confused with euthanasia. Aim To inform healthcare professionals about attitudes of the general public regarding palliative sedation. Design and setting A cross-sectional survey among members of the Dutch general public followed by qualitative interviews. Method One thousand nine hundred and sixty members of the general public completed the questionnaire, which included a vignette describing palliative sedation (response rate 78%); 16 participants were interviewed. Results In total, 22% of the responders indicated knowing the term ‘palliative sedation’. Qualitative data showed a variety of interpretations of the term. Eighty-one per cent of the responders agreed with the provision of sedatives as described in a vignette of a patient with untreatable pain and a life expectancy of <1 week who received sedatives to alleviate his suffering. This percentage was somewhat lower for a patient with a life expectancy of <1 month (74%, P = 0.007) and comparable in the case where the physician gave sedatives with the aim of ending the patient’s life (79%, P = 0.54). Conclusion Most of the general public accept the use of palliative sedation at the end of life, regardless of a potential life-shortening effect. However, confusion exists about what palliative sedation represents. This should be taken into account by healthcare professionals when communicating with patients and their relatives on end-of-life care options. PMID:24152482

Sedation of Patients with Acute Aneurysmal Subarachnoid Hemorrhage with Ketamine Is Safe and Might Influence the Occurrence of Cerebral Infarctions Associated with Delayed Cerebral Ischemia.

PubMed

Von der Brelie, Christian; Seifert, Michael; Rot, Sergej; Tittel, Anja; Sanft, Carsten; Meier, Ullrich; Lemcke, Johannes

2017-01-01

Ketamine has neuroprotective characteristics as well as beneficial cardiocirculatory properties and may thus reduce vasopressor consumption. In contrast, sedation with ketamine (like any other sedative drug) has side effects. This study assesses the influence of ketamine on intracranial pressure (ICP), on the consumption of vasopressors in induced hypertension therapy, and on the occurrence of delayed cerebral ischemia (DCI)-associated cerebral infarctions, with particular focus on the complications of sedation in patients with aneurysmal subarachnoid hemorrhage (SAH). This is a retrospective, observational study. Sixty-five patients with SAH who underwent a period of sedation were included. The clinical course variables (Richmond Agitation and Sedation scale score, ICP values, consumption of vasopressors, complications of sedation, outcome, and other clinical parameters) were analyzed. Cranial computed tomography results were analyzed. Forty-one patients underwent sedation including ketamine (63.1%). Ketamine decreased the ICP in 92.7% of the cases. Vasopressors was reduced in 53.6%. DCI-associated cerebral infarctions occurred significantly less often in the patient cohort being treated with sedation including ketamine (7.3% vs. 25% in the nonketamine group; P = 0.04). The rate of major complications was not higher in the ketamine group. Outcome was not different regarding the groups if they were sedated with or without ketamine. Ketamine decreases the ICP and is not associated with a higher rate of complications. The rate of DCI-associated cerebral infarctions was lower in the ketamine group. Ketamine administration led to a reduction of vasopressors used for induced hypertension. Copyright © 2016 Elsevier Inc. All rights reserved.

Pediatrician Ambiguity in Understanding Palliative Sedation at the End of Life.

PubMed

Henderson, Carrie M; FitzGerald, Michael; Hoehn, K Sarah; Weidner, Norbert

2017-02-01

Palliative sedation is a means of relieving intractable symptoms at the end of life, however, guidelines about its use lack consistency. In addition, ethical concerns persist around the practice. There are reports of palliative sedation in the pediatric literature, which highlight various institutional perspectives. This survey of 4786 pediatric providers sought to describe their knowledge of and current practices around pediatric palliative sedation. Our survey was administered to pediatricians who care for children at the end of life. The survey assessed agreement with a definition of palliative sedation, as well as thoughts about its alignment with aggressive symptom management. Bivariate analyses using χ 2 and analysis of variance were calculated to determine the relationship between responses to closed-ended questions. Open-ended responses were thematically coded by the investigators and reviewed for agreement. Nearly half (48.6%) of the respondents indicated that the stated definition of palliative sedation "completely" reflected their own views. Respondents were split when asked if they viewed any difference between palliative sedation and aggressive symptom management: Yes (46%) versus No (54%). Open-ended responses revealed specifics about the nature of variation in interpretation. Responses point to ambiguity surrounding the concept of palliative sedation. Pediatricians were concerned with a decreased level of consciousness as the goal of palliative sedation. Respondents were split on whether they view palliative sedation as a distinct entity or as one broad continuum of care, equivalent to aggressive symptom management. Institutional-based policies are essential to clarify acceptable practice, enable open communication, and promote further research.

Current sedation practice among general dental practitioners and dental specialists in Jordan: an example of a developing country.

PubMed

Al-Shayyab, Mohammad H; Ryalat, Soukaina; Dar-Odeh, Najla; Alsoleihat, Firas

2013-01-01

The study reported here aimed to identify current sedation practice among general dental practitioners (GDPs) and specialist dental practitioners (SDPs) in Jordan in 2010. Questionnaires were sent by email to 1683 GDPs and SDPs who were working in Jordan at the time of the study. The contact details of these dental practitioners were obtained from a Jordan Dental Association list. Details on personal status, use of, and training in, conscious sedation techniques were sought by the questionnaires. A total of 1003 (60%) questionnaires were returned, with 748 (86.9%) GDPs and 113 (13.1%) SDPs responding. Only ten (1.3%) GDPs and 63 (55.8%) SDPs provided information on the different types of treatments related to their specialties undertaken under some form of sedation performed by specialist and/or assistant anesthetists. Approximately 0.075% of the Jordanian population received some form of sedation during the year 2010, with approximately 0.054% having been treated by oral and maxillofacial surgeons. The main reason for the majority of GDPs (55.0%) and many SDPs (40%) not to perform sedation was lack of training in this field. While some SDPs (26.0%) indicated they did not use sedation because of the inadequacy of sedative facilities. Within the limitations of the present study, it can be concluded that the provision of conscious sedation services in general and specialist dental practices in Jordan is inconsistent and inadequate. This stresses the great need to train practitioners and dental assistants in Jordan to enable them to safely and effectively perform all forms of sedation.

Pectoral nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation.

PubMed

Fujiwara, Atsushi; Komasawa, Nobuyasu; Minami, Toshiaki

2014-01-01

A 71-year-old man was scheduled to undergo cardiac resynchronization therapy device (CRTD) implantation. He was combined with severe chronic heart failure due to ischemic heart disease. NYHA class was 3 to 4 and electrocardiogram showed non-sustained ventricular. Ejection fraction was about 20% revealed by transthoracic echocardiogram. He was also on several anticoagulation medications. We planned to implant the device under the greater pectoral muscle. As general anesthesia was considered risky, monitored anesthesia care utilizing peripheral nerve block and slight sedation was scheduled. Pectoral nerves (PECS) block and intercostal block was performed under ultrasonography with ropivacaine. For sedation during the procedure, continuous infusion of dexmedetomidine without a loading dose was performed. The procedure lasted about 3 hours, but the patient showed no pain or restlessness. Combination of PECS block and intercostal block may provide effective analgesia for CRTD implantation.

[The last phase in the progressive neoplasic disease: care at the end-of-life, refractory symptoms and sedation].

PubMed

González Barón, Manuel; Gómez Raposo, César; Vilches Aguirre, Yolanda

2006-09-23

End-of-life is one of the most stressful phases during course of a neoplasic disease. Frequently, death of patients with cancer comes after a continuous and progressive physical impairment. As death approaches, the medical team might redefine outcomes and treat as priority symptoms and relief suffering. That care encompasses the physical, psychological, social, spiritual, and existential needs of patients and their families. However, symptoms are frequently observed that are intolerable for the patient and which do not respond to usual palliative measures. The intolerable nature and being refractory to treatment indicates to the health-care team, on many occasions, the need for sedation of the patient. The medical team can take comfort in the knowledge that they did their best to provide safe passage to all their patients and that, although they did not always cure them, the patients often were healed.

Hypnosis for cataract surgery in an American Society of Anesthesiologists physical status IV patient.

PubMed

Kiss, G; Butler, J

2011-11-01

A 73-year-old morbidly obese female patient (weight 125 kg, height 156 cm) was scheduled for cataract surgery of her right eye. Due to a number of severe co-morbidities general anaesthesia was contraindicated. However the patient was very anxious and requested sedation if the procedure was to be undertaken under local anaesthesia. She responded very positively to the proposal of utilising perioperative hypnosis. Hypnotic induction was achieved with the heavy eyelid technique, putting the patient into trance within 30 seconds. Continuous relaxing suggestions as described by the patient herself the day before surgery were used to maintain the trance state. She later reported that she was not aware of being in the operating room, but experienced profound relaxation during the procedure. Perioperative hypnosis proved to be a satisfactory option for sedation in this high-risk patient and should be actively considered for similar easily suggestible patients who are undergoing minor surgery.

Sedation in a radiology department--do radiologists follow their own guidelines?

PubMed

Eason, D; Chakraverty, S; Wildsmith, J A W

2011-05-01

The Royal College of Radiologists (RCR) published guidelines in 2003 which aimed to standardise and improve the safety of sedation in the modern Radiology department. As sedation requirements increase, we decided to audit our own departments understandings and practice with respect to sedation. A repeat audit cycle was performed following a re-educational lecture, one year later. Three common sedation case scenarios were incorporated into a questionnaire which detailed questioning on requirements for fasting, monitoring and the order and use of sedation drugs alongside analgesics. These were compared to the 2003 RCR guidelines. The audit was recycled at one year. Despite the RCR guidelines, freely available on the RCR website, there was a persisting variation in practice which revealed a lack of awareness of the requirements for adequate fasting and the importance of giving the opiate before the benzodiazepine (sedative) agent in cases where a combination are chosen. The audit did show a trend towards using shorter acting benzodiazepines, which is in keeping with the guidelines. Monitoring of vital signs was generally, well carried out. General awareness of the RCR guidelines for safe sedation in the Radiology department was initially low and practice found to be variable. Re-education saw some improvements but also, some persisting habitual deviations from the guidelines, particularly with respect to the order in which the opiate and sedative benzodiazepine were given.

Efficacy Outcome Measures for Procedural Sedation Clinical Trials in Adults: An ACTTION Systematic Review.

PubMed

Williams, Mark R; McKeown, Andrew; Dexter, Franklin; Miner, James R; Sessler, Daniel I; Vargo, John; Turk, Dennis C; Dworkin, Robert H

2016-01-01

Successful procedural sedation represents a spectrum of patient- and clinician-related goals. The absence of a gold-standard measure of the efficacy of procedural sedation has led to a variety of outcomes being used in clinical trials, with the consequent lack of consistency among measures, making comparisons among trials and meta-analyses challenging. We evaluated which existing measures have undergone psychometric analysis in a procedural sedation setting and whether the validity of any of these measures support their use across the range of procedures for which sedation is indicated. Numerous measures were found to have been used in clinical research on procedural sedation across a wide range of procedures. However, reliability and validity have been evaluated for only a limited number of sedation scales, observer-rated pain/discomfort scales, and satisfaction measures in only a few categories of procedures. Typically, studies only examined 1 or 2 aspects of scale validity. The results are likely unique to the specific clinical settings they were tested in. Certain scales, for example, those requiring motor stimulation, are unsuitable to evaluate sedation for procedures where movement is prohibited (e.g., magnetic resonance imaging scans). Further work is required to evaluate existing measures for procedures for which they were not developed. Depending on the outcomes of these efforts, it might ultimately be necessary to consider measures of sedation efficacy to be procedure specific.

A small group of neurosecretory cells expressing the transcriptional regulator apontic and the neuropeptide corazonin mediate ethanol sedation in Drosophila.

PubMed

McClure, Kimberly D; Heberlein, Ulrike

2013-02-27

In the fruit fly Drosophila melanogaster, as in mammals, acute exposure to a high dose of ethanol leads to stereotypical behavioral changes beginning with increased activity, followed by incoordination, loss of postural control, and eventually, sedation. The mechanism(s) by which ethanol impacts the CNS leading to ethanol-induced sedation and the genes required for normal sedation sensitivity remain largely unknown. Here we identify the gene apontic (apt), an Myb/SANT-containing transcription factor that is required in the nervous system for normal sensitivity to ethanol sedation. Using genetic and behavioral analyses, we show that apt mediates sensitivity to ethanol sedation by acting in a small set of neurons that express Corazonin (Crz), a neuropeptide likely involved in the physiological response to stress. The activity of Crz neurons regulates the behavioral response to ethanol, as silencing and activating these neurons affects sedation sensitivity in opposite ways. Furthermore, this effect is mediated by Crz, as flies with reduced crz expression show reduced sensitivity to ethanol sedation. Finally, we find that both apt and crz are rapidly upregulated by acute ethanol exposure. Thus, we have identified two genes and a small set of peptidergic neurons that regulate sensitivity to ethanol-induced sedation. We propose that Apt regulates the activity of Crz neurons and/or release of the neuropeptide during ethanol exposure.

A Small Group of Neurosecretory Cells Expressing the Transcriptional Regulator apontic and the Neuropeptide corazonin Mediate Ethanol Sedation in Drosophila

PubMed Central

2013-01-01

In the fruit fly Drosophila melanogaster, as in mammals, acute exposure to a high dose of ethanol leads to stereotypical behavioral changes beginning with increased activity, followed by incoordination, loss of postural control, and eventually, sedation. The mechanism(s) by which ethanol impacts the CNS leading to ethanol-induced sedation and the genes required for normal sedation sensitivity remain largely unknown. Here we identify the gene apontic (apt), an Myb/SANT-containing transcription factor that is required in the nervous system for normal sensitivity to ethanol sedation. Using genetic and behavioral analyses, we show that apt mediates sensitivity to ethanol sedation by acting in a small set of neurons that express Corazonin (Crz), a neuropeptide likely involved in the physiological response to stress. The activity of Crz neurons regulates the behavioral response to ethanol, as silencing and activating these neurons affects sedation sensitivity in opposite ways. Furthermore, this effect is mediated by Crz, as flies with reduced crz expression show reduced sensitivity to ethanol sedation. Finally, we find that both apt and crz are rapidly upregulated by acute ethanol exposure. Thus, we have identified two genes and a small set of peptidergic neurons that regulate sensitivity to ethanol-induced sedation. We propose that Apt regulates the activity of Crz neurons and/or release of the neuropeptide during ethanol exposure. PMID:23447613

An audit of the sedation activity of participants following their attendance on SAAD conscious sedation courses.

PubMed

Walker, Peter

2013-01-01

The aim of this study was to analyse the results of a questionnaire given directly to participants of SAAD courses in 2011, and posted to previous participants, on their own use of conscious sedation. Apart from general interest, such data will help the SAAD Faculty to tailor the courses in future better to meet the needs of participants by providing insights into the attitudes and level of experience in sedation of course participants. Questionnaires were distributed to participants on all the 2011 SAAD courses and to all members of the dental team. In addition, the same questionnaire was posted to dentists who had attended courses in 2010 and 2007. In total 71% of the 157 dentists who completed questionnaires were providing conscious sedation in their practices. The most common technique used was intravenous sedation. Only 3% carried out any advanced techniques. 14% (n = 81) of dentists who had completed a SAAD course previously did not go on to use conscious sedation, and possible reasons for this are discussed. Participants' overall confidence in specific areas of sedation training were rated from 'good' to 'excellent' after completion of a SAAD course. Participants completing SAAD courses believe they have gained in confidence and in knowledge, and obtained the skills required to provide conscious sedation although some identify barriers which prevent them from putting these new skills into practice.

Effects of sedation on echocardiographic variables of left atrial and left ventricular function in healthy cats.

PubMed

Ward, Jessica L; Schober, Karsten E; Fuentes, Virginia Luis; Bonagura, John D

2012-10-01

Although sedation is frequently used to facilitate patient compliance in feline echocardiography, the effects of sedative drugs on echocardiographic variables have been poorly documented. This study investigated the effects of two sedation protocols on echocardiographic indices in healthy cats, with special emphasis on the assessment of left atrial size and function, as well as left ventricular diastolic performance. Seven cats underwent echocardiography (transthoracic two-dimensional, spectral Doppler, color flow Doppler and tissue Doppler imaging) before and after sedation with both acepromazine (0.1 mg/kg IM) and butorphanol (0.25 mg/kg IM), or acepromazine (0.1 mg/kg IM), butorphanol (0.25 mg/kg IM) and ketamine (1.5 mg/kg IV). Heart rate increased significantly following acepromazine/butorphanol/ketamine (mean±SD of increase, 40±26 beats/min) and non-invasive systolic blood pressure decreased significantly following acepromazine/butorphanol (mean±SD of decrease, 12±19 mmHg). The majority of echocardiographic variables were not significantly different after sedation compared with baseline values. Both sedation protocols resulted in mildly decreased left ventricular end-diastolic dimension and mildly increased left ventricular end-diastolic wall thickness. This study therefore failed to demonstrate clinically meaningful effects of these sedation protocols on echocardiographic measurements, suggesting that sedation with acepromazine, butorphanol and/or ketamine can be used to facilitate echocardiography in healthy cats.

