Search

Propofol is widely used to sedate agitated patients in intensive care units. However, it can cause a rare but fatal complication, propofol-related infusion syndrome (PRIS). The pathophysiology of PRIS is not clear, and there is no definitive diagnosis and treatment. We report a successfully treated case of PRIS in a critically ill patient receiving low-dose propofol infusion. A 59-year-old male patient complaining of sudden chest pain repeatedly collapsed in an ambulance and the emergency room, and veno-arterial extracorporeal membrane oxygenation was delivered. He was diagnosed with a total occluded left anterior descending coronary artery in coronary angiography. On day 20, he showed arrhythmia, increased creatinine kinase (CK), and increased CK-MB and troponin I, accompanied by unstable hemodynamic status despite high-dose vasopressors. He was administered propofol for 20 days at an average dose of 1.3 mg/kg/hr owing to issues with agitation and ventilator synchrony. We strongly suspected PRIS and immediately discontinued propofol infusion, and he was successfully treated with aggressive supportive care. PRIS can occur in patients administered propofol for a prolonged period at low doses. Thus, clinicians should use propofol with caution for PRIS and change to alternative sedatives for long-term sedation.

The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was performed under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and performed with venous sedation. We observed satisfactory anesthesia 15-minutes after the intervention and efficient intraoperative pain control within the following 24 hours. Surgical axilla anesthesia is feasible with the described blocks.

Background Various drugs have been endorsed but no standardised premedication protocol exists for paediatric patients. Nebulised form of drug not only results in better patient acceptability but also has improved clinical effectiveness. The present study delineates and evaluates the efficacy and safety of nebulised ketamine and combination of nebulised dexmedetomidine and ketamine for premedication in paediatric patients. Methods Prospective randomised controlled study was planned in patients, 3–10 years of age, undergoing surgeries. Patients received either nebulised ketamine (2 mg/kg) (group X, n = 23) or dexmedetomidine 1 μg/kg plus ketamine (1 mg/kg) (group Y; n = 24), 30 min before shifting inside the operation theatre. The sedation level, haemodynamic response and ill-effects were recorded for 30 min. Results The baseline haemodynamic (HR, MAP, RR and SpO2) parameters were normal and comparable in both the groups. There was no significant variation noticed in terms of HR, MAP, RR and SpO2% in either of the groups at 15 min (p Conclusion Nebulisation is a satisfactory method of premedication for children. A combination of nebulised ketamine with a dose of 1 mg/kg and dexmedetomidine with a dose of 1 μg/kg is capable of producing a satisfactory level of sedation in a more effective manner than sedation induced by nebulised ketamine alone (2 mg/kg).

Background: Propofol is a key component for the management of sedation and shivering during targeted temperature management (TTM) following cardiac arrest. The cardiac depressant effects of propofol have not been described during TTM and may be especially relevant given the stress to the myocardium following cardiac arrest. The purpose of this study is to describe hemodynamic changes associated with propofol administration during TTM. Methods: This single center, retrospective cohort study evaluated adult patients who received a propofol infusion for at least 30 minutes during TTM. The primary outcome was the change in cardiovascular Sequential Organ Failure Assessment (cvSOFA) score 30 minutes after propofol initiation. Secondary outcomes included change in systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), and vasopressor requirements (VR) expressed as norepinephrine equivalents at 30, 60, 120, 180, and 240 minutes after propofol initiation. A multivariate regression was performed to assess the influence of propofol and body temperature on MAP, while controlling for vasopressor dose and cardiac arrest hospital prognosis (CAHP) score. Results: The cohort included 40 patients with a median CAHP score of 197. The goal temperature of 33°C was achieved for all patients. The median cvSOFA score was 1 at baseline and 0.5 at 30 minutes, with a non-significant change after propofol initiation ( P = .96). SBP and MAP reductions were the greatest at 60 minutes (17 and 8 mmHg; P

Background: Clinically significant post-traumatic stress symptoms (PTSS) have been reported in up to a quarter of paediatric intensive care unit (PICU) survivors. Ongoing PTSS negatively impacts children's psychological development and physical recovery. However, few data regarding associations between potentially modifiable PICU treatment factors, such as analgosedatives and invasive procedures, and children's PTSS have been reported. Objectives: We sought to investigate the medical treatment factors associated with children's PTSS after PICU discharge. Methods: A prospective longitudinal cohort study was conducted in two Australian tertiary referral PICUs. Children aged 2-16 y admitted to the PICU between June 2008 and January 2011 for >8 h and

A novel concept for an organ-preserving treatment of pediatric urogenital and perianal rhabdomyosarcoma includes high dose rate brachytherapy following surgical tumor resection. For the duration of the brachytherapy of 6 days plus 2-day recovery break the patients are not allowed to move and are kept under deep sedation, which can lead to difficult weaning from mechanical ventilation, withdrawal, delirium, and prolonged hospital stay. The aim of this study was to evaluate a protocol which includes a switch from fentanyl to ketamine 3 days prior to extubation to help ensure a rapid extubation and transfer from PICU.Patients who underwent surgical tumor resection of rhabdomyosarcoma and subsequent brachytherapy were treated according to a standardized protocol. We evaluated doses of fentanyl, midazolam and clonidine, time of extubation, length of PICU stay and occurrence of withdrawal symptoms and delirium. We compared fentanyl dose at time of extubation, duration of weaning from mechanical ventilation and time to discharge from PICU with patients after isolated severe traumatic brain injury.Twentytwo patients (age 39.9 ± 29.8 months) were treated in our PICU to undergo brachytherapy. Extubation was performed 21.6 ± 13.5 h after the last brachytherapy session with an average fentanyl dose of 1.5 ± 0.5 µg/kg/h and patients were discharged from PICU 58.4 ± 30.3 h after extubation, which all is significantly lower compared to the control group (extubation after 88.0 ± 42.2 h, p 0.001; fentanyl dose at the time of extubation 2.5 ± 0.6 µg/kg/h, p 0.001; PICU discharge after 130.1 ± 148.4 h, p 0.009). Withdrawal symptoms were observed in 9 patients and delirium in 13 patients.A standardized analgesia and sedation protocol including an opioid break, scoring systems to detect withdrawal symptoms and delirium, and tapering plans contributes to successful early extubation and discharge from PICU after long-term deep sedation.

Objectives To describe the efficacy and safety of intranasal midazolam for sedation during essential dental treatment of geriatric patients with major neurocognitive disorder (MND) and care-resistant behaviour (CRB).Background Dental treatment is often impossible in geriatric MND patients with CRB. Intranasal midazolam may provide a non-invasive sedation method, but there is currently no information on its use in geriatric patients.Methods In this observational study, we included geriatric patients with severe MND and CRB needing urgent dental treatment. Each patient received 5 mg midazolam intranasally. Agitation/sedation levels, heart rate, respiration rate and oxygen saturation were recorded at 5-minute intervals.Results Thirty two patients were included. Mean age was 84 (+/- 7) years. Mean (SD) time to treatment start was 13 (+/- 5) minutes, and mean time to maximum sedation 17 (+/- 11) minutes. Sedation was sufficient to enable dental treatment to be completed in 31 (97%) patients. Anxiolysis/light sedation occurred in 16 (50%) patients, and moderate to deep sedation occurred in 16 (50%) patients. No patients suffered from apnoea, although 3 patients required a chin-lift manoeuvre. Hypoxaemia occurred in 1 of these patients and in 2 other patients without airway obstruction. All patients recovered uneventfully. In a regression model, age, weight and other sedative medication use were found not to be associated with maximum sedation depth.Conclusions Of 5 mg intranasal midazolam facilitates treatment of geriatric patients with MND in the comfort of their own environment. More information is needed to guide titration to balance the desired sedation level and patient safety.

