Comparison of conscious sedation for oocyte retrieval between low-anxiety and high-anxiety patients

Pain Management during Ultrasound Guided Transvaginal Oocyte Retrieval - A Narrative Review

Transvaginal oocyte retrieval (TVOR), done for the purpose of assisted reproduction can instigate enormous pain and therefore requires adequate analgesia with the least adverse effects. As the procedure involves retrieving oocytes for in vitro fertilisation, the effect of the anaesthetic drugs on the oocyte quality should also be considered. This review focuses on the various modes of anaesthesia and the anaesthetic drugs which can be administered safely to provide effective analgesia in normal and in special conditions such as women with pre-existing comorbidities. Medline, Embase, PubMed and Cochrane electronic databases were searched according to modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. According to this review, conscious sedation appears to be the most preferred mode of anaesthesia in women undergoing TVOR owing to fewer adverse effects, faster recovery, better patient and specialist comfort and the least effect on oocyte quality and embryo development. Combining it with paracervical block resulted in lesser consumption of the anaesthetic drug, which may have a beneficial effect on the oocyte quality.

Less stress, better success: a scoping review on the effects of anxiety on anesthetic and analgesic consumption

Preoperative anxiety has an incidence of 11-80% in patients undergoing surgical or interventional procedures. Understanding the role of preoperative anxiety on intraoperative anesthetic requirements and postoperative analgesic consumption would allow personalized anesthesia care. Over- or under-anesthetizing patients can lead to complications such as postoperative cognitive dysfunction in elderly patients, or procedural discomfort, respectively. Our scoping review focuses on the current evidence regarding the association between preoperative anxiety and intraoperative anesthetic and/or postoperative analgesic consumption in patients undergoing elective surgical or interventional procedures. Based on 44 studies that met the inclusion criteria, we found that preoperative anxiety has a significant positive correlation effect on intraoperative propofol and postoperative opioid consumption. The analysis of the literature is limited by the heterogeneity of preoperative anxiety tools used, study designs, data analyses, and outcomes. The use of shorter, validated preoperative anxiety assessment tools may help optimize the intraoperative anesthetic and postoperative analgesic regimen. Further research to determine the most feasible and clinically relevant preoperative anxiety tool and subsequent implementation has the potential to optimize perioperative care and improve patient outcomes.

The effect of pre-procedure anxiety on sedative requirements for sedation during upper gastrointestinal endoscopy

Objectives

Sedation for upper gastrointestinal endoscopy, commonly used for diagnosis and treatment of gastrointestinal diseases, has been increasing widespread. Sedative agent requirements during sedation or anesthesia can be affected by many factors such as age and sex. In the present study, we aimed to evaluate the effects of pre-procedural anxiety levels on sedative requirements during upper gastrointestinal endoscopy.

Material and Methods

300 patients between the ages of 18-70 years were studied. Baseline anxiety levels were measured before the procedure using Spielberger's State-Trait Anxiety Inventory (STAI) form X1. Propofol was administered to have BIS values between 65-85 during sedation. Doses of propofol, total procedure time, satisfaction of the patients and endoscopists and BIS values were recorded.

Results

Pre-procedural anxiety was 44 (40-48 [20-70]). We found significant correlations between pre-procedure anxiety and the usage of propofol (mg, mg/kg, mg/kg/dk) at BIS values between 65-85, [respectively, (p= 0.451, p <0.001), (p= 0.455, p <0.001), (p= 0.428, p <0.001)]. No correlation was found between pre-procedure anxiety and procedural or sedation complications (respectively p= 0.111, p= 0.424 and p= 0.408, p= 0.363). We found significant negative correlations between pre-procedure anxiety and the satisfaction of the patients/endoscopist [respectively, (p= -0.477, p <0.001), (p= -0.495, p <0.001)].

Conclusion

Based on the results of this study, we suggest that there is a significant association between the pre-procedural anxiety levels and use of sedative drugs in patients undergoing upper gastrointestinal endoscopy.