A Review of Palliative Sedation.

PubMed

Bobb, Barton

2016-09-01

Palliative sedation has become a standard practice to treat refractory symptoms at end-of-life. Dyspnea and delirium are the two most commonly treated symptoms. The medications used in palliative sedation are usually benzodiazepines, barbiturates, antipsychotics, and/or anesthetics. Some ethical considerations remain, especially surrounding the use of palliative sedation in psychological distress and existential suffering. Copyright © 2016 Elsevier Inc. All rights reserved.

A Follow-up Survey of the Teaching of Conscious Sedation in Dental Schools of the United Kingdom and Ireland

PubMed Central

Leitch, J; Jauhar, S

2006-01-01

The purpose of this follow-up study was to assess and compare the quantity and quality of dental undergraduate teaching in conscious sedation with comparisons to a previous study conducted in 1998. Questionnaires were designed to collect information about undergraduate sedation education from teaching staff and final-year dental undergraduates at the 15 dental schools in the United Kingdom and Ireland. Staff responses from 9 schools (60%) and student responses from 11 schools (73%) were received. From the students' responses, the mean (range) number of cases observed in inhalational sedation was 7 (0–17) and the mean (range) number performed in inhalational sedation was 4 (0–8). The mean (range) number of cases observed in intravenous sedation was 9 (2–19), and the mean (range) number performed was 5 (0–8). There has been an increase in didactic teaching. There has been a decrease in the observing of inhalational cases, but an increase in the hands-on performance of this type of sedation. There is an increase in the hands-on teaching of intravenous sedation. PMID:16863392

Assessment of the sedative effects of buprenorphine administered with 10 μg/kg detomidine in horses.

PubMed

Love, E J; Taylor, P M; Murrell, J; Whay, H R; Waterman-Pearson, A E

2011-04-09

The aim of this randomised, observer-blinded, crossover study was to compare the effects of six treatments, administered intravenously to six horses: saline and saline (S/S); detomidine and saline (D/S); detomidine and 5 µg/kg buprenorphine (D/B5); detomidine and 7.5 µg/kg buprenorphine (D/B7.5); detomidine and 10 µg/kg buprenorphine (D/B10); and detomidine and 25 µg/kg butorphanol (D/BUT). The detomidine dose was 10 µg/kg for all treatments in which it was included. Sedation was subjectively assessed and recorded on a visual analogue scale. Peak sedation, duration of sedation and the area under the curve (AUC) for sedation scores were investigated using a univariate general linear model with post-hoc Tukey tests (P<0.05). Peak sedation and duration of sedation were statistically significantly different between treatments (P<0.001). No sedation was apparent after administration of S/S. The AUC was significantly different between treatments (P=0.010), with S/S being significantly different from D/S, D/BUT, D/B5 and D/B7.5, but not D/B10 (P=0.051).

Patient anxiety and IV sedation in Northern Ireland.

PubMed

Hunt, O; McCurley, N; Dempster, M; Marley, J

2011-06-24

In recent years there has been an increase in the provision of conscious sedation, which is said to be a safe and effective means of managing the anxious patient. However, there are no guidelines to aid the dental practitioner in assessing the patient's need for sedation based on their level of anxiety. The present study investigated the importance of patient anxiety as an indicator for IV sedation, using focus groups to inform the development of narrative vignettes. Ninety-nine practitioners responded to a series of scenarios to determine whether the level of patient anxiety and the patient's demand for IV sedation influenced their decision making. Level of dental anxiety had a stronger influence on the clinician's decision making than patient demand, with increasing levels of dental anxiety being positively associated with the likelihood of clinicians indicating a need for IV patient sedation and also, the likelihood of clinicians providing IV sedation to these patients. Only 14% (n = 14) of respondents reported formally assessing dental anxiety. While dental anxiety is considered to be a key factor in determining the need for IV sedation, there is a lack of guidance regarding the assessment of anxiety among patients.

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate.

PubMed

Cozzi, Giorgio; Norbedo, Stefania; Barbi, Egidio

2017-04-01

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine's impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.

Laryngospasm With Apparent Aspiration During Sedation With Nitrous Oxide.

PubMed

Babl, Franz E; Grindlay, Joanne; Barrett, Michael Joseph

2015-11-01

Nitrous oxide and oxygen mixture has become increasingly popular for the procedural sedation and analgesia of children in the emergency department. In general, nitrous oxide is regarded as a very safe agent according to large case series. We report a case of single-agent nitrous oxide sedation of a child, complicated by laryngospasm and radiographically confirmed bilateral upper lobe pulmonary opacities. Although rarely reported with parenteral sedative agents, laryngospasm and apparent aspiration has not been previously reported in isolated nitrous oxide sedation. This case highlights that, similar to other sedative agents, nitrous oxide administration also needs to be conducted by staff and in settings in which airway emergencies can be appropriately managed. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures.

PubMed

Bitar, George; Mullis, William; Jacobs, William; Matthews, David; Beasley, Michael; Smith, Kevin; Watterson, Paul; Getz, Stanley; Capizzi, Peter; Eaves, Felmont

2003-01-01

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.

Optimal and safe standard doses of midazolam and propofol to achieve patient and doctor satisfaction with dental treatment: A prospective cohort study

PubMed Central

Nonaka, Mutsumi; Nishimura, Akiko; Gotoh, Kinuko; Oka, Shuichirou; Iijima, Takehiko

2017-01-01

Background The incidences of morbidity and mortality caused by pharmacosedation for dental treatment have not yet reached zero. Adverse events are related to inappropriate respiratory management, mostly originating from an overdose of sedatives. Since sedation is utilized for the satisfaction of both the dentist and the patient, the optimal dose should be minimized to prevent adverse events. We attempted to define the optimal doses of midazolam and propofol required to achieve high levels of patient and dentist satisfaction. Methods One thousand dental patients, including those undergoing third molar extractions, were enrolled in this study. A dose of 1 mg of midazolam was administered at 1-minute intervals until adequate sedation was achieved. Propofol was then infused continuously to maintain the sedation level. Both the patients and the dentists were subsequently interviewed and asked to complete a questionnaire. A multivariate logistic regression analysis was used to examine the factors that contributed to patient and dentist satisfaction. Results The peak midazolam dose resulting in the highest percentage of patient satisfaction was 3 mg. Both a lower dose and a higher dose reduced patient satisfaction. Patient satisfaction increased with an increasing dosage of propofol up until 4 mg/kg/hr, reaching a peak of 78.6%. The peak midazolam dose resulting in the highest percentage of dentist satisfaction (78.8%) was 2 mg. Incremental propofol doses reduced dentist satisfaction, in contrast to their effect on patient satisfaction. The strongest independent predictors of patient satisfaction and dentist satisfaction were no intraoperative memory (OR, 5.073; 95% CI, 3.532–7.287; P<0.001) and unintentional movements by the patient (OR, 0.035; 95% CI, 0.012–0.104; P<0.001), respectively. No serious adverse events were reported. Conclusion We found that 3 mg of midazolam and 3 mg/kg/hr of propofol may be the optimal doses for maximizing both patient and dentist satisfaction. Although this level of sedation is relatively light, memory loss and an absence of unintentional patient movements can be expected without adverse events. PMID:28182732

Moral and Legal Issues Surrounding Terminal Sedation and Physician Assisted Suicide

DTIC Science & Technology

2002-09-23

1 MORAL AND LEGAL ISSUES SURROUNDING TERMINAL SEDATION AND PHYSICIAN ASSISTED SUICIDE by CONSTANCE ReJENNA BRADLEY B.S., United States Air Force...Title and Subtitle Moral and Legal Issues Surrounding Terminal Sedation and Physician-Assisted Suicide Contract Number Grant Number Program...Constance ReJenna (M.A., Philosophy) Moral and Legal Issues Surrounding Terminal Sedation and Physician Assisted Suicide Thesis directed by Instructor

Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging.

PubMed

Mekitarian Filho, Eduardo; Robinson, Fay; de Carvalho, Werther Brunow; Gilio, Alfredo Elias; Mason, Keira P

2015-05-01

This prospective observational pilot study evaluated the aerosolized intranasal route for dexmedetomidine as a safe, effective, and efficient option for infant and pediatric sedation for computed tomography imaging. The mean time to sedation was 13.4 minutes, with excellent image quality, no failed sedations, or significant adverse events. Registered with ClinicalTrials.gov: NCT01900405. Copyright © 2015 Elsevier Inc. All rights reserved.

Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption.

PubMed

Mehta, Sangeeta; Meade, Maureen; Burry, Lisa; Mallick, Ranjeeta; Katsios, Christina; Fergusson, Dean; Dodek, Peter; Burns, Karen; Herridge, Margaret; Devlin, John W; Tanios, Maged; Fowler, Robert; Jacka, Michael; Skrobik, Yoanna; Olafson, Kendiss; Cook, Deborah

2016-08-01

Mechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation. This is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night (19:00 to 07:00) and day (07:00 to 19:00) shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial (SBT) conduct, SBT success, and extubation. Nighttime benzodiazepine and opioid doses were significantly higher than daytime doses (mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p < 0.0001; mean difference fentanyl equivalents 356 mcg, 95 % CI 130, 582, p = 0.0021). Mean Sedation Agitation Scale score was similar between night and day, and was at target (3.2 vs 3.3, 95 % CI -0.05, 0.02, p = 0.35). Self-reported nurse workload was similar during the night and day. Patients were more often restrained during day shifts (76.3 % vs 73.7 %, p < 0.0001), and there were more unintentional device removals during the day compared with night (15.9 % vs 9.1 %, p < 0.0001). Increases in nighttime drug doses were independently associated with failure to meet SBT screening criteria, SBT failure, and the decision not to extubate the patient despite successful SBT. Patients received higher doses of opioids and benzodiazepines at night. Higher nighttime doses were associated with SBT failure and delayed extubation. ClinicalTrials.gov NCT00675363 . Registered 7 May 2008.

Pain control in first-trimester surgical abortion: a systematic review of randomized controlled trials.

PubMed

Renner, Regina M; Jensen, Jeffrey T; Nichols, Mark D; Edelman, Alison B

2010-05-01

First-trimester abortions especially cervical dilation and suction aspiration are associated with pain despite various methods of pain control. Following the guidelines for a Cochrane review, we systematically searched for and reviewed randomized controlled trials comparing methods of pain control in first-trimester surgical abortion at less than 14 weeks gestational age using electric or manual suction aspiration. Outcomes included intra- and postoperative pain, side effects, recovery measures and satisfaction. We included 40 trials with 5131 participants. Because of heterogeneity, we divided studies into seven groups: Local anesthesia: Data were insufficient to show a clear benefit of a paracervical block (PCB) compared to no PCB. Reported mean pain scores (10-point scale) during dilation and aspiration were improved with carbonated lidocaine [weighted mean difference (WMD), -0.80; 95% confidence interval (CI), -0.89 to -0.71; WMD, -0.96; 95% CI, -1.67 to -0.25], deep injection (WMD, -1.64; 95% CI, -3.21 to -0.08; WMD, 1.00; 95% CI, 1.09 to 0.91), and with adding a 4% intrauterine lidocaine infusion (WMD, -2.0; 95% CI, -3.29 to -0.71; WMD, -2.8; 95% CI, -3.95 to -1.65). PCB with premedication: Ibuprofen and naproxen resulted in small reduction of intra- and postoperative pain. Conscious sedation: The addition of conscious intravenous sedation using diazepam and fentanyl to PCB decreased procedural pain. General anesthesia: Conscious sedation increased intraoperative but decreased postoperative pain compared to general anesthesia (GA) [Peto odds ratio (Peto OR) 14.77 (95%, CI 4.91-44.38) and Peto OR 7.47 (95% CI, 2.2-25.36) for dilation and aspiration, respectively, and WMD -1.00 (95% CI, -1.77 to -0.23) postoperatively). Inhalation anesthetics are associated with increased blood loss (p<0.001). GA with premedication: The cyclooxygenase (COX)-2 inhibitor etoricoxib; the nonselective COX inhibitors lornoxicam, diclofenac and ketorolac IM; and the opioid nalbuphine improved postoperative pain. Nonpharmacological intervention: Listening to music decreased procedural pain. No major complication was observed. Conscious sedation, GA and some nonpharmacological interventions decreased procedural and postoperative pain, while being safe and satisfactory to patients. Data on the widely used PCB are inadequate to support its use, and it needs to be further studied to determine any benefit.

A comparison of the sedative effect of oral versus nasal midazolam combined with nitrous oxide in uncooperative children.

PubMed

Musani, I E; Chandan, N V

2015-10-01

To compare a combination of oral midazolam (0.2 mg/kg body weight) and nitrous oxide-oxygen sedation with a combination of intranasal midazolam (0.1 mg/kg body weight) and nitrous oxide-oxygen sedation for effectiveness, patient acceptability and safety profile in controlling the behaviour of uncooperative children. Thirty children, 4-10 years of age, referred for dental treatment were included in the study with a crossover design. Each patient was sedated with a combination of either oral midazolam and nitrous oxide-oxygen sedation or intranasal midazolam and nitrous oxide-oxygen sedation at subsequent dental treatment visits. During the treatment procedure, the study recorded scales for drug acceptability, onset of sedation, acceptance of nasal mask, sedation, behavioural, safety, overall behaviour and alertness. The grade of acceptability of midazolam in both groups was consistently good. There was a significant difference (p < 0.001) in the time of onset of sedation, which was significantly quicker with the intranasal administration of midazolam. The mean time of onset for oral midazolam was 20.1 (17-25) min and for intranasal midazolam 12.1 (8-18) min. The efficacy profile of the present study included: acceptance of nasal mask, sedation score, crying levels, motor movements and overall behaviour scores. The results did not show any statistically significant differences. All the parameters were highly satisfactory. The difference in alertness was statistically significant (p value <0.05), being higher in the intranasal group than the oral group and suggestive of faster recovery using intranasal midazolam. The intranasal route of midazolam administration has a quick onset of action and a quick recovery of the patient from sedation as compared to the oral route of midazolam administration. Midazolam administered through the intranasal route is as effective as the oral route at a lower dosage. Therefore, it is an effective alternative to oral route for a paediatric dental situation.

Terminal sedation: between pain relief, withholding treatment and euthanasia.

PubMed

Gevers, J K M

2006-12-01

In the last five to ten years there has been increasing debate on terminal sedation, a medical practice that is difficult to place between other decisions at the end of life, like alleviating pain, withholding treatment, and (in jurisdictions where this is allowed) euthanasia or physician-assisted suicide. Terminal sedation is the administration of sedative drugs with the aim to reduce the consciousness of a terminal patient in order to relieve distress. It is frequently accompanied by the withdrawal (or withholding) of life-sustaining interventions, such as hydration and nutrition. It is typically a measure of the last resort, to be considered in situations where all other measures to reduce pain and suffering have failed. While similar to palliative measures as far as the sedation itself is concerned, withholding of hydration and nutrition brings terminal sedation into the realm of non treatment decisions. At the same time, to the extent that the combination of these two measures may shorten the patient's life, the practice may be easily associated with euthanasia. It is no surprise therefore, that terminal sedation has been called (and has been disqualified as) 'slow euthanasia' or 'backdoor euthanasia'. This paper addresses the question how terminal sedation may be looked upon from a legal point of view. Is it indeed a disguised form of euthanasia, or should it be considered as a practice in its own right? In the latter case, what does it imply in legal terms, and under which conditions and safeguards could it be legally justified? To answer these questions, I will look first at the different clinical realities that may be brought under the heading 'terminal sedation'. Then I will deal with its two components--sedation on the one hand, and withholding artificial feeding on the other--in a legal perspective. The paper ends with conclusions on terminal sedation as a whole.

Midazolam versus diazepam for combined esophogastroduodenoscopy and colonoscopy.