Background: Sedation is often required in the intensive care unit (ICU) but can be harmful if administered inappropriately or excessively. Dexmedetomidine offers a favourable, cooperative sedation profile, despite a higher relative cost. It also has analgesic and opioid-sparing properties. The multidisciplinary ICU at our central South African hospital adopted the use of dexmedetomidine through the course of 2016. The aim of the study was to determine whether this change in practice affected the ICU length of stay (LOS) and duration of mechanical ventilation at this unit.Methods: A retrospective cohort analysis of patients’ files, who were sedated with midazolam and propofol in 2015 and those sedated with dexmedetomidine in 2017, was conducted. The data gathered included the sedatives used, demographic and vital data, ICU LOS, duration of mechanical ventilation and treatment of side-effects. Group 2015 and Group 2017 were also analysed for possible confounders where appropriate, and these confounders were excluded for a re-analysis. Descriptive statistics were used and results were analysed for range, median, interquartile range (IQR), percentage and frequency. For post-hoc analysis of the effect of confounders, the Spearman rank correlation coefficient was used to determine the association between duration and sedative exposure and either duration of ICU stay or mechanical ventilation. The null hypothesis was set at p < 0.05.Results: Group 2015 comprised 52 patients and Group 2017 60 patients. No difference between the groups was found regarding ICU LOS (median [IQR] 5 [2–14] vs 8.5 [5–12.5] days; p = 0.10) or mechanical ventilation (median [IQR] 91 [34–272] vs 129 [58–221] hours; p = 0.44). Those who were sedated with dexmedetomidine had better initial prognoses (median APACHE II score 13 vs 18, p = 0.01), were sedated for greater fractions of their total ICU stay (median 46% vs 25%, p < 0.01), and had a higher incidence of hypotension and bradycardia (36.7% vs 11.4%; p < 0.01); which did not relate to a higher mortality. Spearman’s rank correlation coefficients also showed a weak to moderate association with longer ICU stay and ventilation duration when the duration of sedation with midazolam or propofol was shorter in relation to ICU stay.Conclusion: We did not find a reduction in ICU LOS or mechanical ventilation with the advent of dexmedetomidine in our unit. The lack of regular documentation of sedation levels and scheduled sedation breaks might have contributed to these results. Dexmedetomidine has a role to play in the ICU setting, but it should only be used when clearly indicated. Vigilance for hypotension and bradycardia is required when using dexmedetomidine.

Background: Preoperative anxiety is common in paediatric patients and is associated with negative postoperative outcomes. Sedative premedication may alleviate some of this anxiety. A new sedation protocol using midazolam and ketamine in combination was instituted at our tertiary hospital. We aimed to evaluate the efficacy and the side effect profile of this regimen. Methods: We conducted a retrospective review of paediatric surgical patients who received oral midazolam (0.25 mg/kg) together with ketamine (3 mg/kg) as premedication, prior to induction of anaesthesia for elective surgery. The Watcha scale was used to assess preoperative and postoperative behaviour. Premedication efficacy was assessed using the Wilson sedation scale together with the 4-point anxiety scale. We further compared the incidence of significant preoperative anxiety with the incidence from a previous study. Results: We included 146 patients in our study. There was optimal sedation (Wilson sedation score = 1/2) in 47.9% of the patients (CI 39.9–56.1) with failed sedation (Wilson sedation score = 0) in 34.9% (CI 27.6–43.1) and over-sedation (Wilson sedation score = 3/4) in 17.1% (CI 11.8–24.2) of the patients. Optimal anxiolysis (4-point anxiety scale = 1) was achieved in 76.0% of the patients (CI 68.4–82.3). Failed anxiolysis (4-point anxiety scale = 2/3/4) occurred in 23.3% of the patients (CI 17.7–31.6). The majority of patients had no side effects (79.5%; CI 72.1–85.3). For those who experienced side effects, the most common was hypersalivation (12.3%; CI 7.9–18.8). The incidence of postoperative delirium was 3.4% (CI 1.4–8.0) and there was significantly less anxiety compared to our previous regimen (5.5%; CI 2.7–10.6 versus 13.5%; p = 0.007). Conclusion: The combination of midazolam and ketamine appears effective in providing safe sedation and reducing preoperative anxiety. Side effects occurred in up to a fifth of patients; predominantly hypersalivation. The combination of midazolam and ketamine for premedication should be considered for ASA I–II patients without contraindications undergoing elective surgery.

Mutations in SCN8A gene lead to changes in sodium channels in the brain, which are correlated with severe epileptic syndrome. Due to the rarity, there are few studies that support anesthesia in that population. The present study aims to report alternatives to inhalation anesthesia at epileptic encephalopathy. Case report Male, 4 years old, with SCN8A encephalopathy with surgical indication of orchidopexy. Neuroaxis block was performed and dexmedetomidine was used as a pre-anesthetic and sedation. The anestheticsurgical act was uneventful. Conclusion The association of neuraxial block and dexmedetomidine proved to be a viable alternative for surgery in patients with SCN8A encephalopathy.

Thyroid hormones have an integral role in cardiac homeostasis, and hypothyroidism may be associated with impaired myocardial contractility, altered endothelial function, and blunted response to catecholamines. Herein, the case of a patient with undiagnosed severe hypothyroidism, who developed an acute myocardial infarction and cardiac arrest during sedation for bronchoscopy, is described. He required prolonged resuscitation, which included coronary catheterization and placement of an intra-aortic balloon pump. The resuscitation was noteworthy for blunted physiologic responses to large doses of epinephrine; in particular, persistent bradycardia without evidence of conduction abnormalities. On admission to the intensive care unit, he was hypothermic (31.4°C), bradycardic, and hypotensive. Laboratory investigations revealed profound hypothyroidism, and thyroid hormone replacement was initiated. Within hours of initiation of thyroid hormone replacement, the need for vasopressor support was reduced. He had a complete recovery and was discharged home neurologically intact. The authors of the present report believe that this favorable neurologic outcome could be attributed to efficient resuscitation, prompt coronary revascularization, and profound hypothermia likely related to a hypothyroidism-associated hypometabolic state.

Objectives Acute pain management in opioid users can be challenging in the perioperative period. This study focuses on whether use of opioids increases sedation medication requirements in patients undergoing port placement under moderate sedation. Materials and Methods A retrospective review was performed on all patients undergoing port placement between June 1, 2017, and June 30, 2019. Exclusion criteria included receiving general anesthesia, no sedation, and errors in data entry. Data collection included demographics, use of opioids, benzodiazepines, antidepressants, tobacco, alcohol, and sedation data. Results Opioid, benzodiazepine, and selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) use was significantly associated with higher sedation drug dose requirements. Patients using opioids required 10.5% higher doses of midazolam compared with nonusers. Benzodiazepine users required 16.3% additional dosage of midazolam than nonusers. Finally, patients on SSRIs/SNRIs medications required 11.8% higher midazolam dosing when compared with nonusers. Conclusion Anticipating higher needs of sedation medications during procedures in patients with history of psychotropic agents use can allow for more effective sedation and patient satisfaction. More patient and provider awareness is needed on this topic, as health care policy is moving toward value-based healthcare, with patient satisfaction surveys being one of its indicators.

Background/Aims: The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions.Methods: This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction.Results: A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups.Conclusions: Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.