Influence of pre-anesthesia dynamic frontal-parietal communication on individual susceptibility to propofol

OBJECTIVE

We investigated whether pre-anesthesia dynamic frontal-parietal functional connectivity was correlated with the observed interindividual differences in propofol susceptibility.

METHODS

Three resting-state EEG datasets were used in the study (N = 29, N = 21 and N = 20). We estimated the pre-anesthesia strength and fluctuations of frontal-parietal functional connectivity by using sliding-window analysis. Propofol served as the sole anesthetic drug, and it was administered by using a target-controlled infusion system. Individual susceptibility to propofol was assessed by the induction time, from infusion onset until a bispectral index value of 60 was reached, for subjects in dataset-1 and dataset-2, and susceptibility was assessed by behavioral data for subjects in the external dataset.

RESULTS

We observed in the three datasets that subjects with high susceptibility to propofol had lower pre-anesthesia strength and lower fluctuation of frontal-parietal functional connectivity than the low-susceptibility group at alpha band. Moreover, the induction time was significantly correlated with the estimated pre-anesthesia frontal-parietal functional connectivity measures. We also validated the robustness of these findings by using different window lengths in sliding-window analysis.

CONCLUSIONS

Subjects with weaker pre-anesthesia dynamic frontal-parietal communication are more likely to be anesthetized.

SIGNIFICANCE

These observations suggest that the titration procedure for propofol should consider the pre-anesthesia brain functional state.

The effect of preoperative anxiety level on mean platelet volume and propofol consumption

BACKGROUND

The mean platelet volume (MPV) is an important indicator of platelet function with large platelets showing higher enzymatic and metabolic activity than other platelets. There can be a relationship between increased platelet activity and anxiety and depression. Our primary hypothesis was that patients with high anxiety scores would have higher MPV, and the secondary hypothesis was that propofol induction time and total propofol consumption within the first 30 min of surgery would be higher in patients with higher anxiety scores.

METHODS

The Beck Anxiety Inventory (BAI) was administered to the participating patients 1 day before surgery to evaluate the level of anxiety. Based on the scores from the BAI, 40 patients with an anxiety score of < 8 were assigned to the non-anxious group (Group NA) and 40 patients with an anxiety score of ≥8 were assigned to the anxious group (Group A). At the anesthesia induction the mean time to achieve an entropy value below 60 (T1) was recorded. The total intraoperative propofol consumption within the first 30 min was recorded.

RESULTS

There was a statistically significant difference between the groups in terms of preoperative MPV and demographic data, including age and sex. The mean total propofol consumption at 30 min after induction in the groups was statistically significant. The cut-off value for MPV was calculated as 9.65.

CONCLUSIONS

The preoperative MPV values and propofol consumption at 30 min among patients with high preoperative anxiety scores were high. We suggest that MPV is helpful in the clinical practice in predicting the amount of anesthetic agents required for the 30 mins of anesthesia.

Use of pre-operative anxiety score to determine the precise dose of butorphanol for intra-operative sedation under regional anesthesia: A double-blinded randomized trial

A randomized double-blinded controlled trial was performed to explore the association between pre-operative anxiety and intra-operative butorphanol requirement to evaluate the precise sedative requirement and to confirm the sedative effect of butorphanol in patients receiving lower-limb orthopedic surgery. The Amsterdam pre-operative anxiety and information scale and the Ramsay sedation score (RSS) were used to assess the patients' pre-operative anxiety score and sedation state during surgery. Patients were divided into two groups according to their pre-operative anxiety score prior to administration of pre-medication. Patients in each group were randomly divided into a butorphanol group and a 0.9% saline group. A total of 142 patients were enrolled and 131 patients were analyzed. The sedation scores of patients with high pre-operative anxiety in the 0.9% saline group were lower than those in the butorphanol group at each time-point after infusion. An increased pre-operative anxiety score predicted an increased duration to reach an RSS of 4 for an acceptable level of sedation (r²=0.887, P<0.0001). In conclusion, butorphanol had a good sedative effect on patients with pre-operative anxiety. The following formula was proposed: Precise dose of butorphanol (µg/kg)=15.26 + (0.14× pre-operative anxiety score), which may provide an improvement for patients exhibiting a high level of pre-operative anxiety. The trial was registered prior to patient enrollment at clinicaltrials.gov on 20.01.2018 (trial registration no. NCT03429179).