PubMed

Brouillette, D E; Leventhal, R; Kumar, S; Berman, D; Kajani, M; Yoo, Y K; Carra, J; Tarter, R; Van Thiel, D H

1989-08-01

This study compares the effects of two different benzodiazepines used for conscious sedation during combined upper gastrointestinal endoscopy (EGD) and colonoscopy. Subjects were assessed for their degree of analgesia and amnesia for the procedure, prior experience with endoscopy, and willingness to undergo another similar procedure should such be necessary. The patients were randomized single blind to receive either midazolam or diazepam for their preprocedure sedation. The amount of preprocedure sedation utilized was determined by titration of the dose to achieve slurring of speech. Prior to receiving either agent, the subjects were shown a standard card containing pictures of 10 common objects, were asked to name and remember them, and were told they would be "quizzed" (at 30 min and 24 hr) after being sedated for their recollection as to the objects pictured on the card. Each subject filled out a questionnaire addressing their perceived discomfort during the endoscopic procedure and their memory of the procedure 24 hr after the procedure. Sixty-three percent of the midazolam-sedated subjects reported total amnesia for their colonoscopy vs 20% of diazepam-sedated patients (P less than 0.001). Fifty-three percent of midazolam-sedated patients reported total amnesia of their upper gastrointestinal endoscopy vs only 23% of diazepam-sedated subjects (P less than 0.05). The midazolam-sedated subjects reported experiencing less pain with both upper gastrointestinal endoscopy (P less than 0.05) and colonoscopy (P less than 0.001) than did the diazepam-sedated group. Most importantly, the midazolam group was more willing to undergo another similar endoscopic procedure should they be asked to do so by their physician (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Analgesic and sedative effects of intranasal dexmedetomidine in third molar surgery under local anaesthesia.

PubMed

Cheung, C W; Ng, K F J; Liu, J; Yuen, M Y V; Ho, M H A; Irwin, M G

2011-09-01

Dexmedetomidine (DEX) is an alpha 2-adrenoreceptor agonist, which induces sedation and analgesia. This study aimed to determine whether intranasal DEX offered perioperative sedation and better postoperative analgesia. Patients having unilateral third molar surgery under local anaesthesia were recruited and allocated to receive either intranasal DEX 1 µg kg(-1) (Group D) or same volume of saline (Group P) 45 min before surgery. Patient-controlled sedation with propofol was offered as a rescue sedative. Perioperative sedation, postoperative pain relief and analgesic consumption, vital signs, adverse events, postoperative recovery, and satisfaction in sedation and analgesia were assessed. Thirty patients from each group were studied. Areas under curve (AUC) of postoperative numerical rating scale (NRS) pain scores 1-12 h at rest and during mouth opening were significantly lower in Group D (P=0.003 and 0.009, respectively). AUC BIS values and OAA/S sedation scores were significantly lower before surgery and at the recovery area (all P<0.01) with significantly less intra-operative propofol used in group D (P<0.01). In group D, heart rate was significantly lower at recovery period (P=0.005) while systolic blood pressure in different periods of the study (all P<0.01), but the decreases did not require treatment. More patients from placebo group experienced dizziness (P=0.026) but no serious adverse event was found. No difference was found in postoperative psychomotor recovery and satisfaction in pain relief and sedation. Patients receiving intranasal DEX for unilateral third molar surgery with local anaesthesia were more sedated perioperatively with better postoperative pain relief. No delay in psychomotor recovery was seen.

A novel system for automated propofol sedation: hybrid sedation system (HSS).

PubMed

Zaouter, Cedrick; Taddei, Riccardo; Wehbe, Mohamad; Arbeid, Erik; Cyr, Shantale; Giunta, Francesco; Hemmerling, Thomas M

2017-04-01

Closed-loop systems for propofol have been demonstrated to be safe and reliable for general anesthesia. However, no study has been conducted using a closed-loop system specifically designed for sedation in patients under spinal anesthesia. We developed an automatic anesthesia sedation system that allows for closed-loop delivery of propofol for sedation integrating a decision support system, called the hybrid sedation system (HSS). The objective of this study is to compare this system with standard practice. One hundred fifty patients were enrolled and randomly assigned to two groups: HSS-Group (N = 75), in which propofol was administered using a closed-loop system; Control Group (N = 75), in which propofol was delivered manually. The clinical performance of the propofol sedation control is defined as efficacy to maintain bispectral index (BIS) near 65. The clinical control was called 'Excellent', 'Good', 'Poor' and 'Inadequate' with BIS values within 10 %, from 11 to 20 %, 21 to 30 %, or greater than 30 % of the BIS target of 65, respectively. The controller performance was evaluated using Varvel's parameters. Data are presented as mean ± standard deviation, groups were compared using t test or Chi square test, P < 0.05. Clinical performance of sedation showed 'Excellent' control in the HSS-group for a significantly longer period of time (49 vs. 26 % in the control group, P < 0.0001). 'Poor' and 'Inadequate' sedation was significantly shorter in the HSS Group compared to the Control Group (11 and 10 % vs. 20 and 18 %, respectively, P < 0.0001). The novel, closed-loop system for propofol sedation showed better maintenance of the target BIS value compared to manual administration.

Immunizations under sedation at a paediatric hospital in Melbourne, Australia from 2012-2016.

PubMed

Cheng, Daryl R; Elia, Sonja; Perrett, Kirsten P

2018-05-09

Sedation for immunizations is of particular importance in a subset of paediatric patients with anxiety disorders, needle phobia, developmental or behavioural disorders. The Royal Children's Hospital (RCH) Melbourne offers a unique immunization under sedation service for these patients. We aimed to evaluate the number and types of patients using inpatient sedation for immunizations, distraction and sedation techniques used, and outcomes of these procedures. A medical record review was conducted on all patients who had immunization under sedation between January 2012 to December 2016 in the RCH Day Medical Unit (DMU). A total of 139 children and adolescents had 213 vaccination encounters. More than half of the vaccination encounters involved multiple vaccines. A total of 400 vaccines were administered. One third of patients (32.3%) had multiple DMU admissions for vaccinations. The median age of patients was 13 years. There were only 10 (4.7%) failed attempts at vaccination; all due to patient non-compliance with prescribed sedation. The majority of patients (58.9%) had a diagnosis of needle phobia. Sedation was most commonly adequately achieved with inhaled nitrous oxide (54.7% sole agent). Midazolam was often used as an adjunct therapy (42.8%). Local anaesthetic cream or play therapy, were used in only 5.9% and 3.9% of patients respectively, although this may reflect poor documentation rather than actual practice. For a subset of paediatric patients for which standard immunization procedures have failed, distraction techniques and conscious sedation enable immunizations to be given safely and effectively. Future research will develop protocols to streamline immunization procedures under sedation. Copyright © 2018 Elsevier Ltd. All rights reserved.

Pharmacokinetics of detomidine following intravenous or oral-transmucosal administration and sedative effects of the oral-transmucosal treatment in dogs.

PubMed

Messenger, Kristen M; Hopfensperger, Marie; Knych, Heather K; Papich, Mark G

2016-04-01

To determine the pharmacokinetics of detomidine hydrochloride administered IV (as an injectable formulation) or by the oral-transmucosal (OTM) route (as a gel) and assess sedative effects of the OTM treatment in healthy dogs. 12 healthy adult dogs. In phase 1, detomidine was administered by IV (0.5 mg/m(2)) or OTM (1 mg/m(2)) routes to 6 dogs. After a 24-hour washout period, each dog received the alternate treatment. Blood samples were collected for quantification via liquid chromatography with mass spectrometry and pharmacokinetic analysis. In phase 2, 6 dogs received dexmedetomidine IV (0.125 mg/m(2)) or detomidine gel by OTM administration (0.5 mg/m(2)), and sedation was measured by a blinded observer using 2 standardized sedation scales while dogs underwent jugular catheter placement. After a l-week washout period, each dog received the alternate treatment. Median maximum concentration, time to maximum concentration, and bioavailability for detomidine gel following OTM administration were 7.03 ng/mL, 1.00 hour, and 34.52%, respectively; harmonic mean elimination half-life was 0.63 hours. All dogs were sedated and became laterally recumbent with phase 1 treatments. In phase 2, median global sedation score following OTM administration of detomidine gel was significantly lower (indicating a lesser degree of sedation) than that following IV dexmedetomidine treatment; however, total sedation score during jugular vein catheterization did not differ between treatments. The gel was subjectively easy to administer, and systemic absorption was sufficient for sedation. Detomidine gel administered by the OTM route provided sedation suitable for a short, minimally invasive procedure in healthy dogs.

Need and Demand for Sedation or General Anesthesia in Dentistry: A National Survey of the Canadian Population

PubMed Central

Chanpong, B; Haas, D. A; Locker, D

2005-01-01

The aim of this study was to assess the need and demand for sedation or general anesthesia (GA) for dentistry in the Canadian adult population. A national telephone survey of 1101 Canadians found that 9.8% were somewhat afraid of dental treatment, with another 5.5% having a high level of fear. Fear or anxiety was the reason why 7.6% had ever missed, cancelled, or avoided a dental appointment. Of those with high fear, 49.2% had avoided a dental appointment at some point because of fear or anxiety as opposed to only 5.2% from the no or low fear group. Regarding demand, 12.4% were definitely interested in sedation or GA for their dentistry and 42.3% were interested depending on cost. Of those with high fear, 31.1% were definitely interested, with 54.1% interested depending on cost. In a hypothetical situation where endodontics was required because of a severe toothache, 12.7% reported high fear. This decreased to 5.4% if sedation or GA were available. For this procedure, 20.4% were definitely interested in sedation or GA, and another 46.1% were interested depending on cost. The prevalence of, and preference for, sedation or GA was assessed for specific dental procedures. The proportion of the population with a preference for sedation or GA was 7.2% for cleaning, 18% for fillings or crowns, 54.7% for endodontics, 68.2% for periodontal surgery, and 46.5% for extraction. For each procedure, the proportion expressing a preference for sedation or GA was significantly greater than the proportion having received treatment with sedation or GA (P < 0.001). In conclusion, this study demonstrates that there is significant need and demand for sedation and GA in the Canadian adult population. PMID:15859442

Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population.

PubMed

Chanpong, B; Haas, D A; Locker, D

2005-01-01

The aim of this study was to assess the need and demand for sedation or general anesthesia (GA) for dentistry in the Canadian adult population. A national telephone survey of 1101 Canadians found that 9.8% were somewhat afraid of dental treatment, with another 5.5% having a high level of fear. Fear or anxiety was the reason why 7.6% had ever missed, cancelled, or avoided a dental appointment. Of those with high fear, 49.2% had avoided a dental appointment at some point because of fear or anxiety as opposed to only 5.2% from the no or low fear group. Regarding demand, 12.4% were definitely interested in sedation or GA for their dentistry and 42.3% were interested depending on cost. Of those with high fear, 31.1% were definitely interested, with 54.1% interested depending on cost. In a hypothetical situation where endodontics was required because of a severe toothache, 12.7% reported high fear. This decreased to 5.4% if sedation or GA were available. For this procedure, 20.4% were definitely interested in sedation or GA, and another 46.1% were interested depending on cost. The prevalence of, and preference for, sedation or GA was assessed for specific dental procedures. The proportion of the population with a preference for sedation or GA was 7.2% for cleaning, 18% for fillings or crowns, 54.7% for endodontics, 68.2% for periodontal surgery, and 46.5% for extraction. For each procedure, the proportion expressing a preference for sedation or GA was significantly greater than the proportion having received treatment with sedation or GA (P < 0.001). In conclusion, this study demonstrates that there is significant need and demand for sedation and GA in the Canadian adult population.

Current sedation practice among general dental practitioners and dental specialists in Jordan: an example of a developing country

PubMed Central

Al-Shayyab, Mohammad H; Ryalat, Soukaina; Dar-odeh, Najla; Alsoleihat, Firas

2013-01-01

Purpose The study reported here aimed to identify current sedation practice among general dental practitioners (GDPs) and specialist dental practitioners (SDPs) in Jordan in 2010. Methods Questionnaires were sent by email to 1683 GDPs and SDPs who were working in Jordan at the time of the study. The contact details of these dental practitioners were obtained from a Jordan Dental Association list. Details on personal status, use of, and training in, conscious sedation techniques were sought by the questionnaires. Results A total of 1003 (60%) questionnaires were returned, with 748 (86.9%) GDPs and 113 (13.1%) SDPs responding. Only ten (1.3%) GDPs and 63 (55.8%) SDPs provided information on the different types of treatments related to their specialties undertaken under some form of sedation performed by specialist and/or assistant anesthetists. Approximately 0.075% of the Jordanian population received some form of sedation during the year 2010, with approximately 0.054% having been treated by oral and maxillofacial surgeons. The main reason for the majority of GDPs (55.0%) and many SDPs (40%) not to perform sedation was lack of training in this field. While some SDPs (26.0%) indicated they did not use sedation because of the inadequacy of sedative facilities. Conclusion Within the limitations of the present study, it can be concluded that the provision of conscious sedation services in general and specialist dental practices in Jordan is inconsistent and inadequate. This stresses the great need to train practitioners and dental assistants in Jordan to enable them to safely and effectively perform all forms of sedation. PMID:23700369

A Randomized Controlled Trial Comparing Intranasal Midazolam and Chloral Hydrate for Procedural Sedation in Children.

PubMed

Stephen, Marie Christy Sharafine; Mathew, John; Varghese, Ajoy Mathew; Kurien, Mary; Mathew, George Ani

2015-12-01

To evaluate the efficacy and safety of intranasal midazolam and chloral hydrate syrup for procedural sedation in children. Prospective randomized placebo-controlled trial (double blind, double dummy). Tertiary care hospital over 18 months. Eighty-two children, 1 to 6 years old, undergoing auditory brainstem response testing were randomized to receive either intranasal midazolam with oral placebo or chloral hydrate syrup with placebo nasal spray. Intranasal midazolam was delivered at 0.5 mg/kg (100 mcg per spray) and oral syrup at 50 mg/kg. Children not sedated at 30 minutes had a second dose at half the initial dose. The primary outcomes measured were safety and efficacy. Secondary outcomes were time to onset of sedation, parental separation, nature of parental separation, parental satisfaction, audiologist's satisfaction, time to recovery, and number of attempts. Forty-one children were in each group, and no major adverse events were noted. The chloral hydrate group showed earlier onset of sedation (66%) compared with the intranasal midazolam group (33%). Significant difference in time to recovery was noted in the chloral hydrate group (78 minutes) versus the intranasal midazolam group (108 minutes). The parents' and audiologist's satisfaction was higher for chloral hydrate (95% and 75%) than for intranasal midazolam (49% and 29%, respectively). Overall, sedation was 95% with chloral hydrate versus 51% with intranasal midazolam. Both drugs maintained sedation. Intranasal midazolam and chloral hydrate are both safe and efficacious for pediatric procedural sedation. Chloral hydrate was superior to intranasal midazolam, with an earlier time to onset of sedation, a faster recovery, better satisfaction among parents and the audiologist, and successful sedation. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Randomised Comparative Study on Propofol and Diazepam as a Sedating Agent in Day Care Surgery.

PubMed

Nirwan, Amit S; Jain, Neha; Pragasm, Micheal; Kamblimath, Deepashri; Bhargava, Anurag; Tiwari, Saba

2014-12-01

The study was conducted to assess the usefulness by qualitative comparison between the two intravenous sedative drugs, Diazepam and Propofol and to provide sedation in apprehensive and uncooperative patients undergoing day care oral surgical procedures. The present study was conducted on 20 adult patients, 10 in each group (Propofol and Diazepam) irrespective of age and sex. Intravenous sedation of Propofol compared with Diazepam in terms of onset of action, recovery, and anterograde amnesia, patient co-operation, surgeon's convenience and side effects and other parameters. Propofol was found to be the superior sedating agent compared to Diazepam, having rapid onset and predictability of action, profoundness of amnesia and a faster recovery period, offering advantages of early patient discharge and better patient compliance. Propofol was found to be an ideal sedating agent in day care oral surgical procedures.

Palliative sedation in advanced cancer patients hospitalized in a specialized palliative care unit.

PubMed

Parra Palacio, Santiago; Giraldo Hoyos, Clara Elisa; Arias Rodríguez, Camilo; Mejía Arrieta, Daniel; Vargas Gómez, John Jairo; Krikorian, Alicia

2018-03-29

To describe the practice of palliative sedation (PS) in patients with advanced cancer in a specialized palliative care (PC) unit in Colombia. Descriptive prospective study including all adults with cancer hospitalized under PS in a cancer institute between January and July 2015 in Colombia. Variables examined were diagnosis, physical functioning, symptoms at the start of sedation, medications and dosages used, and type, level, and time of sedation. Descriptive and correlational statistics were obtained. Sixty-six patients were included, 70% of which were women. The patients had an average age of 61 years (range 24-87), and 74% had a Karnofsky Index (KI) of 50% or less. The most frequent diagnosis was breast cancer (22%), and 82% had metastatic cancer. The prevalence of palliative sedation was 2% and the most common symptoms indicating it were dyspnea (59%), delirium (45%), and pain (32%). All patients received midazolam as a sedative. The average time between the interval start and culmination of sedation was 44 h. There was a significant and inverse relationship between functionality and time under sedation. Palliative sedation is a valid therapeutic option for refractory symptoms causing suffering. The results correspond to international reports and guidelines, which suggests that PS is tailored to the needs of the individual patient while maintaining a high scientific standard, even in a context where PC is under development. However, further development of strategies and clear indications towards the use of PS in Colombia are needed, given its still scarce use.