BackgroundKetamine, a dissociative anesthetic, induces remission of depression by antagonizing glutaminergic NMDA receptors. Ketamine has been used previously in outpatient setting for treatment-resistant depression, but we showcase its utility in depression management at the Intensive Care Unit (ICU).Research QuestionCan ketamine be used for depression treatment in ICU patients?Study Design and MethodsA retrospective chart review of ICU patients was done at a tertiary center from 2018 to 2021, to assess the ketamine usage. Among the patients reviewed, ketamine was used for depression in 12, and for analgesia & sedation in 2322 patients. Ketamine was administered in doses of 0.5mg/kg & 0.75mg/kg for depression. Each course consisted of 3 doses of ketamine administered over 3 days. 7 in 12 patients received a single course of ketamine. The rest received 3-4 courses 1 week apart.ResultsKetamine was found to improve mood and affect in most of the patients with depression. 11 in 12 patients had a positive response with better sleep. It has a major advantage over conventional anti-depressants since it takes only a few hours to induce remission. Patients who refused to eat and follow treatment protocol, and who would otherwise succumb to death if not for the rapid remission of depression, were administered ketamine.ConclusionA major drawback of ketamine is that the duration of remission is short, with the response lasting only up to 7 days after a single dose. Hence, all the patients in our study were weaned off ketamine with a supporting antidepressant. Ketamine has been documented to cause cardio-neurotoxicity; however, only one patient had worsening lethargy in our study. To conclude, ketamine has a monumental benefit in treating depression in the ICU. Although our study was associated with positive outcomes, there is a need for prospective studies with long-term follow-up assessments.

BACKGROUND AND OBJECTIVE: Fentanyl is an opioid commonly used to prevent and treat severe pain in neonates; however, its use is off label and mostly based on bodyweight. Given the limited pharmacokinetic information across the entire neonatal age range, we characterized the pharmacokinetics of fentanyl across preterm and term neonates to individualize dosing. METHODS: We pooled data from two previous studies on 164 newborns with a median gestational age of 29.0 weeks (range 23.9-42.3), birthweight of 1055 g (range 390-4245), and postnatal age (PNA) of 1 day (range 0-68). In total, 673 plasma samples upon bolus dosing (69 patients; median dose 2.1 μg/kg, median 2 boluses per patient) or continuous infusions (95 patients; median dose 1.1 μg/kg/h for 30 h) with and without boluses were used for population pharmacokinetic modeling in NONMEM® 7.4. RESULTS: Clearance in neonates with birthweight of 2000 and 3000 g was 2.8- and 5.0-fold the clearance in a neonate with birthweight of 1000 g, respectively. Fentanyl clearance at PNA of 7, 14, and 21 days was 2.7-fold, 3.8-fold, and 4.6-fold the clearance at 1 day, respectively. Bodyweight-based dosing resulted in large differences in fentanyl concentrations. Depending on PNA and birthweight, fentanyl concentrations increased slowly after the start of therapy for both intermittent boluses and continuous infusion and reached a maximum concentration at 12-48 h. CONCLUSIONS: As both prenatal and postnatal maturation are important for fentanyl exposure, we propose a birthweight- and PNA-based dosage regimen. To provide rapid analgesia in the first 24 h of treatment, additional loading doses need to be considered. ispartof: CLINICAL PHARMACOKINETICS vol:61 issue:3 pages:401-412 ispartof: location:Switzerland status: published

Background There is a growing number of pediatric procedures requiring sedation outside the operating room. Among these are auditory brainstem response (ABR) tests, the gold standard for objective hearing evaluation in infants and toddlers. Recently, a nurse-led pediatric sedation service based on a structured protocol has been developed for ABR testing. Objectives To retrospectively analyze the safety and efficacy of the pediatric nurse-led sedation protocol (PNLSP) in a tertiary medical center using Chloral Hydrate (CH) in children undergoing ABR testing. Methods Data from medical charts of children who underwent sedation for ABR testing between January 2014 and December 2017, were retrieved. Analysis of sedation success/failure rates, sleep induction time (SIT), sleep duration time (SDT), and adverse events (AE), was performed. Findings 1348 children with a mean age of 13.4 months (range 3–42 months), classified by the American Society of Anesthesiologists Physical Status Classification System (ASA score) 1–3, were included in the analysis. All children received a fixed dose of 75 mg / kg CH orally or rectally. Sedation success rate was 98.7% and enabled completion of ABR testing. Failure to sedate was evident in 17 children (1.3%), all classified as ASA score 1–2. Median SIT and SDT were 25 and 100 min, respectively. Mild AE occurred in 9 children (0.67%), none of which required further intervention. Conclusions Findings support the use of a structured PNLSP using CH as safe and efficient. The suggested protocol is an effective alternative for general anesthesia (GA) for ABR testing in healthy young children.

Surgical resection is the treatment of choice both for early-stage lung cancer and pulmonary metastatic disease. For patients with lung tumors who are not eligible for surgery, the minimally invasive modality of radiofrequency ablation (RFA) may be curative and, thus, should be considered. However, opinions regarding the optimal anesthetic technique for pulmonary RFA differ. Here the authors report their experience with the use of ultrasound-guided paravertebral block in minimally-sedated patients undergoing pulmonary RFA. This retrospective study was conducted at a single institution. The 17 consecutive patients underwent 19 pulmonary RFA procedures for primary lung tumor or lung metastases. In all patients, RFA was performed according to the protocol of the hospital. Anesthesia in patients receiving RFA for lung tumors consisted of a thoracic paravertebral block (TPVB), performed between T4 and T8, with minimal sedation. This approach allowed intraoperative communication with the patient and apnea pauses as needed. There were no complications after TPVB, which was well-tolerated by all patients. Only two patients required an alfentanil bolus during RFA because of pleuritic pain. No patient required conversion from sedation to general anesthesia. There were no episodes of hemodynamic instability or desaturation (SaO2 ≤95%), and excessive sedation prevented patient collaboration in only one patient. In conclusion, ultrasound-guided single-injection TPVB is a safe and effective anesthetic technique for high-risk patients undergoing RFA for a primary lung tumor or lung metastases.

На сегодняшний день регионарная анестезия при радикальной цистэктомии у пациентов с раком мочевого пузыря выполняется в качестве компонента общей анестезии в условиях искусственной вентиляции легких. Цель работы — оценить безопасность и преимущества выполнения радикальной цистэктомии на фоне комбинированной спинально-эпидуральной анестезии при сохраненном самостоятельном дыхании c последующей оценкой течения послеоперационного периода. Материалы и методы. С 2008 по 2012 г. 96 пациентам в возрасте 67,0 ± 6,5 года произведена радикальная цистэктомия с расширенной тазовой лимфаденэктомией и различными видами деривации мочи с использованием комбинированной спинально-эпидуральной анестезии. Послеоперационная анальгезия включала продленную инфузию наропина 0,2% — 6–8 мл/ч в комбинации с системным введением нестероидных противовоспалительных средств. Оценивали характеристики вариабельности сердечного ритма в частотной области. Результаты и выводы. Развитие спинального блока сопровождалось снижением общей спектральной мощности, преимущественно спектра активности симпатического отдела (LF) — вследствие симпатической блокады, менее выраженным угнетением парасимпатического отдела вегетативной нервной системы. Плотность спектра активности подкорковых нервных центров и процессов гуморальной регуляции (VLF) достоверно не изменялась до момента седации больного. Гемодинамика характеризовалась повышением сердечного индекса на 15,9 %, снижением индекса общего периферического сосудистого сопротивления на 23,2 %.Введение гипнотиков приводило к дальнейшему уменьшению спектральной мощности в диапазоне LF и достоверному подавлению в общей спектральной мощности спектра VLF. Эти изменения вегетативного гомеостаза сопровождались снижением артериального давления, сердечного индекса на фоне недостоверного повышения индекса общего периферического сосудистого сопротивления.Применение субгипнотических доз пропофола с целью достижения медикаментозного сна обеспечивало более стабильное состояние гемодинамики и вегетативного гомеостаза по сравнению с применением бензодиазепинов. Комбинированная спектрально-эпидуральная анестезия является методом выбора анестезиологического пособия при выполнении радикальной цистэктомии. Продленная послеоперационная эпидуральная анальгезия 0,2% наропином обеспечивает максимально раннюю активизацию пациентов, сопровождается ранним восстановлением моторики желудочно-кишечного тракта и пассажа, снижает риск развития респираторных и тромбоэмболических осложнений.