Pain relief for women undergoing oocyte retrieval for assisted reproduction

BACKGROUND

Various methods of conscious sedation and analgesia (CSA) have been used during oocyte retrieval for assisted reproduction. The choice of agent has been influenced by the quality of sedation and analgesia and by concerns about possible detrimental effects on reproductive outcomes.

OBJECTIVES

To assess the effectiveness and safety of different methods of conscious sedation and analgesia for pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval.

SEARCH METHODS

We searched; the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL, and trials registers in November 2017. We also checked references, and contacted study authors for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different methods and administrative protocols for conscious sedation and analgesia during oocyte retrieval.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were intraoperative and postoperative pain. Secondary outcomes included clinical pregnancy, patient satisfaction, analgesic side effects, and postoperative complications.

MAIN RESULTS

We included 24 RCTs (3160 women) in five comparisons. We report the main comparisons below. Evidence quality was generally low or very low, mainly owing to poor reporting and imprecision.1. CSA versus other active interventions.All evidence for this comparison was of very low quality.CSA versus CSA plus acupuncture or electroacupunctureData show more effective intraoperative pain relief on a 0 to 10 visual analogue scale (VAS) with CSA plus acupuncture (mean difference (MD) 1.00, 95% confidence interval (CI) 0.18 to 1.82, 62 women) or electroacupuncture (MD 3.00, 95% CI 2.23 to 3.77, 62 women).Data also show more effective postoperative pain relief (0 to 10 VAS) with CSA plus acupuncture (MD 0.60, 95% CI -0.10 to 1.30, 61 women) or electroacupuncture (MD 2.10, 95% CI 1.40 to 2.80, 61 women).Evidence was insufficient to show whether clinical pregnancy rates were different between CSA and CSA plus acupuncture (odds ratio (OR) 0.61, 95% CI 0.20 to 1.86, 61 women). CSA alone may be associated with fewer pregnancies than CSA plus electroacupuncture (OR 0.22, 95% CI 0.07 to 0.66, 61 women).Evidence was insufficient to show whether rates of vomiting were different between CSA and CSA plus acupuncture (OR 1.64, 95% CI 0.46 to 5.88, 62 women) or electroacupuncture (OR 1.09, 95% CI 0.33 to 3.58, 62 women).Trialists provided no usable data for other outcomes of interest.CSA versus general anaesthesia Postoperative pain relief was greater in the CSA group (0 to 3 Likert: mean difference (MD) 1.9, 95% CI 2.24 to 1.56, one RCT, 50 women).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 1.00, 95% CI 0.43 to 2.35, two RCTs, 108 women, I² = 0%).Evidence was insufficient to show whether groups differed in rates of vomiting (OR 0.46, 95% CI 0.08 to 2.75, one RCT, 50 women) or airway obstruction (OR 0.14, 95% CI 0.02 to 1.22, one RCT, 58 women). Fewer women needed mask ventilation in the CSA group (OR 0.05, 95% CI 0.01 to 0.20, one RCT, 58 women).Evidence was also insufficient to show whether groups differed in satisfaction rates (OR 0.66, 95% CI 0.11 to 4.04, two RCTs, 108 women, I² = 34%; very low-quality evidence).Trialists provided no usable data for outcomes of interest.2. CSA + paracervical block (PCB) versus other interventions.CSA + PCB versus electroacupuncture + PCB Intraoperative pain scores were lower in the CSA + PCB group (0 to 10 VAS: MD -0.66, 95% CI -0.93 to -0.39, 781 women, I² = 76%; low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.96, 95% CI 0.72 to 1.29, 783 women, I² = 9%; low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus general anaesthesiaEvidence was insufficient to show whether groups differed in postoperative pain scores (0 to 10 VAS: MD 0.49, 95% CI -0.13 to 1.11, 50 women; very low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.70, 95% CI 0.22 to 2.26, 51 women; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus spinal anaesthesiaPostoperative pain scores were higher in the CSA + PCB group (0 to 10 VAS: MD 1.02, 95% CI 0.48 to 1.56, 36 women; very low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.24 to 3.65, 38 women; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus PCBEvidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.44 to 1.96, 150 women; low-quality evidence) or satisfaction (OR 1.63, 95% CI 0.68 to 3.89, 150 women, low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus CSA only Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.62, 95% CI 0.28 to 1.36, one RCT, 100 women; very low-quality evidence). Rates of postoperative nausea and vomiting were lower in the CS + PCB group (OR 0.42, 95% CI 0.18 to 0.97, two RCTs, 140 women, I² = 40%; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.