The association of dopamine agonists with daytime sleepiness, sleep problems and quality of life in patients with Parkinson's disease--a prospective study.

PubMed

Happe, S; Berger, K

2001-12-01

Reports that dopamine agonists (DA) precipitate sudden daytime sleep episodes in Parkinson's disease (PD) patients have received widespread attention. It remains unclear if non-ergoline and ergoline DAs have differential sedating effects or if sedation rather represents a class effect of DAs. The aim of this study was the evaluation of sleep disturbances and the quality of life (QoL) in PD patients with different dopaminergic treatment strategies. This analysis is part of the FAQT-study, a prospective German cohort study evaluating determinants of QoL in PD patients. A subgroup of 111 PD patients was evaluated twice, at baseline and after one year of follow-up, using standardised and validated questionnaires (Unified Parkinson's disease rating scale (UPDRS), Hoehn and Yahr classification, Center for Epidemiologic Studies Depression Scale (CESD), Short Form-36 (SF-36), Parkinson Disease Questionnaire (PDQ-39)). The impact of treatment strategies on sleep problems, daytime sleepiness, bad dreams and hallucinations, depression and QoL in PD patients was analysed separately for ergoline DAs, non-ergoline DAs and the patient group taking no DA. At baseline, sleep problems were reported by about one third of the patients with and without DA medication. Excessive daytime sleepiness (EDS) was higher in the two DA groups (ergoline 11.9%, non-ergoline 9.1%) than among patients not taking DAs (4.5 %). At follow-up, sleep problems in general had decreased among patients taking DAs continuously and among those newly taking DAs, while the sleep problems increased in patients discontinuing DAs. However, EDS had increased to 25% in patients newly taking DAs, and decreased to 15.9% in those taking them continuously. QoL scores at follow-up were slightly increased in the patient groups newly taking and discontinuing DAs (the latter except in physical functioning) while those on continuing DA-medication remained unchanged. No differential effects of ergoline or non-ergoline DAs on sleep problems were found. Different dopaminergic treatment strategies did not influence QoL. Our results support the evidence that sedation may be rather a class effect of DAs.

Proposed Guideline Revisions for Dental Sedation and General Anesthesia: Why Target the Safest Level of Sedation?

PubMed

Dionne, Raymond A

2016-09-01

Recently proposed revisions to the American Dental Association's Guidelines for the Use of Sedation and General Anesthesia by Dentists, aimed at improving safety in dental offices, differentiate between levels of sedation based on drug-induced changes in physiologic and behavioral states. However, the author of this op-ed is concerned the proposed revisions may have far-reaching and unintended consequences.

Sedation of Pediatric Patients in Magnetic Resonance Imaging

DTIC Science & Technology

2000-01-03

f-U. 7. SEDATION OF PEDIATRIC PATIENTS IN MAGNETIC RESONANCE IMAGING Alesia D. Ricks APPROVED: ll^fll JohnJ>. McDonough,-CRNA, Ed.D., Chair...any copyrighted material in the thesis entitled: " Sedation of Pediatric Patients in Magnetic Resonance Imaging" beyond brief excerpts is with the...arise from such copyright violations. IV f SEDATION OF PEDIATRIC PATIENTS IN MAGNETIC RESONANCE IMAGING By CAPT ALESIA D. RICKS, RN, BSN, NQUSAF

Discovery of unexpected pain in intubated and sedated patients.

PubMed

Clukey, Lory; Weyant, Ruth A; Roberts, Melanie; Henderson, Ann

2014-05-01

The perceptions of patients who are restrained and sedated while being treated with mechanical ventilation in the intensive care unit are not well understood. The effectiveness of sedation used to aid in recovery and enhance comfort during intubation is unknown. To explore the perceptions of patients who were intubated and receiving pain medication while sedated and restrained in the intensive care unit, in particular, their experience and their memories of the experience. In a phenomenological study, 14 patients who were intubated and receiving pain medication while sedated and restrained were interviewed at the bedside. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. Three major themes were identified from the data: lack of memory of being restrained; a perception of being intubated as horrific; nursing behaviors that were helpful and comforting. An unexpected discovery was that sedation may be interfering with pain assessment and management. Being intubated can be painful and traumatic despite administration of sedatives and analgesics. Sedation may mask uncontrolled pain for intubated patients and prevent them from communicating this condition to a nurse. Nurses may need to evaluate current interventions in order to provide maximum comfort and promote optimal positive outcomes for intensive care patients who are intubated.

Assessment of hemispheric dominance for receptive language in pediatric patients under sedation using magnetoencephalography.

PubMed

Rezaie, Roozbeh; Narayana, Shalini; Schiller, Katherine; Birg, Liliya; Wheless, James W; Boop, Frederick A; Papanicolaou, Andrew C

2014-01-01

Non-invasive assessment of hemispheric dominance for receptive language using magnetoencephalography (MEG) is now a well-established procedure used across several epilepsy centers in the context of pre-surgical evaluation of children and adults while awake, alert and attentive. However, the utility of MEG for the same purpose, in cases of sedated patients, is contested. Establishment of the efficiency of MEG is especially important in the case of children who, for a number of reasons, must be assessed under sedation. Here we explored the efficacy of MEG language mapping under sedation through retrospective review of 95 consecutive pediatric patients, who underwent our receptive language test as part of routine clinical evaluation. Localization of receptive language cortex and subsequent determination of laterality was successfully completed in 78% (n = 36) and 55% (n = 27) of non-sedated and sedated patients, respectively. Moreover, the proportion of patients deemed left hemisphere dominant for receptive language did not differ between non-sedated and sedated patients, exceeding 90% in both groups. Considering the challenges associated with assessing brain function in pediatric patients, the success of passive MEG in the context of the cases reviewed in this study support the utility of this method in pre-surgical receptive language mapping.

Assessment of hemispheric dominance for receptive language in pediatric patients under sedation using magnetoencephalography

PubMed Central

Rezaie, Roozbeh; Narayana, Shalini; Schiller, Katherine; Birg, Liliya; Wheless, James W.; Boop, Frederick A.; Papanicolaou, Andrew C.

2014-01-01

Non-invasive assessment of hemispheric dominance for receptive language using magnetoencephalography (MEG) is now a well-established procedure used across several epilepsy centers in the context of pre-surgical evaluation of children and adults while awake, alert and attentive. However, the utility of MEG for the same purpose, in cases of sedated patients, is contested. Establishment of the efficiency of MEG is especially important in the case of children who, for a number of reasons, must be assessed under sedation. Here we explored the efficacy of MEG language mapping under sedation through retrospective review of 95 consecutive pediatric patients, who underwent our receptive language test as part of routine clinical evaluation. Localization of receptive language cortex and subsequent determination of laterality was successfully completed in 78% (n = 36) and 55% (n = 27) of non-sedated and sedated patients, respectively. Moreover, the proportion of patients deemed left hemisphere dominant for receptive language did not differ between non-sedated and sedated patients, exceeding 90% in both groups. Considering the challenges associated with assessing brain function in pediatric patients, the success of passive MEG in the context of the cases reviewed in this study support the utility of this method in pre-surgical receptive language mapping. PMID:25191260

Midazolam conscious sedation in a large Danish municipal dental service for children and adolescents.

PubMed

Uldum, Birgitte; Hallonsten, Anna-Lena; Poulsen, Sven

2008-07-01

The aim of this study was to describe the introduction and the first six years use of midazolam for conscious sedation in a municipal dental service in Denmark. In 1998, all dentists were introduced to midazolam conscious sedation. A sedation chart was filled in for each session, and parents' assessment was obtained. In 2004, all clinical materials were collected. Six hundred and eighty sessions were performed; 63.7% of the children were between 2 and 6 years of age; 88.5% belonged to American Society of Anesthesiologists grade 1; 74.8% of the sedations performed used the oral route of administration. Restorations were performed during 60.3% of the sessions, and extractions during 38.4%. Complications during the sessions were rare, the most frequent being double vision (6.1%), hiccups (2.7%), and paradoxical reaction (2.0%). Using Wilton's sedation scale, 42.9% were calm and 27.7% were agitated during treatment, whereas after treatment 61.7% were calm; 80.4% of the parents were very positive towards this sedation method. Sedation with midazolam for dental treatment of children with dental fear and anxiety is a feasible and an efficient method with a low rate of complications. It can probably reduce the need for dental treatment under general anaesthesia.

Survey of Current Clinical and Curriculum Practices of Postgraduate Pediatric Dentistry Programs in Nonintravenous Conscious Sedation in the United States.

PubMed

Morin, Aline; Ocanto, Romer; Drukteinis, Lesbia; Hardigan, Patrick C

2016-10-15

The purposes of this study were to: (1) describe the sedation protocols of postgraduate pediatric dentistry programs (PPDPs) in the U.S.; (2) evaluate how consistent they were with current American Academy of Pediatric Dentistry sedation guidelines and Commission on Dental Accreditation (CODA) sedation curriculum requirements; (3) identify barriers to and tools for implementing these guidelines; and (4) determine the independent association between PPDPs' adherence to guidelines and the program setting. In February 2015, a 40-item questionnaire was e-mailed to all postgraduate pediatric dentistry program directors (PPDPDs) of CODA-accredited programs in the U.S. (n equals 74). Data were analyzed using descriptive statistics and Kruskal-Wallis and pairwise Nemenyi tests. Fifty-two PPDPDs responded (70 percent). Since the 2013 change in CODA sedation requirements, only a limited number of PPDPs (36 percent) were found to be noncompliant with CODA standards. PPDPDs trained at hospital-based programs were found to direct programs that were more compliant with CODA sedation standards (P<.05). A major perceived barrier to increasing the number of sedation cases was the lack of a patient pool (37 percent). Further efforts should be made by teaching institutions for programs to be compliant with American Academy of Pediatric Dentistry and Commission on Dental Accreditation sedation standards.

Walking the line. Palliative sedation for existential distress: still a controversial issue?

PubMed

Schur, Sophie; Radbruch, Lukas; Masel, Eva K; Weixler, Dietmar; Watzke, Herbert H

2015-12-01

Adequate symptom relief is a central aspect of medical care of all patients especially in those with an incurable disease. However, as an illness progresses and the end of life approaches, physical or psychoexistential symptoms may remain uncontrollable requiring palliative sedation. Although palliative sedation has become an increasingly implemented practice in the care of terminally ill patients, sedation in the management of refractory psychological symptoms and existential distress is still a controversial issue and much debated. This case report presents a patient who received palliative sedation for the treatment of existential distress and discusses considerations that may arise from such a therapeutic approach.

[Influence of detomidine on echocardiographic function parameters and cardiac hemodynamics in horses with and without heart murmur].

PubMed

Gehlen, H; Kroker, K; Deegen, E; Stadler, P

2004-03-01

30 warmblood horses were examined before and after sedation with 20 micrograms/kg BW detomidine, to determine changes of cardiac function parameters, using B-mode, M-mode and Doppler echocardiography. 15 horses showed a heart murmur, but no clinical signs of cardiac heart failure, 15 horses had neither a heart murmur nor other signs of cardiac disease. After sedation with detomidine we could recognise a significant increase of end-diastolic left atrium diameter, an increase of end-systolic left ventricular diameter and aortic root diameter. The end-systolic thickness of papillary muscle and interventricular septum showed a decrease. Fractional shortening and amplitude of left ventricular wall motion was decreased after sedation. The mitral valve echogram revealed a presystolic valve closure and an inflection in the Ac slope (B-notch) in xy horses before sedation. Both increased after sedation with detomidine. Doppler echocardiography showed a decrease of blood flow velocity and velocity time integral (VTI) in the left and right ventricular outflow tract after sedation. Regurgitant flow signals were intensified following sedation in xy horses, especially at the mitral valve.

Pharmacodynamic and pharmacokinetic effects of the intravenous CB1 receptor agonist Org 26828 in healthy male volunteers.

PubMed

Zuurman, Lineke; Passier, Paul C C M; de Kam, Marieke L; Kleijn, Huub J; Cohen, Adam F; van Gerven, Joop M A

2010-11-01

An ideal drug for outpatient treatments under conscious sedation would have both sedative and analgesic properties. CB1/CB2 agonists are expected to have sedative, amnestic, analgesic and anti-emetic properties. The main objective of this first study in humans was to assess the sedative properties of intravenous Org 26828. In addition, pharmacokinetics, amnestic properties, postural stability, and behavioural and cardiovascular effects were studied. Midazolam intravenous 0.1 mg/kg and placebo were used as controls. The pharmacokinetic parameters (Cmax and AUC0-inf) of the main metabolite Org 26761 were proportional to dose. No effects were observed after doses up to 0.3 μg/kg of Org 26828. Dose-related effects were observed at higher doses. Although subjects reported subjective sedation after administration of Org 26828 at 3 and 6 μg/kg, the observed sedation was considerably less than after midazolam. Doses higher than the maximum tolerated dose of 1 μg/kg of Org 26828 caused unpleasant central nervous system effects (anxiety, paranoia, hallucinations). Therefore, Org 26828 is not suitable for providing sedation for outpatient surgical procedures.

Minimal and moderate oral sedation in the adult special needs patient.

PubMed

Coke, John M; Edwards, Michael D

2009-04-01

Oral minimal/moderate sedation can be an effective tool to aid in the dental management of adult special needs patients. Specific sedative drugs must be chosen by the dentist that can be used safely and effectively on these patients. This article focuses on a select number of these drugs, specific medical and pharmacologic challenges presented by adult special needs patients, and techniques to safely administer oral minimal and moderate sedation.

[AWAKE CRANIOTOMY: IN SEARCH FOR OPTIMAL SEDATION].

PubMed

Kulikova, A S; Sel'kov, D A; Kobyakov, G L; Shmigel'skiy, A V; Lubnin, A Yu

2015-01-01

Awake craniotomy is a "gold standard"for intraoperative brain language mapping. One of the main anesthetic challenge of awake craniotomy is providing of optimal sedation for initial stages of intervention. The goal of this study was comparison of different technics of anesthesia for awake craniotomy. Materials and methods: 162 operations were divided in 4 groups: 76 cases with propofol sedation (2-4mg/kg/h) without airway protection; 11 cases with propofol sedation (4-5 mg/kg/h) with MV via LMA; 36 cases of xenon anesthesia; and 39 cases with dexmedetomidine sedation without airway protection. Results and discussion: brain language mapping was successful in 90% of cases. There was no difference between groups in successfulness of brain mapping. However in the first group respiratory complications were more frequent. Three other technics were more safer Xenon anesthesia was associated with ultrafast awakening for mapping (5±1 min). Dexmedetomidine sedation provided high hemodynamic and respiratory stability during the procedure.

Assessment of the sedative effects of buprenorphine administered with 20 microg/kg detomidine in horses.

PubMed

Love, E J; Taylor, P M; Murrell, J; Whay, H R; Waterman-Pearson, A E

2011-04-16

The aim of this randomised, observer-blinded, crossover study was to compare the effects of four treatments, administered intravenously to six horses: saline and saline; 10 µg/kg detomidine and 7.5 µg/kg buprenorphine; 20 µg/kg detomidine and 7.5 µg/kg buprenorphine; and 20 µg/kg detomidine and 10 µg/kg buprenorphine. Sedation was subjectively assessed and recorded on a visual analogue scale. Peak sedation and duration of sedation were investigated using a univariate general linear model with post-hoc Tukey tests (P<0.05). Increasing the dose of detomidine from 10 to 20 µg/kg increased the degree of sedation when administered with the same dose of buprenorphine (7.5 µg/kg). When administered with 20 µg/kg detomidine, increasing the dose of buprenorphine from 7.5 to 10 µg/kg did not influence the degree of sedation achieved.

[Helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury].