Given a reduced cognitive reserve in patients in ophthalmic surgery, an anesthesiologist should pay special attention when choosing a method of anesthesia to prevent the development of postoperative cognitive dysfunction. The concept of multimodal anesthesia makes it possible to reduce the total number of narcotic analgesics and ataractics used intraoperatively while maintaining an adequate level of anesthesia and sedation, both intraoperatively and in the postoperative period. In ophthalmic surgery, regional anesthesia (pterygopalatine fossa blockade) is used before surgery in combination with infusion of dexmedetomidine. Materials and methods. The study was conducted at the premises of Dnipropet­rovsk Regional Clinical Ophthalmologic Hospital, 61 patients were examined after penetrating keratoplasty. The age of the subjects ranged from 18 to 60 years (mean age of 52.1 ± 2.0 years). Patients were randomized into two groups. Group d (n = 30) are patients who received anesthesia according to the following scheme: premedication for 40 min — infusion of dexmedetomidine, ondansetron 4 mg, dexamethasone 4 mg, ketorolac 30 mg intravenously; induction — propofol 2–2.5 mg/kg fractionally until the onset of the clinical signs of anesthesia, fentanyl 0.005% 0.1 mg; relaxation on the background of atracurium besylate 0.3–0.6 mg/kg, tracheal intubation; maintenance of anesthesia: oxygen — sevoflurane mixture with FiO2 50–55 %, end-expired sevoflurane 1.4–1.8 vol.% (1–1.5 minimum alveolar concentration), use of low-flow technique. In the second group (db, n = 31), anesthesia was performed as in group d with the addition of pterygopalatine fossa blockade. Group d included 18 (60 %) men and 12 (40 %) women, mean age of 49.5 ± 2.5 years; db group — 16 (51.61 %) men and 15 (48.39 %) women (p = 0.583 according to the chi-square), mean age of 55.5 ± 3.2 years (p = 0.142 according to the t-test). Results. A comparative analysis of changes in cognitive status between db and d groups has shown no significant changes (p, Актуальність. Враховуючи знижений початковий когнітивний резерв у пацієнтів в офтальмохірургії, лікарю-анестезіологу потрібно звернути особливу увагу при виборі методу анестезії на запобігання розвитку післяопераційних когнітивних дисфункцій (ПОКД). Концепція мультимодального знеболювання дає змогу знизити загальну кількість використаних під час оперативного втручання наркотичних анальгетиків та атарактиків зі збереженням адекватного рівня анестезії та седації як інтра­операційно, так і в післяопераційному періоді. В офтальмохірургії використовується регіонарна анестезія (блокада крилопіднебінної ямки) в поєднанні з інфузією дексмедетомідину до оперативного втручання. Матеріали та методи. Дослідження проведено на базі КП «Дніпропетровська обласна клінічна офтальмологічна лікарня», обстежено 61 пацієнт після операції з наскрізної кератопластики. Вік обстежених коливався від 18 до 60 років (середній вік — 52,1 ± 2,0 року). Пацієнти були рандомізовані на дві групи. Група d (n = 30) — це пацієнти, яким анестезіологічне забезпечення було виконано за такою схемою: премедикація за 40 хв — інфузійно дексмедетомідин, ондансетрон 4 мг, дексаметазон 4 мг, кеторолак 30 мг внутрішньовенно; індукція — пропофол 2–2,5 мг/кг фракційно до досягнення клінічних симптомів наркозу, фентаніл 0,005% 0,1 мг; релаксації на тлі атракурію безилату 0,3–0,6 мг/кг, інтубація трахеї; підтримка анестезії — киснево-севофлуранова суміш FiO2 50–55 %, севофлуран 1,4–1,8 об.% на видиху (1–1,5 МАС), використання методики низьких потоків. У другій групі (db, n = 31) анестезіологічне забезпечення було виконано, як і в групі d, з додаванням блокади крилопіднебінної ямки. У групі d було 18 (60 %) чоловіків і 12 (40 %) жінок, середній вік — 49,5 ± 2,5 року; у групі db — 16 (51,6 %) чоловіків і 15 (48,38 %) жінок (р = 0,583 за критерієм χ2), середній вік — 55,5 ± 3,2 року (р = 0,142 за t-критерієм). Результати. При проведенні порівняльного аналізу змін когнітивного стану між групами db та d за шкалою оцінки психічного статусу (MMSE) та за краткою шкалою оцінювання лобної дисфункції (FAB) отримали результат без суттєвих відмінностей (p

Anesthetic management of chelonians represents a unique challenge; the order Chelonia includes numerous species that display diverse anatomic features, habitats, body sizes, temperaments, and metabolic rates. Owing to their peculiar characteristics, safe and effective sedation and anesthesia may be more complicated than in other animals. For example, gas inductions are not indicated, and intravenous catheterization requires practice. The pharmacology of anesthetic drugs is severely impacted by body/environmental temperature, site of administration, and organ function. This review will summarize the current knowledge in terms of anatomy, physiology, and drug metabolism in chelonians, before discussing practical aspects of anesthesia.

Background: The effectiveness and side effects of dexmedetomidine (DEX) in combination with midazolam and propofol have not been comparatively studied in a single clinical trial as sedative agents to general anesthesia before. Objective: The objective of this study is to compare intra and post-operative sedation between DEX-Midazolam and DEX-Propofol in patients who underwent major abdominal surgery on the duration of general anesthesia, hemodynamic and sedation effect. Method: This prospective, randomized, double-blinded clinical trial included 50 patients who were 20 to 60 years of age and admitted for major abdominal surgery. The patients were randomly assigned by a computer-generated random numbers table to sedation with DEX plus midazolam (DM group) (n=25) or DEX plus propofol (DP group) (n=25). In the DM group, patients received a bolus dose of 0.1 mg/kg of midazolam and immediately initiated the intravenous (i.v.) infusion of DEX 1 μg/kg over a 10 min and 0.5 μg/kg/hr by continuous i.v. infusion within operation period. In the DP group, patients received pre-anesthetic i.v. DEX 1 μg/kg over 15 min before anesthesia induction and 0.2-1 μg/kg/hr by continuous i.v. infusion during the operative period. After preoxygenation for at least 2 min, during the surgery, patients received propofol infusion dose of 250 μg/kg/min for 15 min then a basal infusion dose of 50 μg/kg/min. The bispectral index (BIS) value, as well as mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), oxygen saturation (SaO2), percutaneous arterial oxygen saturation (SpO2) and end-tidal carbon dioxide tension (ETCO2) were recorded before anesthesia (T0), during anesthesia (at 15-min intervals throughout the surgical procedure), by a blinded observer. Evidence of apnea, hypotension, hypertension and hypoxemia were recorded during surgery. Results: The hemodynamic changes, including HR, MAP, BIS, VT, SaO2, and RR had a downward tendency with time, but no significant difference was observed between the groups (P>0.05). However, the two groups showed no significant differences in ETCO2 and SPO2 values in any of the assessed interval (P>0.05). In this study, the two groups showed no significant differences in the incidence of nausea, vomiting, coughing, apnea, hypotension, hypertension, bradycardia and hypoxemia (P>0.05). Respiratory depression and serious adverse events were not reported in either group. Extubation time after surgery was respectively 6.3 ± 1.7 and 5.8 ± 1.4 hr. in the DM and DP groups and the difference was not statistically significant (P= 0.46). Conclusion: Our study showed no significant differences between the groups in hemodynamic and respiratory changes in each of the time intervals. There were also no significant differences between the two groups in the incidence of complication intra and post-operative. Further investigations are required to specify the optimum doses of using drugs which provide safety in cardiovascular and respiratory system without adverse disturbance during surgery. Clinical Trial Registration Number: HTCY-MA2018-74.