AUTHORS' CONCLUSIONS

The evidence does not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte retrieval. Simultaneous use of sedation combined with analgesia such as the opiates, further enhanced by paracervical block or acupuncture techniques, resulted in better pain relief than occurred with one modality alone. Evidence was insufficient to show conclusively whether any of the interventions influenced pregnancy rates. All techniques reviewed were associated with a high degree of patient satisfaction. Women's preferences and resource availability for choice of pain relief merit consideration in practice.

Ambulatory colonoscopy under sedoanalgesia in adult patients with and without irritable bowel syndrome: A prospective, cross-sectional, and double-blind comparison

BACKGROUND/AIMS

It is unclear whether patients with irritable bowel syndrome (IBS) require a high dose of sedatives during colonoscopy. In this study, we investigated the pre-procedural anxiety levels, sedative consumption, procedure times, complications, and patient's satisfaction between patients with IBS and controls for ambulatory colonoscopy under sedation.

MATERIALS AND METHODS

Rome III criteria were used in the diagnosis of IBS. Anxiety levels were measured using Spielberger's State-Trait Anxiety Inventory (STAI) and Beck Anxiety Inventory (BAI). Patients received a fixed dose of midazolam (0.02 mg/kg), fentanyl (1 μg/kg), ketamine (0.3 mg/kg), and incremental doses of propofol under sedation protocol. Demographic data, heart rate, blood pressure, and oxygen saturation were measured. Procedure times, recovery and discharge times, drug doses used, complications associated with the sedation, and patient's satisfaction scores were also recorded.

RESULTS

The mean Trait (p=0.015), State (p=0.029), Beck anxiety scores (p=0.018), the incidence of disruptive movements (p=0.044), and the amount of propofol (p=0. 024) used were significantly higher in patients with IBS. There was a decline in mean systolic blood pressure at the 6th minute in patients with IBS (p=0.026). No association was found between the sedative requirement and the anxiety scores.

CONCLUSION

Patients with IBS who underwent elective colonoscopy procedures expressed higher pre-procedural anxiety scores, required more propofol consumption, and experienced more disruptive movements compared with controls. On the contrary, the increased propofol consumption was not associated with the increased pre-procedural anxiety scores.