PubMed

Kato, Hideya; Nishiwaki, Yuko; Hosoi, Kunihiko; Shiomi, Naoto; Hirata, Masashi

2013-09-01

We report helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury. A 20-year-old male sustained traumatic injury to the cervical spinal cord during extracurricular activities in a college. On arrival at the hospital, a halo vest was placed on the patient and tracheostomy was performed. On the 38th hospital day, he was transported a distance of 520km by helicopter to a specialized hospital in Fukuoka for medical repatriation. Cabin space was narrow. Since power supply and carrying capacity were limited, battery-driven and portable medical devices were used. In consideration for patient's psychological stress, he was sedated with propofol. RSS (Ramsay sedation scale) scores were recorded to evaluate whether the patient was adequately sedated during helicopter transportation. Prior to transport, we rehearsed the sedation using bispectral index monitoring (BIS) in the hospital to further ensure the patient's safety during the transport.

Acute ethanol responses in Drosophila are sexually dimorphic

PubMed Central

Devineni, Anita V.; Heberlein, Ulrike

2012-01-01

In mammalian and insect models of ethanol intoxication, low doses of ethanol stimulate locomotor activity whereas high doses induce sedation. Sex differences in acute ethanol responses, which occur in humans, have not been characterized in Drosophila. In this study, we find that male flies show increased ethanol hyperactivity and greater resistance to ethanol sedation compared with females. We show that the sex determination gene transformer (tra) acts in the developing nervous system, likely through regulation of fruitless (fru), to at least partially mediate the sexual dimorphism in ethanol sedation. Although pharmacokinetic differences may contribute to the increased sedation sensitivity of females, neuronal tra expression regulates ethanol sedation independently of ethanol pharmacokinetics. We also show that acute activation of fru-expressing neurons affects ethanol sedation, further supporting a role for fru in regulating this behavior. Thus, we have characterized previously undescribed sex differences in behavioral responses to ethanol, and implicated fru in mediating a subset of these differences. PMID:23213244

Functional magnetic resonance imaging reflects changes in brain functioning with sedation.

PubMed

Starbuck, Victoria N; Kay, Gary G; Platenberg, R. Craig; Lin, Chin-Shoou; Zielinski, Brandon A

2000-12-01

Functional magnetic resonance imaging (fMRI) studies have demonstrated localized brain activation during cognitive tasks. Brain activation increases with task complexity and decreases with familiarity. This study investigates how sleepiness alters the relationship between brain activation and task familiarity. We hypothesize that sleepiness prevents the reduction in activation associated with practice. Twenty-nine individuals rated their sleepiness using the Stanford Sleepiness Scale before fMRI. During imaging, subjects performed the Paced Auditory Serial Addition Test, a continuous mental arithmetic task. A positive correlation was observed between self-rated sleepiness and frontal brain activation. Fourteen subjects participated in phase 2. Sleepiness was induced by evening dosing with chlorpheniramine (CP) (8 mg or 12 mg) and terfenadine (60 mg) in the morning for 3 days before the second fMRI scan. The Multiple Sleep Latency Test (MSLT) was also performed. Results revealed a significant increase in fMRI activation in proportion to the dose of CP. In contrast, for all subjects receiving placebo there was a reduction in brain activation. MSLT revealed significant daytime sleepiness for subjects receiving CP. These findings suggest that sleepiness interferes with efficiency of brain functioning. The sleepy or sedated brain shows increased oxygen utilization during performance of a familiar cognitive task. Thus, the beneficial effect of prior task exposure is lost under conditions of sedation. Copyright 2000 John Wiley & Sons, Ltd.

An Innovative Approach to Improving the Accuracy of Delirium Assessments Using the Confusion Assessment Method for the Intensive Care Unit.

PubMed

DiLibero, Justin; O'Donoghue, Sharon C; DeSanto-Madeya, Susan; Felix, Janice; Ninobla, Annalyn; Woods, Allison

2016-01-01

Delirium occurs in up to 80% of intensive care unit (ICU) patients. Despite its prevalence in this population, there continues to be inaccuracies in delirium assessments. In the absence of accurate delirium assessments, delirium in critically ill ICU patients will remain unrecognized and will lead to negative clinical and organizational outcomes. The goal of this quality improvement project was to facilitate sustained improvement in the accuracy of delirium assessments among all ICU patients including those who were sedate or agitated. A pretest-posttest design was used to evaluate the effectiveness of a program to improve the accuracy of delirium screenings among patients admitted to a medical ICU or coronary care unit. Two hundred thirty-six delirium assessment audits were completed during the baseline period and 535 during the postintervention period. Compliance with performing at least 1 delirium assessment every shift was 85% at baseline and improved to 99% during the postintervention period. Baseline assessment accuracy was 70.31% among all patients and 53.49% among sedate and agitated patients. Postintervention assessment accuracy improved to 95.51% for all patients and 89.23% among sedate and agitated patients. The results from this project suggest the effectiveness of the program in improving assessment accuracy among difficult-to-assess patients. Further research is needed to demonstrate the effectiveness of this model across other critical care units, patient populations, and organizations.

Dexmedetomidine Dose Dependently Enhances the Local Anesthetic Action of Lidocaine in Inferior Alveolar Nerve Block: A Randomized Double-Blind Study.

PubMed

Ouchi, Kentaro; Sugiyama, Kazuna

2016-01-01

Dexmedetomidine (DEX) dose dependently enhances the local anesthetic action of lidocaine in rats. We hypothesized that the effect might also be dose dependent in humans. We evaluated the effect of various concentrations of DEX with a local anesthetic in humans. Eighteen healthy volunteers were randomly assigned by a computer to receive 1.8 mL of 1 of 4 drug combinations: (1) 1% lidocaine with 2.5 ppm (parts per million) (4.5 μg) DEX, (2) lidocaine with 5.0 ppm (9.0 μg) DEX, (3) lidocaine with 7.5 ppm (13.5μg) DEX, or (4) lidocaine with 1:80,000 (22.5 μg) adrenaline (AD), to produce inferior alveolar nerve block. Pulp latency and lower lip numbness (for assessing onset and duration of anesthesia) were tested, and sedation level, blood pressure, and heart rate were recorded every 5 minutes for 20 minutes, and every 10 minutes from 20 to 60 minutes. Pulp latency of each tooth increased compared with baseline, from 5 to 15 minutes until 60 minutes. There were no significant intergroup differences at any time point. Anesthesia onset was not different between groups. Anesthesia duration was different between groups (that with DEX 7.5 ppm was significantly longer than that with DEX 2.5 ppm and AD; there was no difference between DEX 2.5 ppm and AD). Blood pressure decreased from baseline in the 5.0 and 7.5 ppm DEX groups at 30 to 60 minutes, although there was no hypotension; moreover, heart rate did not change in any group. Sedation score did not indicate deep sedation in any of the groups. Dexmedetomidine dose dependently enhances the local anesthetic action of lidocaine in humans. Dexmedetomidine at 2.5 ppm produces similar enhancement of local anesthesia effect as addition of 1:80,000 AD.

Memory effects of sedative drugs in children and adolescents--protocol for a systematic review.

PubMed

Viana, Karolline A; Daher, Anelise; Maia, Lucianne C; Costa, Paulo S; Martins, Carolina C; Paiva, Saul M; Costa, Luciane R

2016-02-18

Some sedatives used in children and adolescents can affect memory function. Memory impairment of traumatic experience can minimize the chance of future psychological trauma. Knowledge about the potential of different sedatives to produce amnesia can help in the decision-making process of choosing a sedative regimen. The aim of this systematic review is to evaluate the effect of different sedatives on memory of perioperative events in children and adolescents. Electronic databases and other sources, such as trial registers, gray literature, and conference abstracts will be searched. Randomized controlled trials will be included that assess memory of perioperative events in children and adolescents 2-19 years old receiving sedative drugs as premedication or as agents for procedural sedation in a medical or dental settings. The outcomes will be loss of memory after and before sedative administration (anterograde and retrograde amnesia). Two independent reviewers will perform screening, study selection, and data extraction. Disagreement at all levels will be resolved by consensus or by involving a third reviewer. Assessment of the risk of bias of included studies will be performed according to "Cochrane Collaboration's Tool for Assessing Risk of Bias in Randomized Trials." Clinical and methodological heterogeneity across studies will be evaluated to determine if it is possible to combine or not combine study results in a meta-analysis. To the best of our knowledge, there is no systematic review that specifically addresses this question. Findings from the review will be useful in the decision-making process about the best sedative for minimizing recall of the medical/dental event and possible psychological trauma. PROSPERO CRD42015017559.

Clonidine Sedation Effects in Children During Electroencephalography.

PubMed

Barzegar, Mohammad; Piri, Reza; Naghavi-Behzad, Mohammad; Ghasempour, Masoumeh

2017-09-01

It is very important to have proper management in children with Seizure. Electroencephalography (EEG) as a diagnostic instrument has a key role in determining the management method of seizure in children. Because of poor cooperation of some children (especially children with attention deficit hyperactivity disorders and developmental disorders) in performing EEG, it is the best choice to sedate children before EEG. The aim of present study is to evaluate the sedation efficacy of clonidine in children before EEG. In a randomized clinical trial, 45 children age 2 to 12 with seizure, who referred to Children Hospital of Tabriz University of Medical Sciences and candidate for EEG, were studied. Sedation before EEG induced by 0.5 to 2.0 mg clonidine orally. Sedation score (0 to 5) measured by using eyes condition, response to voice, and response to touch. Successful sedation, EEG performing, and hemodynamic stability were evaluated during sedation. Of all patients, 40 patients (88.88%) were sedated successfully, and EEG was performed for all of the children. Mean onset time of clonidine effect was 35.47±13.56 minutes and mean time of that the patients' level of consciousness back to the level before administrating of clonidine was 77.55±26.87 minutes. Hemodynamic states of all patients were stable during the study, and there were no significant changes in vital sign of patients. In conclusion, clonidine can be considered as a safe alternative medication for sedation for EEG, which is fortunately associated with no significant change in vital signs, which may complicate overall status of patients.

Nonmedical use of sedatives in urban Bengaluru.

PubMed

Nattala, Prasanthi; Murthy, Pratima; Thennarasu, K; Cottler, Linda B

2014-07-01

Nonmedical sedative use is emerging as a serious problem in India. However, there is paucity of literature on the patterns of use in the population. The aim of the present analysis was to explore sedative use patterns in an urban metropolis. Data for the present analysis come from the parent study on nonmedical prescription drug use in Bengaluru, India. Participants (n = 717) were recruited using a mall-intercept approach, wherein they were intercepted in five randomly selected shopping malls, and administered an interview on their use of prescription drugs. Past 12-month nonmedical sedative use was reported by 12%, benzodiazepines being the commonest. Reasons cited for nonmedical use included "sleeplessness, pain relief, stress." A majority (73%) reported sedative use "in ways other than as prescribed," compared to "use without prescription" (27%). All prescriptions were issued by general physicians in private hospitals. About 11% among those who used "in ways other than as prescribed," and 100% of nonprescribed users, reported irregular use (skipping doses/stopping/restarting). Among those who used "in ways other than prescribed," pharmacy stores were the source of obtaining the sedatives. Among "nonprescribed users," family/friends were the main source. Three-percent reported using sedatives and alcohol together in the same use episode. In multivariate logistic regression analyses, nonmedical sedative use was significantly associated with graduation-level education or above (adjusted odds ratio [aOR]: 2.53, 95% confidence interval [CI]: 1.30-4.91), and married status (aOR: 2.32, 95% CI: 1.04-5.18). Findings underscore the need for considering various contextual factors in tailoring preventive interventions for reducing nonmedical sedative use.

Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer.

PubMed

De Vries, Kay; Plaskota, Marek

2017-04-01

Palliative sedation is a method of symptom management frequently used in hospices to treat uncontrolled symptoms at the end of life. There is a substantial body of literature on this subject; however, there has been little research into the experiences of hospice nurses when administering palliative sedation in an attempt to manage the terminal restlessness experienced by cancer patients. Semistructured interviews were conducted with a purposive sample of seven hospice nurses who had cared for at least one patient who had undergone palliative sedation within the past year in a hospice in the south of England in the United Kingdom. A phenomenological approach and Colaizzi's stages of analysis were employed to develop themes from the data. Facilitating a "peaceful death" was the primary goal of the nurses, where through the administration of palliative sedation they sought to enable and support patients to be "comfortable," "relaxed," and "calm" at the terminal stage of their illness. Ethical dilemmas related to decision making were a factor in achieving this. These were: medication decisions, "juggling the drugs," "causing the death," sedating young people, the family "requesting" sedation, and believing that hospice is a place where death is hastened. Hospice nurses in the U.K. frequently encounter ethical and emotional dilemmas when administering palliative sedation. Making such decisions about using palliative sedation causes general discomfort for them. Undertaking this aspect of care requires confidence and competence on the part of nurses, and working within a supportive hospice team is of fundamental importance in supporting this practice.

Comparison of NREM sleep and intravenous sedation through local information processing and whole brain network to explore the mechanism of general anesthesia.

PubMed

Li, Yun; Wang, Shengpei; Pan, Chuxiong; Xue, Fushan; Xian, Junfang; Huang, Yaqi; Wang, Xiaoyi; Li, Tianzuo; He, Huiguang

2018-01-01

The mechanism of general anesthesia (GA) has been explored for hundreds of years, but unclear. Previous studies indicated a possible correlation between NREM sleep and GA. The purpose of this study is to compare them by in vivo human brain function to probe the neuromechanism of consciousness, so as to find out a clue to GA mechanism. 24 healthy participants were equally assigned to sleep or propofol sedation group by sleeping ability. EEG and Ramsay Sedation Scale were applied to determine sleep stage and sedation depth respectively. Resting-state functional magnetic resonance imaging (RS-fMRI) was acquired at each status. Regional homogeneity (ReHo) and seed-based whole brain functional connectivity maps (WB-FC maps) were compared. During sleep, ReHo primarily weakened on frontal lobe (especially preoptic area), but strengthened on brainstem. While during sedation, ReHo changed in various brain areas, including cingulate, precuneus, thalamus and cerebellum. Cingulate, fusiform and insula were concomitance of sleep and sedation. Comparing to sleep, FCs between the cortex and subcortical centers (centralized in cerebellum) were significantly attenuated under sedation. As sedation deepening, cerebellum-based FC maps were diminished, while thalamus- and brainstem-based FC maps were increased. There're huge distinctions in human brain function between sleep and GA. Sleep mainly rely on brainstem and frontal lobe function, while sedation is prone to affect widespread functional network. The most significant differences exist in the precuneus and cingulate, which may play important roles in mechanisms of inducing unconciousness by anesthetics. Institutional Review Board (IRB) ChiCTR-IOC-15007454.

The effects of nitric oxide synthase inhibitors on the sedative effect of clonidine.

PubMed

Soares de Moura, R; Rios, A A; de Oliveira, L F; Resende, A C; de Lemos Neto, M; Santos, E J; Correia, M L; Tano, T

2001-11-01

The mechanism underlying the Niteroi, Rio de Janeiro sedative effect of clonidine, an alpha2-adrenoceptor agonist, remains uncertain. Because activation of alpha2-adrenoceptors induces release of nitric oxide (NO), we tested the hypothesis that the sedative effect of clonidine depends on NO-related mechanisms. The effect of 7-nitro indazole on the sleeping time induced by clonidine was studied in Wistar rats. In addition, we examined the effect of clonidine, alpha-methyldopa, and midazolam on the thiopental-induced sleeping time in rats pretreated with N(G)-nitro-L-arginine-methyl-ester (L-NAME). The sleeping time induced by clonidine was significantly decreased by 7-nitro indazole. Thiopental sleeping time was increased by clonidine, alpha-methyldopa, and midazolam. L-NAME reduced the prolongation effect of clonidine and alpha-methyldopa, but did not alter the effect of midazolam on the thiopental-induced sleeping time. The inhibitory effect of L-NAME on clonidine-dependent prolongation of thiopental-induced sleeping time was reversed by L-arginine. These results suggest that NO-dependent mechanisms are involved in the sedative effect of clonidine. In addition, this effect seems to be specific for the sedative action of alpha2-adrenoceptors agonists. Clonidine, an antihypertensive drug, is also a sedative. This sedative effect, although an adverse event in the treatment of hypertensive patients, can be helpful for sedation of surgical patients. The mechanism of this effect, however, is unknown. In this study, we show that the sedative effect of clonidine is mediated by nitric oxide, because it could be prevented by pretreatment with nitric oxide synthase inhibitors.

Chloral hydrate administered by a dedicated sedation service can be used safely and effectively for pediatric ophthalmic examination.