Snakes can be more challenging to anesthetize compared with other animals because of anatomic and physiologic differences, a wide range of patient sizes, and variable responses to anesthetic agents. Snakes have preferred optimal temperature zones, which, along with physiologic characteristics, such as the ability to shunt blood toward or away from the lungs, can have an impact on anesthesia. Injectable agents, including benzodiazepines, α2-agonists, opioids, propofol, and alfaxalone, as well as inhalant anesthetics can be used to anesthetize snakes. Pain management must be incorporated to the anesthetic plan when performing procedures that are expected to produce nociception.

Veterinarians often need to sedate or anesthetize fish to perform physical examinations or other diagnostic procedures. Sedation may also be required to transport fish. Painful procedures require complete anesthesia with appropriate antinociceptive agents. Regulations and withdrawal times apply to food animal species in many countries. Specific protocols are therefore warranted in commercial fish versus ornamentals. Tonic immobility of elasmobranchs and electric anesthesia should never be used to perform painful procedures. Anesthetic monitoring in fish remains challenging. This review summarizes ornamental fish anesthesia and discusses techniques used in the commercial fish industry and in field conditions.

With the increasing frequency of rabbits as veterinary patients, the expectation for high-quality, intensive veterinary care, and resultantly an understanding of anesthesia has been increasing. Sedation and general anesthesia are commonly required for many routine and emergency procedures in rabbits, and this results in the need for a strong awareness of anesthetic principles, knowledge of limitations of anesthesia, and maintenance of high standards of anesthesia.

With their increase in popularity in North America as pets, miniature companion pigs are in need of veterinary professionals familiar with sedation and anesthesia for the species. This article provides a review of the agents used for sedation, premedication, induction, and maintenance of anesthesia for miniature companion pigs. This review also covers species-specific anatomic and physiologic factors of miniature companion pigs with respect to administration of anesthetics, endotracheal intubation, anesthetic maintenance, and common complications so that the reader can make an informed anesthetic plan for the species.

Introduction and objectives The advantages of sedation in patients undergoing transesophageal echocardiography (TEE) are well established, but the increasing number of TEE studies may limit the capacity of anesthesiology services. In this study we analyze the effectiveness and safety of a moderate sedation program carried out by non-anesthesiology professionals (NAP). Methods Descriptive and prospective study that included all consecutive patients undergoing a TEE procedure under moderate sedation by NAP and by anesthesiology professionals (AP) from September 2018 to September 2019. Patients were selected according to a specific algorithm agreed upon with the Anesthesiology Department. We analyze current indications for TEE, complication rates, and recovery times associated with sedation. Results We performed 267 procedures in 252 patients (54% male, 69 years). Main indications were screening or monitoring of surgical and percutaneous cardiac interventions (47.9%), endocarditis (28.5%) and stroke (20.6%). Patients in the NAP group were younger (59 vs 71 years), less hypertensive (43% vs 61%), with less lung disease (4% vs 24%), lower risk of difficult airway (1% vs 22%) and lower comorbidity (ASA scale ≥ III 13% vs 77%). Complications were more frequent in the AP group (26% vs 9%), mainly mild respiratory (19% vs 9%). Events were associated with the presence of lung disease and higher ASA degree. Recovery time was longer in the AP sedation group (20 min vs 15 min). Conclusions TEE indications are changing and involve larger and more complex studies. Moderate sedation with propofol performed by NAP is safe in selected patients, with adequate recovery times.

Introduction and objectives Alpha2 adrenergic agonists, such as clonidine, are used as adjuvants during anesthesia due to their analgesic, sedative, and cardiovascular effects. The objective of the present study was to compare the effect of clonidine administered intravenously and intrathecally on the postoperative pain score of patients undergoing laparoscopic cholecystectomy, according to the route of administration and postoperative opioid consumption. Methods This randomized clinical trial, blind to patients and evaluator, assessed 60 patients, candidates for elective laparoscopic cholecystectomy under standardized general anesthesia techniques. Patients were randomly allocated into three groups (20 in each group): Control Group (CG), Intrathecal Clonidine Group (ITCG), and Intravenous Clonidine Group (IVCG). The primary outcome was the comparison of pain, Blood Pressure (BP) and Heart Rate (HR) scores among groups. The secondary outcome was report of adverse effects such as bradycardia, hypotension and sedation, and the need for rescue medication. Results The mean age was 37.2 ± 8.2 years, and the mean body mass was 28.3 ± 3.6 kg.m-2. Regarding HR (p = 0.003) and pain (p = 0.027), patients in ITCG and CG showed a different profile over time, with CG showing higher consumption of morphine as rescue medication (p = 0.005). Conclusion The administration of intrathecal and intravenous clonidine in low doses can reduce hemodynamic parameters and decrease postoperative requirement of analgesics. Further studies should investigate the ideal dose and method.

Background Methamphetamine (M) is a widely used, powerful sympathomimetic drug that produces significant CNS stimulation. Its use is associated with psychiatric disorders, abnormal brain chemistry, and cardiovascular disease. Pre-hospital M use is associated with increased intubation, intensive care unit admission, and hospital length of stay. The purpose of this study was to determine the influence of acute M use on analgesia and sedation requirements in mechanically ventilated trauma patients. Methods This single center retrospective cohort study included injured adult patients (≥16 years) admitted to the trauma intensive care unit (TICU) between 2016 and 2018 who were mechanically ventilated and had a urine drug screen (UDS) completed. The primary outcome was the median sedation and total analgesia administered during the first 48 hours of TICU admission, expressed as propofol, dexmedetomidine, lorazepam, and morphine equivalents. Secondary endpoints included the median Richmond Agitation Sedation Scale (RASS) score, median Critical Pain Observation Tool (CPOT) score, ventilator days, length of stay, in-hospital mortality, and discharge disposition. Results A total of 245 patients were included in the final analysis (53 M+ and 192 M-). The patients were mostly men (78%) and sustained blunt trauma (89%) with a median age of 35 (IQR 26-52) years and median ISS of 11 (IQR 4-24). A M+ UDS was associated with increased morphine requirements, defined as greater than the cohort median of 1.91 mg/kg, during the first 12 hours of admission on the univariable analysis (OR 2.03; 95% CI, 1.07-3.82). There was no difference in median propofol (M+ 30 mcg/kg/min vs. M- 30 mcg/kg/min, p=0.58) or total morphine equivalents (M+ 5.42 mg/kg s. M- 3.89 mg/kg, p=0.30) over 48 hours between M+ and M- groups to achieve similar RASS and CPOT scores. Conclusion To achieve the same level of pain control and depth of sedation, intubated TICU patients with a M+ UDS do not require more analgesia and sedation than patients with a M- UDS during the first 48 hours of admission.

Amphibians commonly are managed under human care for research, education, conservation, and companionship and frequently are in need of sedation, anesthesia, or end-of-life care involving euthanasia. Objective investigation of sedative and anesthetic protocols in these taxa still is in its infancy, but knowledge of current best practices is paramount to appropriate care. Tricaine methanesulfonate delivered via immersion (bath) is the most common anesthetic agent in amphibians, but several other effective techniques have been identified. This summary provides a comprehensive review of the current evidence-based literature regarding amphibian sedative, anesthetic, and euthanasia techniques.

Pediatric anesthesia practice has expanded to provide deep sedation or general anesthesia in many different locations throughout the hospital. Special considerations of space, patient access, and physical environment are imposed on the anesthesiologist in many of these locations. It is vital that each of these locations is appropriately equipped and staffed to established standards to provide safe and effective anesthesia patient care. Patient monitoring and standards of care should be provided as is current practice in the O.R. Simple anesthesia regimens based on intravenous infusion of propofol will provide optimal results in many cases. In other cases (e.g. Cath Lab and cardiac MRI), there is a need for more complex regimens in order to ensure the success of the planned procedure. Recommendations for protocols to be used in each location are provided.