Efficacy of bispectral index monitoring for prevention of anestheticawareness and complications during oocyte pick-up procedure

Background/aim: This study was planned by considering that the use of bispectral index (BIS) monitoring ensures sufficient depth of anesthesia and avoids anesthetic awareness and patient movement in the oocyte pick-up (OPU) procedure.Materials and methods: Ninety-eight patients undergoing OPU were randomly divided into 2 groups as the control group (n = 48) and BIS group (n = 50). After propofol and remifentanil induction, the control group was given additional propofol according to reaction response, while the BIS group was given propofol at BIS values of 60 and above with the aim that BIS values be 40?60. Total procedure time, recovery time, patient movement, additional propofol consumption, total number of oocytes, and awareness during anesthesia were recorded. Results: Demographic data were similar in the two groups (P > 0.05 for all). The recovery time in the BIS group was significantly shorter compared to the control group (P < 0.001) while additional propofol consumption was found to be significantly lower (P < 0.001). Baseline BIS values fell compared to all other times after induction significantly (P < 0.001). No patient had anesthesia awareness.Conclusion: During the OPU procedure BIS monitoring is considered to prevent anesthesia awareness, intraoperative movement, and complications caused by insufficient anesthetic use as it ensures optimal doses of anesthetic agents used and early recovery.

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

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.

Do psychological interventions reduce preoperative anxiety?

The systematic review investigates whether, during preoperative assessments, nurse-delivered psychological interventions reduce anxiety levels preoperatively for patients undergoing elective surgery. Seventeen studies met the inclusion criteria for data extraction and in-depth critiquing. Of these, two were discarded due to lack of validity, while the remaining studies were organised thematically in a narrative synthesis, generating two principal results: patients' preoperative anxieties were lowered by nurse-delivered general preoperative psychological interventions; and patients valued individualised preoperative interventions delivered by nurses. However, the single oncology study in the review showed an elevation in preoperative anxiety, regardless of intervention, and highlights the need for more research in this under-reviewed area. In the meantime, the authors believe that service improvements should be implemented to ensure that, where possible, psychological preoperative interventions are individualised.

SEDASYS(®), airway, oxygenation, and ventilation: anticipating and managing the challenges

In May 2013, the FDA (Federal Drug Administration) approved SEDASYS(®), a device that enables non-anesthesia physicians to provide mild-to-moderate sedation to patients undergoing colonoscopy and esophagogastroduodenoscopy. SEDASYS(®) is the first among the devices being built to provide computer-assisted personalized sedation. Although the intention of this approval is to cut the anesthesia related expenses, it is likely to create new challenges to the users-both clinical and administrative-that might even increase the cost. Deep sedation is required frequently for a successful completion of the procedure, which poses unforeseen challenges. The present review aims to provide clear information to the users regarding pre-procedure assessment, possible sedation related complications and management options.

Role of anxiety in the comfort of nonsedated average-risk screening sigmoidoscopy

OBJECTIVES

The aim of this prospective study was to assess the role of generalized anxiety disorder in the comfort of nonsedated, average-risk screening sigmoidoscopy.

METHODS

Patients were asked to complete a screening questionnaire before undergoing average-risk colon cancer screening with nonsedated sigmoidoscopy. The questionnaire included demographic information and a series of Likert-based and visual analog scales designed to assess patient comfort, procedural symptom severity, and satisfaction. The Primary Care Evaluation of Mental Disorders questionnaire was used to assess for generalized anxiety disorder. Comfort levels and postprocedural symptom severity were recorded immediately after the procedure and 1 week postprocedure. χ and t tests were used to analyze the data.

RESULTS

Eighty-one patients were enrolled in the study. Twenty-seven patients tested positive for anxiety (high anxiety), whereas 54 tested negative (low anxiety). There were no differences in anxiety according to sex (P = 0.53), or age (P = 0.32). There was no difference in reaching the splenic flexure between high- and low-anxiety patients (P = 0.15); however, pairwise comparisons revealed patients with high anxiety reported significantly higher levels of abdominal pain after the procedure (P < 0.01) and still recalled higher pain from the procedure 1 week later (P < 0.01) than those patients with low anxiety scores. Furthermore, those patients with high anxiety reported significantly more procedure-related cramping and bloating both immediately after the procedure and again 1 week later (P < 0.01). Finally, patients with high anxiety reported the procedure as being more uncomfortable 1 week later, when compared with low-anxiety patients (P = 0.01).