PubMed

Karaoui, Mohammed; Varadaraj, Varshini; Munoz, Beatriz; Collins, Megan E; Al Djasim, Leyla; Al Naji, Esam; Hamweyah, Karam; Shamrani, Mohammed Al; Craven, Earl Randy; Friedman, David S

2018-05-10

To determine safety and efficacy of oral chloral hydrate sedation (CHS) for outpatient pediatric ophthalmic procedures. Prospective, interventional case series METHODS-SETTING: - King Khaled Eye Specialist Hospital. Children ages 1 month to 5 years undergoing CHS for ocular imaging/evaluation PROCEDURES: Details on chloral hydrate dose administered, sedation achieved, vitals, and adverse events were recorded OUTCOME MEASURES: Primary Outcome: Percent of patients with a sedation level ≥4 at 45 minutes post chloral hydrate administration. Time from sedation to discharge; adverse events, including changes in vital signs following chloral hydrate administration. 324 children were recruited with a mean age of 2.2 (SD: 1.3) years and mean weight of 10.9 (SD: 3.3) kg. Adequate sedation was obtained with a mean chloral hydrate first dose of 77.4 (SD: 14.7) mg/kg in 306 (94.4%) patients, with an additional 6 patients (1.9%) achieving adequate sedation with a second dose (overall adequate sedation: 96.3%). Mean reductions in heart rate, respiratory rate and oxygen (O 2 ) saturation from pre-sedation to 25 min post-sedation were 11.7 (SD: 14.3) beats-per-minute, 1.2 (SD: 2.4) breaths-per-minute, and 0.81 (SD: 1.2) %, respectively (p<0.001 for all). In multivariable regression, odds of remaining sedated 45 minutes after chloral hydrate administration was 2.53 times higher for American Society of Anesthesiologists (ASA) class II or III patients than for ASA I (95% CI: 1.11-5.78, p=0.03), 1.03 times higher per mg increase in initial dose of chloral hydrate (95% CI: 1.01-1.06, p=0.006), and 2.70 times higher per unit increase in number of planned procedures (95% CI: 1.63-4.47, p<0.001). Three patients developed minor adverse events: 2 cases of O 2 desaturation and 1 paradoxical reaction, none requiring significant intervention. Patients were discharged a median of 90 minutes after chloral hydrate administration. Chloral hydrate administered by a dedicated sedation service as in this prospective assessment can be used safely and effectively for outpatient pediatric ophthalmic procedures. Copyright © 2018 Elsevier Inc. All rights reserved.

Moderate Sedation Changes for Bronchoscopy in 2017.

PubMed

Nelson, Michael E

2017-10-01

The reimbursement for procedures using moderate (conscious) sedation has changed significantly as of January 1, 2017. Due to the increasing use of anesthesia services to provide moderate sedation during endoscopy, the Centers for Medicare & Medicaid Services made the decision to remove work relative value units from many of the services requiring moderate sedation, including the bronchoscopy codes. If a bronchoscopist provides moderate sedation to a patient without using anesthesia services or another qualified provider, that work (and revenue) can be reclaimed by using the relevant codes. An understanding of the recent changes in coding and billing is essential for appropriate reimbursement. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

A simple anaesthetic and monitoring system for magnetic resonance imaging.

PubMed

Rejger, V S; Cohn, B F; Vielvoye, G J; de Raadt, F B

1989-09-01

Clinical magnetic resonance imaging (MRI) is a digital tomographic technique which utilizes radio waves emitted by hydrogen protons in a powerful magnetic field to form an image of soft-tissue structures and abnormalities within the body. Unfortunately, because of the relatively long scanning time required and the narrow deep confines of the MRI tunnel and Faraday cage, some patients cannot be examined without the use of heavy sedation or general anaesthesia. Due to poor access to the patient and the strong magnetic field, several problems arise in monitoring and administering anaesthesia during this procedure. In this presentation these problems and their solutions, as resolved by our institution, are discussed. Of particular interest is the anaesthesia circuit specifically adapted for use during MRI scanning.

Effects of three methadone doses combined with acepromazine on sedation and some cardiopulmonary variables in dogs.

PubMed

Bitti, Flavia S; Campagnol, Daniela; Rangel, Julia Pp; Nunes Junior, Juarez S; Loureiro, Bárbara; Monteiro, Eduardo R

2017-03-01

To evaluate the sedative and cardiopulmonary effects of three methadone doses, combined with acepromazine, in dogs. Prospective, randomized, complete block study. Six healthy, adult, cross-bred dogs weighing 17.2±4.4 kg (mean±standard deviation). Each dog was administered four treatments: acepromazine (0.05 mg kg -1 ) alone or acepromazine (same dose) in combination with methadone (0.25, 0.50 or 0.75 mg kg -1 ). All drugs were administered intramuscularly. Sedation was scored by a numeric descriptive scale (NDS, range 0-3) and a simple numerical scale (SNS, range 0-10). Heart rate, invasive blood pressure, arterial blood gases and rectal temperature were measured at 15 to 30 minute intervals for 120 minutes. According to NDS scores, mild to moderate sedation (NDS=1-2) was observed in most dogs in the acepromazine treatment, with only one out of six dogs scored as exhibiting intense sedation (NDS=3). All treatments with methadone resulted in significantly higher SNS scores compared with acepromazine alone. In these treatments, most dogs exhibited intense sedation (NDS=3). Increasing the dose of methadone from 0.25 to 0.50 or 0.75 mg kg -1 prolonged sedation in a dose-related manner, but did not influence the degree of sedation. The main adverse effects following administration of acepromazine-methadone treatments were decreased blood pressure, mild respiratory acidosis and decreased rectal temperature. These effects were well tolerated and resolved without treatment. In this study in six dogs, acepromazine-methadone administration resulted in intense sedation in most dogs. The results are interpreted to indicate that a low dose of methadone (0.25 mg kg -1 ) administered in combination with acepromazine (0.05 mg kg -1 ) will induce short-term sedation in dogs, whereas higher doses of methadone should be administered when prolonged sedation is desired. Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

The safety and efficacy of intranasal midazolam sedation combined with inhalation sedation with nitrous oxide and oxygen in paediatric dental patients as an alternative to general anaesthesia.

PubMed

Wood, Michael

2010-01-01

Conscious Decision' was published in 2000 by the Department of Health, effectively ending the provision of dental general anaesthesia (DGA) outside the hospital environment. Other aspects of dental anxiety and behavioural management and sedation techniques were encouraged before the decision to refer for a DGA was reached. Although some anxious children may be managed with relative analgesia (RA), some may require different sedation techniques for dentists to accomplish dental treatment. Little evidence has been published in the UK to support the use of alternative sedation techniques in children. This paper presents another option using an alternative conscious sedation technique. to determine whether a combination of intranasal midazolam (IN) and inhalation sedation with nitrous oxide and oxygen is a safe and practical alternative to DGA. A prospective clinical audit of 100 cases was carried out on children referred to a centre for DGA. 100 children between 3 and 13 years of age who were referred for DGA were treated using this technique. Sedation was performed by intranasal midazolam followed by titrating a mixture of nitrous oxide and oxygen. A range of dental procedures was carried out while the children were sedated. Parents were present during the dental treatment. Data related to the patient, dentistry and treatment as well as sedation variables were collected at the treatment visit and a telephonic post-operative assessment from the parents was completed a week later. It was found that 96% of the required dental treatment was completed successfully using this technique, with parents finding this technique acceptable in 93% of cases. 50% of children found the intranasal administration of the midazolam acceptable. There was no clinically relevant oxygen desaturation during the procedure. Patients were haemodynamically stable and verbal contact was maintained throughout the procedure. In selected cases this technique provides a safe and effective alternative to DGA and could reduce the number of patients referred to hospitals for DGA. It is recommended that this technique should only be used by dentists skilled in sedation with the appropriate staff and equipment at their disposal.

Sedative Effects of Levocetirizine: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

PubMed

Snidvongs, Kornkiat; Seresirikachorn, Kachorn; Khattiyawittayakun, Likhit; Chitsuthipakorn, Wirach

2017-02-01

As a substrate of P-glycoprotein, levocetirizine should not cause sedative effects. However, while cetirizine, a mixture of levocetirizine and dextrocetirizine, can slightly penetrate the blood brain barrier, the sedative effects of levocetirizine are still under study. The aim of this study was to investigate the sedative effects of levocetirizine. An electronic literature search was performed using Medline and EMBASE from January 01, 2001 through August 6, 2015. Randomized controlled trials (RCTs) comparing levocetirizine with other antihistamines or placebo for patients with allergy and healthy subjects were selected. Primary outcome was risk ratio between levocetirizine and comparators. Secondary outcome was change in psychomotor speed. Data were pooled for meta-analysis using a fixed-effect model. Forty-eight studies of 18,014 patients met the inclusion criteria. When compared to placebo, levocetirizine produced modest sedative effects (RR: 1.67; 95% CI 1.17, 2.38). However, when compared to other second-generation antihistamines, sedative effects of levocetirizine did not differ (RR: 1.23; 95% CI 0.96, 1.58). In subgroup analysis, there was no difference between the sedative effects of levocetirizine and fexofenadine (RR: 1.7; 95% CI 0.59, 4.88), desloratadine (RR: 1.58; 95% CI 0.9, 2.77), loratadine (RR: 1.56; 95% CI 0.28, 8.56), bilastine (RR: 1.17; 95% CI 0.48, 2.84), olopatadine (RR: 1.09; 95% CI 0.81, 1.47), azelastine (RR: 0.19; 95% CI 0.01, 3.68) and rupatadine (RR: 1.47; 95% CI 0.14, 15.72). When compared to first-generation antihistamines, levocetirizine had less sedative effects and less change of reaction time (mean difference: -250.76 s; 95% CI -338.53, -162.98). Levocetirizine has modest sedative effects with a risk ratio of 1.67 when compared with placebo. The sedative effects observed for levocetirizine are not different from other second-generation antihistamines.

A Comparison of Fospropofol to Midazolam for Moderate Sedation During Outpatient Dental Procedures

PubMed Central

Yen, Philip; Prior, Simon; Riley, Cara; Johnston, William; Smiley, Megann; Thikkurissy, Sarat

2013-01-01

Moderate intravenous (IV) sedation combined with local anesthesia is common for outpatient oral surgery procedures. An ideal sedative agent must be safe and well tolerated by patients and practitioners. This study evaluated fospropofol, a relatively new sedative/hypnotic, in comparison to midazolam, a commonly used benzodiazepine, for IV moderate sedation during oral and maxillofacial surgery. Sixty patients were randomly assigned to either the fospropofol or the midazolam group. Each participant received 1 μg/kg of fentanyl prior to administration of the selected sedative. Those in the fospropofol group received an initial dose of 6.5 mg/kg, with 1.6 mg/kg supplemental doses as needed. Those in the midazolam group received initial doses of 0.05 mg/kg, followed by 0.02 mg/kg supplemental doses. The quality of sedation in each patient was evaluated with regard to (a) onset of sedation, maintenance, and recovery profile; (b) patient and surgeon satisfaction; and (c) hemodynamic stability and adverse effects. The fospropofol group demonstrated shorter physical recovery times than midazolam patients, taking a mean of 11.6 minutes versus 18.4 minutes for physical recovery (P = .007). Cognitive recovery comparison did not find any difference with a mean of 7.5 minutes versus 8.8 minutes between the 2 drug groups (P = .123). The fospropofol group had a higher rate of local anesthetic injection recall (90.5 vs 44.4%, P = .004). Other parameters of recall were comparable. Two adverse effects demonstrated significance, with more patients in the midazolam group experiencing tachycardia (48.2 vs 9.4%, P = .001), and more patients in the fospropofol group experiencing perineal discomfort (40.6 vs 0, P < .001). No significant difference was found in any other measures of sedation safety, maintenance, or satisfaction. Fospropofol, when administered intravenously by a dentist anesthesiologist at the indicated dose in this study, appears to be a safe, well-tolerated alternative to midazolam for intravenous moderate sedation during minor oral surgery procedures. PMID:24423419

[Analysis of palliative sedation in hospitalised elderly patients: Effectiveness of a protocol].

PubMed

Mateos-Nozal, Jesús; García-Cabrera, Lorena; Montero Errasquín, Beatriz; Cruz-Jentoft, Alfonso José; Rexach Cano, Lourdes

2016-01-01

To measure changes in the practice of palliative sedation during agony in hospitalised elderly patients before and after the implementation of a palliative sedation protocol. A retrospective before-after study was performed in hospitalised patients over 65 years old who received midazolam during hospital admission and died in the hospital in two 3-month periods, before and after the implementation of the protocol. Non-sedative uses of midazolam and patients in intensive care were excluded. Patient and admission characteristics, the consent process, withdrawal of life-sustaining treatments, and the sedation process (refractory symptom treated, drug doses, assessment and use of other drugs) were recorded. Association was analysed using the Chi(2) and Student t tests. A total of 143 patients were included, with no significant differences between groups in demographic characteristics or symptoms. Do not resuscitate (DNR) orders were recorded in approximately 70% of the subjects of each group, and informed consent for sedation was recorded in 91% before vs. 84% after the protocol. Induction and maintenance doses of midazolam followed protocol recommendations in 1.3% before vs 10.4% after the protocol was implemented (P=.02) and adequate rescue doses were used in 1.3% vs 11.9% respectively (P=.01). Midazolam doses were significantly lower (9.86mg vs 18.67mg, P<.001) when the protocol was used than when it was not used. Ramsay sedation score was used in 8% vs. 12% and the Palliative Care Team was involved in 35.5% and 16.4% of the cases (P=.008) before and after the protocol, respectively. Use of midazolam slightly improved after the implementation of a hospital protocol on palliative sedation. The percentage of adequate sedations and the general process of sedation were mostly unchanged by the protocol. More education and further assessment is needed to gauge the effect of these measures in the future. Copyright © 2015 SEGG. Published by Elsevier Espana. All rights reserved.

Pediatric heart transplantation: demographics, outcomes, and anesthetic implications.

PubMed

Schure, Annette Y; Kussman, Barry D

2011-05-01

The evolving demographics, outcomes, and anesthetic management of pediatric heart transplant recipients are reviewed. As survival continues to improve, an increasing number of these patients will present to our operating rooms and sedation suites. It is therefore important that all anesthesiologists, not only those specialized in cardiac anesthesia, have a basic understanding of the physiologic changes in the transplanted heart and the anesthetic implications thereof. © 2010 Blackwell Publishing Ltd.

Effect of cold compress application on tissue temperature in healthy dogs.

PubMed

Millard, Ralph P; Towle-Millard, Heather A; Rankin, David C; Roush, James K

2013-03-01

To measure the effect of cold compress application on tissue temperature in healthy dogs. 10 healthy mixed-breed dogs. Dogs were sedated with hydromorphone (0.1 mg/kg, IV) and diazepam (0.25 mg/kg, IV). Three 24-gauge thermocouple needles were inserted to a depth of 0.5 (superficial), 1.0 (middle), and 1.5 (deep) cm into a shaved, lumbar, epaxial region to measure tissue temperature. Cold (-16.8°C) compresses were applied with gravity dependence for periods of 5, 10, and 20 minutes. Tissue temperature was recorded before compress application and at intervals for up to 80 minutes after application. Control data were collected while dogs received identical sedation but with no cold compress. Mean temperature associated with 5 minutes of application at the superficial depth was significantly decreased, compared with control temperatures. Application for 10 and 20 minutes significantly reduced the temperature at all depths, compared with controls and 5 minutes of application. Twenty minutes of application significantly decreased temperature at only the middle depth, compared with 10 minutes of application. With this method of cold treatment, increasing application time from 10 to 20 minutes caused a further significant temperature change at only the middle tissue depth; however, for maximal cooling, the minimum time of application should be 20 minutes. Possible changes in tissue temperature and adverse effects of application > 20 minutes require further evaluation.

Are Slow Waves of Intracranial Pressure Suppressed by General Anaesthesia?

PubMed

Lalou, Despina Afroditi; Czosnyka, Marek; Donnelly, Joseph; Lavinio, Andrea; Pickard, John D; Garnett, Matthew; Czosnyka, Zofia

2018-01-01

Slow waves of intracranial pressure (ICP) are spontaneous oscillations with a frequency of 0.3-4 cycles/min. They are often associated with pathological conditions, following vasomotor activity in the cranial enclosure. This study quantifies the effects of general anaesthesia (GA) on the magnitude of B-waves compared with natural sleep and the conscious state. Four groups of 30 patients each were formed to assess the magnitude of slow waves. Group A and group B consisted of normal pressure hydrocephalus (NPH) patients, each undergoing cerebrospinal fluid (CSF) infusion studies, conscious and under GA respectively. Group C comprised conscious, naturally asleep hydrocephalic patients undergoing overnight ICP monitoring; group D, which included deeply sedated head injury patients monitored in the intensive care unit (ICU), was compared with group C. The average amplitude for group A patients was higher (0.23 ± 0.10 mmHg) than that of group B (0.15 ± 0.10 mmHg; p = 0.01). Overnight magnitude of slow waves was higher in group C (0.20 ± 0.13 mmHg) than in group D (0.11 ± 0.09 mmHg; p = 0.002). Slow waves of ICP are suppressed by GA and deep sedation. When using slow waves in clinical decision-making, it is important to consider the patients' level of consciousness to avoid incorrect therapeutic and management decisions.