Purpose of review The purpose of this article is to review new drugs and devices for nonoperating room anesthesia (NORA). Recent findings Remimazolam is an ultra-short-acting, water-soluble intravenous benzodiazepine with a fast onset and offset that has been approved recently for use in procedural sedation. Phase III trials have established the effectiveness of remimazolam sedation compared with placebo and midazolam in gastrointestinal endoscopy and bronchoscopy. More research is required investigating remimazolam in real-world NORA settings, including comparisons with propofol sedation. Oliceridine is a μ-agonist with selectivity for the G protein pathway and low potency for β-arrestin recruitment. As such it may be associated with less nausea, vomiting and respiratory depression than traditional opioids used. Although no studies have been published about oliceridine use in NORA to date, results from surgical studies indicate a potential place in nonoperating room practice. Research continues into alternative methods of drug delivery, such as patient-controlled sedation but no new devices are described. Summary Further studies are required before these new drugs and devices are embraced in NORA.

Background Accurate and timely evaluation of vocal cord function following thyroid surgery relieves the stress of both surgeon and anesthesiologist along with optimizing ongoing management. Conventional direct laryngoscopy is the commonly used tool for vocal cord assessment during extubation in thyroid surgeries. Videolaryngoscopes, are not well researched as an equipment to prognosticate extubation in thyroid surgery. Appropriate visualization and assessment of vocal cords during extubation with videolaryngoscopes can be useful for record keeping and documentation. This study was therefore conducted to compare the conventional direct laryngoscopy with prototypes of channeled and non-channeled videolaryngoscopes – Airtraq and McGrath respectively for extubation in thyroid surgery. Objective The aim of the study was to compare laryngoscopic view, vocal cord mobility during extubation after thyroid surgeries and to assess patient comfort during laryngoscopy. Methods Following approval from the Institutional Ethics board and informed consent from the patients, a prospective randomised study was conducted in 66 patients. Patients posted for elective thyroid surgery were recruited and followed a routine anaesthesia protocol for intubation. Towards the end of surgery dexmedetomidine infusion was started and patients appropriately reversed. Depending on the group, allotted patients underwent laryngoscopy either with standard direct laryngoscope with the Macintosh blade, McGrath MAC blade 3, or Airtraq size 3 optical laryngoscope. During laryngoscopy Cormack-Lehane grading, vocal cord mobility and patient reactivity were assessed and patients were extubated. Results Glottic visualization as assessed by the Cormack-Lehane grades were comparable among the three groups. Change in the Cormack-Lehane grading when compared with the one at the time of intubation was better with Airtraq than the other two groups with a p value of 0.023. The patient reactivity score was statistically significant between the groups (p = 0.006), and Airtraq scored better. The Ramsay sedation scores at different time intervals was not significant between the groups. Vocal cord mobility grading and complications were not different between the three groups. Conclusion Videolaryngoscopes provide a better glottic view during extubation with better patient reactivity scores. Airtraq outperformed standard laryngoscope and McGrath having better Cormack-Lehane grades and a better patient reactivity score.

Objective To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication. Methods Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events. Results 15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (−3.5 beats per minute (BPM) [95% CI: −5.1, −1.9]) through midpoint (−7.2 BPM [95% CI: −12.1, −2.3]) and at end of sedation (−8.7 BPM [95% CI: −13.1, −4.4]). Decrease in HR after DEX administration at start was −11.6 BPM [95% CI: −16.0, −7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by −6.9 [95% CI: −10.4, −3.3] at start, −7.8 [95% CI: −11.4, −4.2] at middle, and by −6.6 [95% CI: −14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia. Conclusions DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.

Background Transvenous lead extraction (TLE) for implantable cardiac‐devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID‐19, longer recovery‐times and increased procedural‐costs. We report the feasibility/safety of TLE using conscious‐sedation alone with immediate GA/cardiac‐surgery back‐up if needed. Methods Retrospective case‐series of consecutive TLEs performed using conscious‐sedation alone between March 2016 and December 2019. All were performed in the electrophysiology‐laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking‐stylets/cutting‐sheaths, including mechanical‐sheaths. Baseline patient‐characteristics, procedural‐details and TLE outcomes (including procedure‐related complications/death) were recorded. Results A total of 130 leads were targeted in 54 patients, mean age ± SD 74.6 ± 11.8years, 47(87%) males; dual‐chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy‐defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean ± SD/median (range) lead‐dwell times were 11.0 ± 8.8/8.3 (0.3‐37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse‐generator erosion (n = 27; 50%); mean 2.1 ± 2.0 leads were removed per procedure/mean procedure‐time was 100 ± 54 min. Local anesthetic (LA) was used for all (mean‐dose: 33 ± 8 ml 1% lidocaine), IV drug‐doses used (mean ± SD) were: midazolam: 3.95 ± 2.44 mg, diazepam: 4.69 ± 0.89 mg and fentanyl: 57 ± 40 µg. Complete lead‐extraction was achieved in 110 (85%) leads, partial lead‐extraction (, TLE undertaken using LA/conscious‐sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolisation of Covid‐19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.

OBJECTIVES Different anesthesia techniques are used for surgical implantation of paddle lead electrodes for neurostimulation through a laminectomy. We wanted to evaluate the use of dexmedetomidine as sedative for this procedure in a series of patients. Second, we wanted to verify whether the stimulation pattern and position of the electrode had to be changed during the procedure guided by the patient's feedback. MATERIAL AND METHODS Twenty-five consecutive patients received surgical implantation of a spinal cord stimulation electrode under conscious sedation using dexmedetomidine and local anesthesia. We evaluated the effects of the administered drug, the patient comfort, and the adequacy of the stimulation pattern. RESULTS Twenty-four patients completed the procedure with only dexmedetomidine and local anesthetic. Infusion was started on average 55 minutes (sd 29) prior to incision. The mean dose of lidocaine was 430 mg (sd 95). There were no significant hemodynamic changes. Median time to reach Modified Aldrete's score postoperative was 67 minutes (sd 38). In 46% of the patients, the position of the electrode was changed guided by the feedback of the patient. More than half of the patients remember most details of the procedure. Only four patients mentioned substantial discomfort and only three would definitely not want to undergo this procedure again. CONCLUSIONS Implantation of spinal cord stimulation electrodes through a surgical laminectomy using dexmedetomidine is a safe and feasible procedure with adequate comfort for patient and surgeon. This way of working increases the optimal position of the electrode resulting in the most convenient stimulation pattern and avoiding revisions.

Study objective We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. Methods We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. Results Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). Conclusion In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.

Long-latency auditory evoked potentials (LLAEPs) may help further advances in understanding consciousness under general anesthesia and promote more objective means of assessing sedation depth than conventional clinical signs. Among the LLAEP components, the auditory N1 shows promise as a measure of sedation depth and a marker of consciousness, but findings are so far inconclusive. Research with animals can help elucidate the effects of various anesthetics on the N1 and other LLAEPs, but investigations of LLAEPs under anesthesia in animals is lacking. To address this deficit, we examined the P1, N1, P2, and N2, along with their corresponding peak-to-peak complexes, in 10 Wistar rats anesthetized with 1.5–2 % isoflurane in pure oxygen and again after recovery. While under anesthesia, subdermal needle electrodes were inserted and secured for electroencephalographic (EEG) recordings. LLAEPs were assessed during a 20-min, passive, two-tone (500 ms inter-tone interval) paradigm with randomized short (1 s) and long (5 s) inter-pair intervals (IPIs). Overall, while the LLAEP peaks under isoflurane were less defined, they were not eliminated. The peak-to-peak amplitudes, particularly the P1-N1, were significantly smaller under isoflurane than during post-recovery. Our preliminary findings indicate that isoflurane produces global suppression across LLAEP components, presumably reflecting impaired integration of top-down and bottom-up attention and sensory systems under profound sedation with isoflurane.