Anesthesia and sedation in pediatric gastrointestinal endoscopic procedures: A review

PubMed Central

Dar, Abdul Q; Shah, Zahoor A

2010-01-01

Gastrointestinal (GI) endoscopic procedure has become an essential modality for evaluation and treatment of GI diseases. Intravenous (IV) sedation and General Anesthesia (GA) have both been employed to minimize discomfort and provide amnesia. Both these procedures require, at the very least, monitoring of the level of consciousness, pulmonary ventilation, oxygenation and hemodynamics. Although GI endoscopy is considered safe, the procedure has a potential for complications. Increased awareness of the complications associated with sedation during GI endoscopy in children, and involving the anesthesiologists in caring for these children, may be optimal for safety. Belonging to a younger age group, having a higher ASA class and undergoing IV sedation were identified as risk factors for developing complications. Reported adverse events included inadequate sedation, low oxygen saturation, airway obstruction, apnea needing bag mask ventilation, excitement and agitation, hemorrhage and perforation. A complication rate of 1.2% was associated with procedures performed under GA, as compared to 3.7% of complications associated with IV sedation. IV sedation was seen to be independently associated with a cardiopulmonary complication rate 5.3% times higher when compared to GA. GA can therefore be considered safer and more effective in providing comfort and amnesia. PMID:21160616

Safety and Efficacy of 3 Pediatric Midazolam Moderate Sedation Regimens

PubMed Central

Gentz, Rachel; Casamassimo, Paul; Amini, Homa; Claman, Dan; Smiley, Megann

2017-01-01

Our aim was to characterize effectiveness and complications in children receiving oral midazolam alone, nasal midazolam alone, or oral midazolam with other sedatives. Children received oral midazolam alone, nasal midazolam, or oral midazolam in combination with other sedative medications. All subjects received a presedation history and physical examination and were sedated per protocol by any of 28 resident providers under attending supervision. Sedations were rated for success and complications by clinicians. Postoperative complications were assessed by trained staff up to 48 hours postoperatively. Seven hundred and one encounters, completed over 24 months, yielded 650 usable sedations. The majority of children were healthy (469; 68.2%) and 86% (532) weighed between 10 and 25 kg. Sedations were deemed successful in about 80% of cases. Planned treatment was completed in over 85% of encounters. Oral midazolam alone yielded the best behavior. Physical assessment factors of behavior and age were correlated (P = .035) with effectiveness. Hiccups and a positive medical history were significantly related (P = .049). Side effects of either nausea/vomiting, dysphoria, or hiccups occurred in less than 10% of cases. All 3 regimens were effective with minimal postoperative complications. PMID:28604093

Flubromazolam--A new life-threatening designer benzodiazepine.

PubMed

Łukasik-Głębocka, Magdalena; Sommerfeld, Karina; Teżyk, Artur; Zielińska-Psuja, Barbara; Panieński, Paweł; Żaba, Czesław

2016-01-01

In addition to designer benzodiazepines such as etizolam, deschloroetizolam, pyrazolam, diclazepam, nifoxipam, or clonazolam, a new psychoactive substance like flubromazolam, triazole of flubromazepam has become available. Flubromazolam is currently not marketed as a medication but rather as a research chemical and recreational drug. It mostly causes sedative effects but also has moderate anti-anxiety and muscle relaxant effects. A case of a severe intoxication of flubromazolam has been reported. A 27-year-old man, presented with deep coma, bilateral pinpoint unreactive pupils, acute respiratory failure and hypotension, complicated by hypoxic ischemic changes in the central nervous system. A positive result of a urine screening test confirmed the presence of benzodiazepines, which resulted in administration of flumazenil and improved patient consciousness. Quantitative method of liquid chromatography indicated flubromazolam in the patient's serum at 59 ng/mL and urine at 105 ng/mL about 19 h after ingestion of 3 mg dose. On admission, serum creatine kinase was 15,960 U/L. The patient was treated with mechanical ventilation, intravenous fluids, flumazenil and continuous infusion of norepinephrine at a dose of 0.12 µg/kg/min. The patient survived and on the ninth day of hospitalization he was transferred to the Department of Neurology. Flubromazolam is a new designer drug. Recreational use may be a cause of prolonged, severe intoxication associated with coma, hypotension, and rhabdomyolysis.

Selective phosphodiesterase 5 inhibition does not reduce propofol sedation requirements but affects speed of recovery and plasma cyclic guanosine 3',5'-monophosphate concentrations in healthy volunteers.

PubMed

Engelhardt, Thomas; MacDonald, Jamie; Galley, Helen F; Webster, Nigel R

2005-10-01

Cyclic guanosine 3',5'-monophosphate (cyclic GMP) has been implicated in modulating the effects of anesthesia. We hypothesized that limiting the breakdown of cyclic GMP through selective phosphodiesterase inhibition would influence propofol sedation requirements and plasma cyclic GMP concentrations. Ten volunteers received 100 mg of sildenafil or placebo orally in this placebo-controlled, double-blind, randomized crossover pilot study. Propofol sedation was achieved using a target-controlled infusion system until loss of verbal contact (LVC). Plasma cyclic GMP concentrations were determined at baseline, LVC, and 30 min after LVC. There was no difference in the amount of propofol used, predicted plasma concentration, or duration of sedation in volunteers after sildenafil compared with placebo treatment. Return of spontaneous verbal contact was faster after sildenafil (4 [3-8] min versus 6 [3-5] min, median [range], P = 0.019). Cyclic GMP concentrations were reduced during propofol sedation in the placebo group compared with baseline (P < 0.004). The plasma cyclic GMP concentrations were larger (P = 0.004) at LVC in the sildenafil group compared with placebo. We have shown that selective phosphodiesterase 5 inhibition decreases recovery time from propofol sedation without affecting propofol requirements. The decrease of plasma cyclic GMP concentrations during propofol sedation in the placebo group indicates a potential role of cyclic GMP in propofol anesthesia in humans. Plasma cyclic guanosine 3',5'-monophosphate (cyclic GMP) concentrations are reduced during propofol sedation. Selective phosphodiesterase 5 inhibition, however, does not reduce propofol sedation requirements or plasma cyclic GMP concentrations but affects speed of recovery in healthy volunteers.

Efficacy and safety of rectal thiopental sedation in outpatient echocardiographic examination of children.

PubMed

Okutan, V; Lenk, M K; Sarici, S U; Dündaröz, R; Akin, R; Gökçay, E

2000-11-01

The efficacy and safety of rectal thiopental administration in sedation for paediatric echocardiographic examination were prospectively investigated in infants with known or suspected congenital heart disease in an outpatient manner. A total of 1150 patients (546F, 604M) were studied; 264 were 7 d to 6 mo old (group I), 572 were 6 mo to 2-y-old (group II), and 314 were 2 to 6-y-old (group III). Thiopental sodium dissolved in 10 ml of water in a syringe to which a 6-F feeding catheter was attached was administered prior to echocardiographic examination to patients in groups I, II and III with doses of 50, 35 and 25 mg/kg, respectively in an emergency care environment. Length of time to achieve sedation (induction time), duration of sedation, length of time to return to normal activity (recovery time), whether sedation was successful and side effects were recorded. In the overall study population, sedation was successful in 1094 (95.1%) of the patients, the induction time was 16.34 +/- 3.69 min, the duration of sedation was 35.07 +/- 7.04 min, the recovery time was 63.25 +/- 10.17 min and the overall side-effect prevalence was 2%. Sedation was significantly more successful, the induction time was significantly shorter, the recovery time was significantly longer and side effects significantly more prominent in groups I and II compared to group III. Rectally administered thiopental is a safe and efficacious agent for sedation of infants and young children with known or suspected congenital heart disease who are undergoing echocardiography in an outpatient cardiology clinic, provided that it is used in an emergency care setting considering the risk of respiratory depression even though the prevalence of this side effect is significantly low.

Evaluation of nitrous oxide-oxygen and triclofos sodium as conscious sedative agents.

PubMed

Subramaniam, Priya; Girish Babu, K L; Lakhotia, Disha

2017-01-01

Conscious sedation is used in the pediatric dentistry to reduce fear and anxiety in children and promote favorable treatment outcomes. To achieve them, the primary clinical need is for a well-tolerated, effective, and expedient analgesic and sedative agent that is safe to use. The aim of the present study was to evaluate the efficacy of nitrous oxide-oxygen and triclofos sodium as conscious sedative agents in 5-10-year-old children. Sixty children aged 5-10 years showing anxious, uncooperative, and apprehensive behavior were randomly divided and assigned into two groups (Groups A and B) such that Group A received 40% nitrous oxide-60% oxygen and Group B received triclofos sodium in the dose of 70 mg/kg body weight, given 30 min before the treatment procedure. During the whole course of sedation procedure, the response of the child was assessed using Houpt's behavior rating scale. The acceptance of route of drug administration by the patient and parent was also assessed. Data obtained were statistically evaluated using the Mann-Whitney U-test and Chi-square test. Children sedated with triclofos sodium were significantly more drowsy and disoriented compared to those sedated with nitrous oxide. The overall behavior of children in both the groups was similar. Good parental acceptance was observed for both the routes of administration. Patients accepted the oral route significantly better than inhalation route. Both nitrous oxide-oxygen and triclofos sodium were observed to be effective sedative agents, for successful and safe use in 5-10-year-old dental patients. Patients showed a good acceptance of the oral route compared to the inhalation route for sedation.

Comparison of NREM sleep and intravenous sedation through local information processing and whole brain network to explore the mechanism of general anesthesia

PubMed Central

Pan, Chuxiong; Xue, Fushan; Xian, Junfang; Huang, Yaqi; Wang, Xiaoyi; He, Huiguang

2018-01-01

Background The mechanism of general anesthesia (GA) has been explored for hundreds of years, but unclear. Previous studies indicated a possible correlation between NREM sleep and GA. The purpose of this study is to compare them by in vivo human brain function to probe the neuromechanism of consciousness, so as to find out a clue to GA mechanism. Methods 24 healthy participants were equally assigned to sleep or propofol sedation group by sleeping ability. EEG and Ramsay Sedation Scale were applied to determine sleep stage and sedation depth respectively. Resting-state functional magnetic resonance imaging (RS-fMRI) was acquired at each status. Regional homogeneity (ReHo) and seed-based whole brain functional connectivity maps (WB-FC maps) were compared. Results During sleep, ReHo primarily weakened on frontal lobe (especially preoptic area), but strengthened on brainstem. While during sedation, ReHo changed in various brain areas, including cingulate, precuneus, thalamus and cerebellum. Cingulate, fusiform and insula were concomitance of sleep and sedation. Comparing to sleep, FCs between the cortex and subcortical centers (centralized in cerebellum) were significantly attenuated under sedation. As sedation deepening, cerebellum-based FC maps were diminished, while thalamus- and brainstem-based FC maps were increased. Conclusion There’re huge distinctions in human brain function between sleep and GA. Sleep mainly rely on brainstem and frontal lobe function, while sedation is prone to affect widespread functional network. The most significant differences exist in the precuneus and cingulate, which may play important roles in mechanisms of inducing unconciousness by anesthetics. Trial registration Institutional Review Board (IRB) ChiCTR-IOC-15007454. PMID:29486001

Palliative sedation in Dutch general practice from 2005 to 2011: a dynamic cohort study of trends and reasons

PubMed Central

Donker, Gé A; Slotman, Frank G; Spreeuwenberg, Peter; Francke, Anneke L

2013-01-01

Background Little is known about the quantity and reasons for use of palliative sedation in general practice. Aim To gain more insight into the trends of and reasons for palliative sedation in Dutch general practice. Design and setting Dynamic cohort study using registrations and questionnaire data of Dutch GPs. Method Data collected in the years from 2005 until 2011 in the Dutch Sentinel General Practice Network were analysed. Trends and reasons for use of palliative sedation were analysed using multilevel analyses to control for clustering of observations within general practices. Results From 2005–2011, 183 cases were reported from 56 general practices. The incidence of palliative sedation fluctuated between 33.7 per 100 000 patients in 2006 and 15.2 in 2011. No rise or decline during the period was observed. Palliative sedation was applied in 5.7% of all deaths and most frequently used in younger patients with cancer. The mean number of refractory symptoms was 2.6 (SD 1.2); pain (69.4%), dyspnoea (53.0%), and fear (39.3%). Patient involvement in decision making before the start of palliative sedation (87.4%) was less frequently present in patients suffering from cardiovascular or chronic obstructive pulmonary disease and in older patients compared to patients with cancer (P<0.05). Pending euthanasia requests were present in 20.8% of cases; the choice for palliative sedation in these cases was clearly motivated. Conclusion Palliative sedation is performed in a small proportion of dying patients in Dutch general practice, without a rise or decline observed from 2005 to 2011. Patients with non-cancer diseases are less frequently involved in decision making than patients with cancer, possibly related to sudden deterioration. PMID:24152481

Effect of environmental noise and music on dexmedetomidine-induced sedation in dogs

PubMed Central

Seddighi, Reza M.; Ng, Zenithson; Sun, Xiaocun; Rezac, DJ

2017-01-01

Background Previous studies in human patients suggest depth of sedation may be affected by environmental noise or music; however, related data in domestic animals is limited. The objective of the current study was to investigate the effect of noise and music on dexmedetomidine-induced (DM- 10 µg/kg, IM) sedation in 10 dogs. Methods In a crossover design, post-DM injection dogs were immediately subjected to recorded human voices at either 55–60 decibel (dB) (Noise 1) or 80–85 dB (Noise 2); classical music at 45–50 dB (Music); or background noise of 40–45 dB (Control+). Control− included IM saline injection and exposure to 40–45 dB background noise. Sedation was assessed via monitoring spontaneous behavior and accelerometry (delta-g) throughout three 20-min evaluation periods: baseline, noise exposure, and post-treatment. Sedation was further assessed during two restraint tests at 30 min (R1) and 40 min (R2) post-injection. A mixed model for crossover design was used to determine the effect of noise exposure and time on either spontaneous behavior scores or delta-g. The restraint scores were analyzed using a two-way repeated measures ANOVA. Results Spontaneous behavior scores indicated less sedation during Noise 2 compared to Control+ (P = 0.05). R2 restraint scores for all DM treatments except Noise 2 indicated significantly higher sedation than Control− [C+ (P = 0.003), M (P = 0.014) and N1 (P = 0.044)]. Discussion Results suggest that the quality of sedation is negatively impacted by high-intensity noise conditions (80–85 dB), but exposure to music did not improve sedation in this population of research dogs. PMID:28785527

A comparison of ketamine + midazolam to propofol for procedural sedation for lumbar puncture in pediatric oncology by nonanesthesiologists-a randomized comparative trial.

PubMed

Chayapathi, Varsha; Kalra, Manas; Bakshi, Anita S; Mahajan, Amita

2018-05-04

Both ketamine-midazolam and propofol are frequently used in pediatric oncology units for procedural sedation. However, there are no prospective, randomized comparative trials (RCT) comparing the two groups when the procedure is performed by nonanesthesiologists. To compare ketamine + midazolam (group A) and propofol (group B) as sedative agents for intrathecal chemotherapy with regard to efficacy, side effects, time to induction, time to recovery, and smoothness of recovery. A partially-blinded RCT was conducted between August 2015 and March 2017 after gaining institutional ethics committee approval. Children aged 1-12 years requiring intravenous sedation for intrathecal chemotherapy were included. Patients were allocated to two treatment arms using computer-generated randomization tables, after obtaining written consent. The initial doses used were: ketamine 2 mg/kg, midazolam 0.2 mg/kg, and propofol 2.5 mg/kg, as per standard recommendations. The patient, parents, and person analyzing the data were blinded. Time to sedation, dose required, depth of sedation, vital parameters, time and smoothness of recovery, and emergence phenomena were documented. We enrolled 152 patients (76 each in group A and B). Nine patients had a failure of sedation (all in group B). Mean time to sedation and recovery was shorter in group B (P < 0.001). Transient drop in saturation was more frequent in group B, without statistical significance (P = 0.174). Mean depth of sedation was greater in group A (P < 0.001). Emergence symptoms were more frequently experienced in group A (P < 0.001). Ketamine-midazolam combination is safer and more effective. Propofol is faster in onset and recovery, and has smoother emergence with poor efficacy at recommended initial doses. © 2018 Wiley Periodicals, Inc.

Dexmedetomidine Use in Critically-Ill Children with Acute Respiratory Failure

PubMed Central

Grant, Mary Jo C.; Schneider, James B.; Asaro, Lisa A.; Dodson, Brenda L.; Hall, Brent A.; Simone, Shari L.; Cowl, Allison S.; Munkwitz, Michele M.; Wypij, David; Curley, Martha A.Q.

2016-01-01

Objective Care of critically-ill children includes sedation but current therapies are suboptimal. To describe dexmedetomidine (DEX) use in children supported on mechanical ventilation for acute respiratory failure. Design Secondary analysis of data from the RESTORE clinical trial. Setting Thirty-one pediatric ICUs. Patients Data from 2449 children; 2 weeks to 17 years old. Interventions Sedation practices were unrestrained in the usual care arm. Patients were categorized as receiving dexmedetomidine as a primary sedative (DEXp), secondary sedative (DEXs), periextubation agent (DEXe), or never prescribed. DEX exposure and sedation and clinical profiles are described. Measurements and Main Results Of 1224 usual care patients, 596 (49%) received DEX. DEXp patients (N=138; 11%) were less critically ill (PRISM III-12 score median 6 [IQR 3–11]) and when compared to all other cohorts, experienced more episodic agitation. In the intervention group, time in sedation target improved from 28% to 50% within one day of initiating DEXp. DEXs usual care patients (N=280; 23%) included more children with severe PARDS or organ failure. DEXs patients experienced more inadequate pain (22% vs 11%) and sedation (31% vs 16%) events. DEXe patients (N=178; 15%) were those known to not tolerate an awake, intubated state and experienced a shorter ventilator weaning process (2.1 vs 2.3 days). Conclusions Our data support the use of dexmedetomidine as a primary agent in low criticality patients offering the benefit of rapid achievement of targeted sedation levels. Dexmedetomidine as a secondary agent does not appear to add benefit. The use of dexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. These data support a broader armamentarium of pediatric critical care sedation. PMID:27654816

When there are no good choices: illuminating the borderland between proportionate palliative sedation and palliative sedation to unconsciousness.

PubMed

Reid, Thomas T; Demme, Richard A; Quill, Timothy E

2011-01-01

Despite state-of-the-art palliative care, some patients will require proportionate palliative sedation as a last-resort option to relieve intolerable suffering at the end of life. In this practice, progressively increasing amounts of sedation are provided until the target suffering is sufficiently relieved. Uncertainty and debate arise when this practice approaches palliative sedation to unconsciousness (PSU), especially when unconsciousness is specifically intended or when the target symptoms are more existential than physical. We constructed a case series designed to highlight some of the common approaches and challenges associated with PSU and the more aggressive end of the spectrum of proportionate palliative sedation as retrospectively identified by palliative care consultants over the past 5 years from a busy inpatient palliative care service at a tertiary medical center in Rochester (NY, USA). Ten cases were identified as challenging by the palliative care attendings, of which four were selected for presentation for illustrative purposes because they touched on central issues including loss of capacity, the role of existential suffering, the complexity of clinical intention, the role of an institutional policy and use of anesthetics as sedative agents. Two other cases were selected focusing on responses to two special situations: a request for PSU that was rejected; and anticipatory planning for total sedation in the future. Although relatively rare, PSU and more aggressive end-of-the-spectrum proportionate palliative sedation represent responses to some of the most challenging cases faced by palliative care clinicians. These complex cases clearly require open communication and collaboration among caregivers, patients and family. Knowing how to identify these circumstances, and how to approach these interventions of last resort are critical skills for practitioners who take care of patients at the end of life.

Palliative sedation in Dutch general practice from 2005 to 2011: a dynamic cohort study of trends and reasons.

PubMed

Donker, Gé A; Slotman, Frank G; Spreeuwenberg, Peter; Francke, Anneke L

2013-10-01

Little is known about the quantity and reasons for use of palliative sedation in general practice. To gain more insight into the trends of and reasons for palliative sedation in Dutch general practice. Dynamic cohort study using registrations and questionnaire data of Dutch GPs. Method Data collected in the years from 2005 until 2011 in the Dutch Sentinel General Practice Network were analysed. Trends and reasons for use of palliative sedation were analysed using multilevel analyses to control for clustering of observations within general practices. From 2005-2011, 183 cases were reported from 56 general practices. The incidence of palliative sedation fluctuated between 33.7 per 100 000 patients in 2006 and 15.2 in 2011. No rise or decline during the period was observed. Palliative sedation was applied in 5.7% of all deaths and most frequently used in younger patients with cancer. The mean number of refractory symptoms was 2.6 (SD 1.2); pain (69.4%), dyspnoea (53.0%), and fear (39.3%). Patient involvement in decision making before the start of palliative sedation (87.4%) was less frequently present in patients suffering from cardiovascular or chronic obstructive pulmonary disease and in older patients compared to patients with cancer (P<0.05). Pending euthanasia requests were present in 20.8% of cases; the choice for palliative sedation in these cases was clearly motivated. Palliative sedation is performed in a small proportion of dying patients in Dutch general practice, without a rise or decline observed from 2005 to 2011. Patients with non-cancer diseases are less frequently involved in decision making than patients with cancer, possibly related to sudden deterioration.

Nonmedical use of sedatives in urban Bengaluru

PubMed Central

Nattala, Prasanthi; Murthy, Pratima; Thennarasu, K.; Cottler, Linda B.

2014-01-01

Background: Nonmedical sedative use is emerging as a serious problem in India. However, there is paucity of literature on the patterns of use in the population. Aim: The aim of the present analysis was to explore sedative use patterns in an urban metropolis. Materials and Methods: Data for the present analysis come from the parent study on nonmedical prescription drug use in Bengaluru, India. Participants (n = 717) were recruited using a mall-intercept approach, wherein they were intercepted in five randomly selected shopping malls, and administered an interview on their use of prescription drugs. Results: Past 12-month nonmedical sedative use was reported by 12%, benzodiazepines being the commonest. Reasons cited for nonmedical use included “sleeplessness, pain relief, stress.” A majority (73%) reported sedative use “in ways other than as prescribed,” compared to “use without prescription” (27%). All prescriptions were issued by general physicians in private hospitals. About 11% among those who used “in ways other than as prescribed,” and 100% of nonprescribed users, reported irregular use (skipping doses/stopping/restarting). Among those who used “in ways other than prescribed,” pharmacy stores were the source of obtaining the sedatives. Among “nonprescribed users,” family/friends were the main source. Three-percent reported using sedatives and alcohol together in the same use episode. In multivariate logistic regression analyses, nonmedical sedative use was significantly associated with graduation-level education or above (adjusted odds ratio [aOR]: 2.53, 95% confidence interval [CI]: 1.30-4.91), and married status (aOR: 2.32, 95% CI: 1.04-5.18). Conclusions: Findings underscore the need for considering various contextual factors in tailoring preventive interventions for reducing nonmedical sedative use. PMID:25316935

Estimating the need for dental sedation: evaluating the threshold of the IOSN tool in an adult population.

PubMed

Liu, T; Pretty, I A; Goodwin, M

2013-04-01

The aim of this study was, through a service evaluation, to assess the use of the IOSN tool in determining whether threshold values were appropriate for identification of IV sedation and general anaesthetic (GA) cases from a referral population. A total of 105 patients were taken from a dental minor oral surgery referral service within a north west primary care trust over the course of six months. The IOSN tool was completed to assess: treatment complexity, medical and behavioural factors and patient anxiety levels. Each patient was then followed through to treatment. The type of sedation modality they received was compared to their IOSN score previously calculated and these results evaluated. The findings suggest that 94% of patients were treated within primary care by the MOS service, of which 58% received local anaesthetic (LA) alone and 42% were treated by LA with IV sedation. There was a general marked trend as the IOSN score increased so did the treatment modality from LA, through sedation to GA. Logistic regression using the components of the IOSN tool to predict sedation use indicated the IOSN predictors distinguished between those who required sedation and those who didn't (chi-square = 56.411, p <0.0001, df = 3) with treatment complexity (Exp B = 10.836, p <0.0001) and anxiety (Exp B = 4.319, p <0.0001) shown to be significant factors in determining sedation need. The data collected have shown that there is a positive relationship between the IOSN score and the type of treatment modality the patient received, suggesting that the threshold values are correctly set. It is concluded that IOSN tool is a useful means of aiding the clinician in both assessing and referring patients for that sedation need.

Dissociations in the expression of the sedative effects of triazolam.

PubMed

Weingartner, H J; Sirocco, K; Rawlings, R; Joyce, E; Hommer, D

1995-05-01

Fifteen normal volunteers were administered 0.250, 0.375, and 0.500 mg of triazolam and placebo in a double-blind repeated measures cross-over design. Subjects demonstrated dose-dependent impairments in free recall, a test of explicit memory requiring awareness and reflection, and sedation as assessed by objective behavioral measures (the digit symbol substitution task) and subjective visual analogue scales. The sedative drug response did not account for the impairment in free recall. Differences in performance of the two tests of sedation indicated that the effect of this drug on reflective processes accounts for impairment in episodic memory and the inability to track the sedative effects of this drug at the higher doses tested in this study.

A study to assess the value of bispectral analysis in intravenous sedation with midazolam during third molar surgery under local anaesthesia.

PubMed

Cheung, C W; Irwin, M G; Chiu, W K; Ying, C L A

2008-12-01

This study aimed to determine whether bispectral index (BIS) can be used as an indicator of sedation and recovery with intravenous midazolam. In Part A, 30 healthy patients undergoing third molar extraction under local anaesthesia were recruited. They were sedated with intravenous midazolam titrated to clinical endpoints. BIS values were recorded when adequately sedated (BIS(S)) and when clinical recovery criteria were met (BIS). In Part B, another 30 patients were sedated to the range of BIS(S) obtained in Part A. Recovery was assessed postoperatively when the range of BIS(R) from Part A was reached. BIS titrated patients required less midazolam (p < 0.001). Seventy percent of Part B patients required increments of midazolam during surgery, compared to 16.7% in Part A (p < 0.001). Total dose of midazolam given was lower in Part B (p = 0.025). BIS is not effective as a sole indicator of endpoint in sedation with intravenous midazolam.

[Indications of dexmedetomidine in the current sedoanalgesia tendencies in critical patients].

PubMed

Romera Ortega, M A; Chamorro Jambrina, C; Lipperheide Vallhonrat, I; Fernández Simón, I

2014-01-01

Recently, dexmedetomidine has been marketed in Spain and other European countries. The published experience regarding its use has placed dexmedetomidine on current trends in sedo-analgesic strategies in the adult critically ill patient. Dexmedetomidine has sedative and analgesic properties, without respiratory depressant effects, inducing a degree of depth of sedation in which the patient can open its eyes to verbal stimulation, obey simple commands and cooperate in nursing care. It is therefore a very useful drug in patients who can be maintained on mechanical ventilation with these levels of sedation avoiding the deleterious effects of over or infrasedation. Because of its effects on α2-receptors, it's very useful for the control and prevention of tolerance and withdrawal to other sedatives and psychotropic drugs. The use of dexmedetomidine has been associated with lower incidence of delirium when compared with other sedatives. Moreover, it's a potentially useful drug for sedation of patients in non-invasive ventilation. Copyright © 2013 Elsevier España, S.L. y SEMICYUC. All rights reserved.

[Evaluation of N2O inhalation and oral midazolam conscious sedation in pediatric dentistry of children with intellectual disability].

PubMed

Tian, Xiao-hua; Yang, Yan-zhong; Li, Xiao-feng

2015-06-01

To evaluate the effect of N2O inhalation and oral midazolam sedation on uncooperative patients with intellectual disability in pediatric dentistry. N2O inhalation (35%-50%) and oral midazolam conscious sedation (dosages range: 0.50-0.75 mg/kg) were applied to 67 uncooperative pediatric patients with intellectual disability in outpatient department. The patients were divided into 2 groups: group A (N2O inhalation conscious sedation) and group B(oral midazolam conscious sedation).Treatment results and safety were statistically analyzed by Chi-square test with SPSSl3.0 software package. The mean success rate was 70%. The success rate in group B (75%) was higher than group A (67%). The overall incidence of adverse reactions was 13%(9/67). The adverse reaction rate in group B (25%) was significantly higher than group A (5%, P<0.05). N2O inhalation and oral midazolam conscious sedation are effective and safe in pediatric dental uncooperative patients with intellectual disability.

Oral Midazolam Sedation For Uncooperative Children In Outpatient Paedodontics: Time For Reappraisal.

PubMed

Kapur, Aditi; Jain, Kajal; Goyal, A; Mahoney, Greg

2016-01-01

Sedation is frequently desired to facilitate dental procedures in uncooperative paediatric patients. Oromucosal Midazolam sedation is a popular choice among paediatric dentists world wide due to its many advantages such as ease of administration, good efficacy, presence of reversal agents and a wide margin of safety. On the other hand, many investigators have reported that midazolam sedation may not be successful for carrying out all types of dental procedures. This may be attributed to diverse nature of various treatment plans coupled with the extent of behavioural changes in the child and operator's experience. Due to the heterogeneity involved in treatment of paediatric dental procedures, the specific indications for oral midazolam use that ensure its success rate, probably need to be defined. This may enable the clinicians to have a convenient and quicker option for managing the cases rather than facing sedation failure or at times, ending up giving general anaesthetics. This article therefore brings forth the possible causes of midazolam sedation failure and proposes a 'case selection criterion'.

The rate of adverse events during IV conscious sedation.

PubMed

Schwamburger, Nathan T; Hancock, Raymond H; Chong, Chol H; Hartup, Grant R; Vandewalle, Kraig S

2012-01-01

Conscious sedation has become an integral part of dentistry; it is often used to reduce anxiety or fear in some patients during oral surgery, periodontal surgery, implant placement, and general dentistry procedures. The purpose of this study was to evaluate the frequency of adverse events during IV conscious sedation provided by credentialed general dentists and periodontists in the United States Air Force (USAF). Sedation clinical records (Air Force Form 1417) from calendar year 2009 were requested from all USAF bases. A total of 1,468 records were reviewed and 19 adverse events were noted in 17 patients. IV complication (infiltration) was the most common adverse event. The overall adverse event rate was 1.3 per 100 patients treated. The results of this study show that moderate sedation provided by general dentists and periodontists in the USAF has a low incidence of adverse events, and conscious sedation remains a viable option for providers for the reduction of anxiety in select patients.

Why intravenous moderate sedation should be taught in graduate endodontic programs.

PubMed

Montagnese, Thomas Anthony

2012-03-01

The purpose of this opinion article is to present reasons why intravenous moderate sedation should be taught in graduate endodontic programs. Access to oral health care is an area of much interest and concern, but some patients are unable to get endodontic care because they have special needs. Special needs can refer to patients who fear dentistry itself and other aspects of dental treatment. A variety of phobias and medical, developmental, and physical conditions can make it difficult for some patients to tolerate the endodontic care they need and want. Moderate sedation can help many of these patients. Endodontists in general are not trained to provide intravenous moderate sedation. By incorporating intravenous moderate sedation into endodontic practice, many of these patients can be treated. The first step in achieving this goal is to add intravenous moderate sedation training to graduate endodontic programs. The long-term effect will be to make specialty endodontic care available to more people.

The role of midazolam-induced sedation in bone marrow aspiration/trephine biopsies.

PubMed

Mainwaring, C J; Wong, C; Lush, R J; Smith, J G; Singer, C R

1996-12-01

This study was undertaken in 102 adult patients to evaluate the safety and efficacy of intravenous (i.v.) midazolam in the setting of bone marrow aspiration and trephine biopsy (BMAT). Combined local anaesthetic (LA) and sedation was used in 87% of patients and 13% received LA alone. Amnesia occurred in all sedated patients with only 9% experiencing a mild degree of post-procedure pain. This contrasted sharply with the non-sedated group, in whom 85% had intense pain during the biopsy followed by protracted local discomfort in approximately 54%. Drowsiness and some psychomotor impairment were the only notable sedation-related side-effects in approximately 20%. None required assisted ventilation. There was a resounding patient preference for BMAT with sedation. Considering the ease of use, safety and efficacy of i.v. midazolam, the availability of flumazenil as a reversal agent and the undoubted positive effects on quality of life, we would advocate using it in BMAT provided that there were no contraindications.