Cardiac surgical pain is of moderate-to-severe intensity. Ineffective pain control may lead to increased cardiopulmonary complications and poor surgical outcomes. This study aimed to assess the efficacy of ultrasound-guided erector spinae plane block in providing analgesia in adult cardiac surgeries.Prospective, randomized, double-blinded clinical trial.Single-center, tertiary care hospital with university affiliation.Thirty patients of either sex, aged 18-to-60 years, body mass index 19-to-30 kg/mPatients were randomly categorized into two groups of 15 patients each to receive bilateral erector spinae plane block with 20 mL per side of 0.25% levobupivacaine (group E) or sham block with 20 mL of normal saline (group C).Mean analgesic requirement in terms of fentanyl equivalents (µg) in the first 24 hours postoperatively was 225 ± 112 in group E and 635 ± 145 in group C (95% confidence interval, 313.10-506.90; p0.05). Mean time to first rescue analgesia was 356.9 ± 34.5 in group E and 123.9 ± 13.1 minutes in group C (p0.05). Cox proportional hazard ratio for rescue analgesic requirement in group E-to-group C was 5.0. Duration of mechanical ventilation was 88.4 ± 17 and 103.5 ± 18 minutes in groups E and C, respectively (p0.05). Ramsay sedation score at six hours postextubation was 1.45 ± 0.53 in group E and 3.19 ± 0.62 in group C (p0.05). Mean numerical rating score was 3.67 ± 1.41 in group E and 4.50 ± 1.00 in group C (p = 0.17). No significant differences were observed in the incidences of postoperative nausea vomiting, pruritus, and erector spinae plane block-related infection and pneumothorax.Single-shot erector spinae plane block provides superior analgesia as compared with sham block. It decreased the first 24-hour postoperative analgesic consumption by 64.5% and risk of pain by five times in the authors' population. It also reduced the sedation and duration of mechanical ventilation in postcardiac surgery patients.

Background The sedative effect of intraoperative sedation in elderly surgery exerts critical influence on the prognosis. Comparison on the safety and efficacy between dexmedetomidine and midazolam in many clinical randomized controlled trials (RCTs) was inconsistent and suspicious. We aim to comprehensively evaluate the safety and efficacy between dexmedetomidine and midazolam for intraoperative sedation in the elderly via meta-analysis and systematic reviews. Methods RCTs regarding to the comparison of sedative effects and safety between dexmedetomidine and midazolam in elderly patients (aged ≥ 60 years) will be comprehensively searched from 2000 October to 2022 May through 4 English databases and 4 Chinese databases. After extraction in duplicate, the systematic review and meta-analysis will be performed on the primary outcomes (hemodynamic changes, sedative effect, cognitive function) and secondary outcomes (analgesic effect, surgical characteristics, complications, or adverse reactions) for assessing the two therapy methods using Review Manager software (Version 5.3). Sensitivity analysis will be conducted to evaluate the heterogeneity of the results; funnel plot and Egger’s trial will be performed to analyze publication bias of the included studies, and trial sequential analysis will be applied to assess the robustness and reliability of preliminary meta-analysis results. Finally, rating quality of evidence and strength of recommendations on the meta results will be summarized by Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Discussion This systematic review and meta-analysis will evaluate the safety and efficacy between dexmedetomidine and midazolam for intraoperative sedation in the elderly; it will give an insight on the application of dexmedetomidine and midazolam and will provide evidence-based reference for clinical decision-making. Systematic review registration PROSPERO CRD42021221897

Objective. To study the effects of dexmedetomidine in combination with ropivacaine in patients undergoing craniocerebral surgery and their efficiency on cognitive function and inflammatory response of patients. Methods. 100 patients undergoing craniocerebral surgery in our hospital from November 2018 to September 2020 were randomly selected and divided into a control group and an experimental group by drawing lots, with 50 cases in each group. Patients in the control group received routine anesthesia, while those in the experimental group received 1 μg/kg of dexmedetomidine combined with 0.5% of ropivacaine for anesthesia to compare the anesthesia onset time, analgesic time, postoperative awake time, Social Disability Screening Schedule (SDSS) cognitive function score after waking, visual analogue scale (VAS) pain score, Ramsay sedation score, incidence of adverse reactions, postoperative inflammatory factor expression levels, and changes in heart rate, oxygen saturation, and blood pressure at T0, T1, T2, T3, and T4 between the two groups. Results. The anesthesia onset time, SDSS cognitive function score after waking, VAS pain score, Ramsay sedation score, incidence of adverse reactions, and postoperative inflammatory factor expression levels in the experimental group were significantly lower than those in the control group ( P < 0.05 ). The analgesic time and postoperative awake time in the experimental group were significantly longer than those in the control group, with statistical significance ( P < 0.05 ). There were no statistically significant differences in the changes of heart rate, oxygen saturation, and blood pressure at T0, T1, T2, T3, and T4 between the two groups ( P > 0.05 ). Conclusion. Dexmedetomidine combined with ropivacaine has high application value in craniocerebral surgery.

To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p

Background Digit replantation under wide-awake local anesthesia is a challenging method, and there are only a few works of literature on this procedure. This article describes the authors' clinical experience in finger replantation under wide-awake local anesthesia compared to general anesthesia. Methods Fifty-one patients who received single finger replantation after initial sharp amputation were included in the study of whom 16 received wide-awake local anesthesia and 35 general anesthesia treatment. The indications for wide-awake local anesthesia were sharp amputation injury, estimated operation time less than 3 hours, and cooperative patients. The wide-awake local anesthesia was performed with 1% or 2% lidocaine infiltrated at the volar midpoint of the metacarpophalangeal joint of the affected digit without sedation medications. Demographic data included surgical outcome, waiting time, operation time, and hospital stay. Results A total of 51 consecutive patients were included in this study. There were significantly shorter waiting times and operation times in the wide-awake local anesthesia group. The other parameters showed no significant differences. The overall success rate was 76.47 percent, with a mean overall operation time of 206 minutes. Conclusions In selected patients, finger replantation can be successfully performed under wide-awake local anesthesia, which has lower anesthesia risk and fewer medical expenses than general anesthesia. The method is feasible for single-digit replantation. Therefore, the finger replantation under wide-awake local anesthesia is a practicable alternative to general anesthesia. Clinical question/level of evidence Therapeutic, III.

OBJECTIVES The aim of this study was to assess whether the use of topical pharyngeal anesthesia improves endoscopist- and patient-reported tolerance and satisfaction, the total dose of propofol used and the rate of adverse effects associated with this procedure. METHODS This double-blind randomized clinical trial was conducted in patients undergoing elective oesophagogastroduodenoscopy, who met the inclusion criteria. Patients were randomly assigned to receive five squirts of lidocaine 10% spray (50 mg, n = 268) or placebo (n = 271) 3 min before starting the procedure or sedation. The main outcome measures were patient- and endoscopist-reported tolerance, and additionally, satisfaction with the procedure, adverse events and supplementary propofol used. RESULTS In the lidocaine group, it was twice (odds ratio [OR] 2.136, 95% confidence interval [CI] 1.228-3.715) or three times (OR 3.311, 95% CI 1.623-6.757) more likely that the endoscopist rated the procedure as well tolerated and easy to intubate than as well tolerated but the patient difficult to intubate or as poorly tolerated, respectively. Further, in these patients, less propofol was used (80 vs. 100 mg, P = 0.001). Controls were more likely to cough during the intubation (OR 2.172, 95% CI 1.378-3.423) and the procedure (OR 1.989, 95% CI 1.325-2.984), as well as more likely to retch (OR 3.582, 95% CI 1.667-7.7). CONCLUSIONS Topical lidocaine may improve the procedure as rated by the endoscopist, as well as reduce the requirement for propofol and rate of adverse events such as retching and coughing. No adverse events associated with lidocaine administration were observed. ClinicalTrials registration no. NCT02733471.

We aimed to evaluate the clinical benefits of dexmedetomidine (DEX) in comparison with the standard of care (SOC) sedation in critically ill, septic patients. Electronic databases (PubMed, EMBASE, Cochrane Central, Scopus, and Google Scholar) were systematically searched to identify only randomized clinical trials performed up until February 12, 2021. The primary outcomes were 28-day mortality, 90-day mortality, and intensive care unit (ICU) length of stay (LOS). We calculated risk ratios (RRs), 95% confidence intervals (CIs) for dichotomous data, and weighted mean differences (WMDs) for continuous data using a random-effects model. Seven randomized clinical trials were included, with a total of 529 patients in the DEX group and 520 patients in the SOC group. Compared with SOC, DEX was associated with a nonstatistically significant reduced 28-day mortality (RR = 0.76; 95% CI [0.51, 1.14]; P = 0.19), 90-day mortality (RR = 0.94; 95% CI [0.75, 1.18]; P = 0.60), and ICU LOS (WMD = −0.85; 95% CI [-2.60, 0.90]; P = 0.34). We conclude that among septic patients on sedation, the use of DEX in the ICU demonstrated no significant difference from SOC sedation protocols with respect to 28-day mortality, 90-day mortality, and total ICU LOS. Our findings suggest that DEX does not confer clinical benefit over SOC sedation in critically ill patients with sepsis.

Objective: comparison of general anesthesia (GA) and intravenous conscious sedation during left atrial appendage occlusion (LAAO).Materials and Methods. The study included 120 patients from LAAO Register at the National Medical Research Center of Cardiology, who were divided into GA (n = 100) and intravenous sedation (n = 20) groups. In-hospital outcomes were assessed, as well as outcomes and data of transesophageal echocardiography (TEE) at 45 days and 6 months.Results. 3 patients required intraoperative conversion of the anesthetic method to GA. The duration of the procedure, the time of fluoroscopy, the amount of contrast medium, and the technical success did not differ signifcantly between the two groups. The incidence of in-hospital complications in the GA group was 10%, and 15% in the intravenous sedation group (p = 0.453). There were no statistically signifcant differences between the groups in long-term outcomes and TEE data after 45 days and 6 months.Conclusion. Combined intravenous sedation with local anesthesia is an effective and fairly safe method of anesthesiological support for implantation of the occluder of the left atrial auricle. It can be used in patients with a high risk of GA, with predictable difculties of tracheal intubation, as well as if the patient wishes accordingly. The limitations of the use of intravenous sedation in combination with local anesthesia are anatomical variants of SFM that are difcult for occluder implantation, as well as the patient's low tolerance to ECG in consciousness.

We have developed an automated anesthesia control system that uses biological information to provide closed-loop control of drug administration for total intravenous anesthesia with propofol, remifentanil, and rocuronium. In this study, we investigated whether the control of sedatives, analgesics, and muscle relaxants delivered by this system is non-inferior to that delivered by anesthesiologists. During anesthesia management by our automated administration control system and by anesthesiologists, the concentration of each drug at the site of effect (calculated from drug administration history) and biometric information (bispectral index, blood pressure, pulse rate, and single contraction ratio %T1) were tabulated during the period from the start to end of surgery. The primary efficacy endpoint was the ratio of adequate anesthesia time, in which all three factors of sedation, analgesia, and muscle relaxation were maintained within the target range, to the period from the start to end of surgery under total intravenous anesthesia. Percentage of time under appropriate anesthesia was 73.24 ± 17.24 in the automatic group (n = 28) and 59.94 ± 29.06 in the manual group (n = 28). The lower limit of the 97.5% one-sided confidence interval for the difference between the two group means was 0.51%, indicating the non-inferiority of the automatic group to the manual group (p = 0.002). The incidence of adverse events did not differ significantly between the groups. The clinical use of our automated anesthesia control system should allow for the maintenance of adequate anesthesia by adjusting the doses of intravenous anesthetics in the same way as anesthesiologists do.

BackgroundThe best anesthetic management strategy for patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains uncertain. Most studies have focused on anterior–circulation stroke caused by large artery occlusion. Nevertheless, limited data are available on the appropriate choice of anesthetic for acute basilar artery occlusion (BAO). We aimed to investigate the effect of anesthetic method on clinical outcomes in patients with BAO undergoing MT.MethodsPatients undergoing MT for acute BAO in the BASILAR registry (Acute Basilar Artery Occlusion Study) were included. We divided patients into three groups according to the anesthetic technique used during MT: general anesthesia (GA), local anesthesia (LA), and conscious sedation (CS). Propensity score matching was performed to achieve baseline balance.Results639 patients were included. GA was used in 257 patients (40.2%), LA was used in 250 patients (39.1%), and CS was used in 132 patients (20.7%). After 1:1 matching, favorable outcome, mortality, and hemorrhagic transformation rates, as well as modified Rankin Scale (mRS) score at 90 days, did not differ between the GA, LA, and CS groups.ConclusionsThe choice of anesthetic strategy, GA, LA, or CS, did not affect the clinical outcomes of patients with acute BAO treated with MT in the BASILAR registry.

Objective To assess the effect of continuous wound infusion (CWI) with preperitoneal ropivacaine on postoperative analgesia and compare it with the epidural administration of ropivacaine and morphine in bitches undergoing ovariohysterectomy. Study design A parallel, randomized, clinical, prospective and nonblinded study. Animals A group of 38 Greyhound bitches. Methods In the catheter group (CathG), CWI with ropivacaine 1% (1 mg kg–1 + 0.8 mg kg–1 hour–1) was applied to the preperitoneal space over the surgical incision. In the epidural group (EpiG), ropivacaine 0.5% (1.3 mg kg–1) and morphine (0.1 mg kg–1) were epidurally administered. Occipital-coccygeal length was used to calculate the volume for the epidural. Pain was scored using a dynamic interactive visual analogue scale (DIVAS) and Glasgow composite measure pain scale–short form (CMPS-SF) before anaesthesia and at 2, 4, 6, 18, 21 and 24 hours after extubation. Incisional sensitivity using a dynamometer (MWTs-incision) was evaluated simultaneously. Plasma ropivacaine and cortisol concentrations, degree of sedation, motor blockade and response to interdigital clamping were measured or assessed. A two-way mixed analysis of variance and a Mann–Whitney U test were used to analyse data; p Results No differences were detected in the DIVAS (p = 0.301), CMPS-SF (p = 0.600) scores, MWTs-incision measurements (p = 0.257) and cortisol values (p = 0.878) between the groups. Rescue analgesia was required in two dogs, one in each group, at 2 hours. Sedation, motor blockade and negative response to interdigital clamping were detected in EpiG at 2, 4 and 6 hours. Mean plasma ropivacaine values were higher in CathG (0.475 ± 0.164 ng mL–1) than in EpiG (0.184 ± 0.213 ng mL–1; p = 0.001). Conclusion and clinical relevance Compared with epidural ropivacaine and morphine, CWI with preperitoneal ropivacaine is an effective analgesic technique for postoperative pain management in bitches undergoing ovariohysterectomy without motor blockade.

PURPOSE/OBJECTIVES To examine patient characteristics that predispose to higher opioid administration during tandem and ovoid (T&O) high-dose rate (HDR) brachytherapy. METHODS A single-institution retrospective review was performed on patients who underwent brachytherapy for cervical cancer. Patients were included if they received at least one fraction of HDR T&O brachytherapy with analgesia administration recorded in the Medication Administration Record. Fentanyl dose was dichotomized as "low" (mean