CONCLUSIONS

The level of anxiety correlated directly to pain and discomfort postprocedure and related inversely to the level of satisfaction. Better management of anxiety may lead to better procedural comfort in nonsedated procedures.

A preoperative stress inquiry and a vulnerable US military population

The preoperative setting is fraught with many stressors, often increasing in magnitude as patients progress through the perioperative environment. Individuals exposed to traumatic or threatening environments, such as US military personnel involved in combat operations, may be at increased risk of developing altered mental and physical health conditions. Collectively, this may result in a hyperarousal state significantly amplifying psychological symptoms and magnifying physiological alterations. The purposes of this article are to (1) describe stress-related concepts and preoperative stress, (2) discuss potential risk factors for preoperative stress in the adult surgical population, (3) present various psychological and physiological measures of preoperative stress, (4) explore preoperative stress interventions, and (5) discuss potential implications for future preoperative stress research in high-stressed populations.

Pain relief for women undergoing oocyte retrieval for assisted reproduction

BACKGROUND

Various methods of conscious sedation and analgesia have been used for pain relief during oocyte recovery in in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) procedures. The choice of agent has also been influenced by the quality of sedation and analgesia as well as by concerns about possible detrimental effects on reproductive outcomes.

OBJECTIVES

To assess the effectiveness and safety of different methods of conscious sedation and analgesia on pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval.

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL (from their inception to present); the National Research Register and Current Controlled Trials. We searched reference lists of included studies for relevant studies and contacted authors for information on unpublished and ongoing trials. There was no language restriction. The search was updated in July 2012.

SELECTION CRITERIA

Only randomised controlled trials comparing different methods of conscious sedation and analgesia for pain relief during oocyte recovery were included.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two review authors. Interventions were classified and analysed under broad categories or strategies of sedation and pain relief to compare different methods and administrative protocols of conscious sedation and analgesia. Outcomes were extracted and the data were pooled when appropriate.

MAIN RESULTS

With this update, nine new studies were identified resulting in a total of 21 trials including 2974 women undergoing oocyte retrieval. These trials compared five different categories of conscious sedation and analgesia: 1) conscious sedation and analgesia versus placebo; 2) conscious sedation and analgesia versus other active interventions such as general and acupuncture anaesthesia; 3) conscious sedation and analgesia plus paracervical block versus other active interventions such as general, spinal and acupuncture anaesthesia; 4) patient-controlled conscious sedation and analgesia versus physician-administered conscious sedation and analgesia; and 5) conscious sedation and analgesia with different agents or dosage. Evidence was generally of low quality, mainly due to poor reporting of methods, small sample sizes and inconsistency between the trials.Conflicting results were shown for women's experience of pain. Compared to conscious sedation alone, more effective pain relief was reported when conscious sedation was combined with electro-acupuncture: intra-operative pain mean difference (MD) on 1 to 10 visual analogue scale (VAS) of 3.00 (95% CI 2.23 to 3.77); post-operative pain MD in VAS units of 2.10 (95% CI 1.40 to 2.80; N = 61, one trial, low quality evidence); or paracervical block (MD not calculable).The pooled data of four trials showed a significantly lower intra-operative pain score with conscious sedation plus paracervical block than with electro-acupuncture plus paracervical block (MD on 10-point VAS of -0.66; 95% CI -0.93 to -0.39; N = 781, 4 trials, low quality evidence) with significant statistical heterogeneity (I(2) = 76%). Patient-controlled sedation and analgesia was associated with more intra-operative pain than physician-administered sedation and analgesia (MD on 10-point VAS of 0.60; 95% CI 0.16 to 1.03; N = 379, 4 trials, low quality evidence) with high statistical heterogeneity (I(2) = 83%). Post-operative pain was reported in only nine studies. As different types and dosages of sedative and analgesic agents, as well as administrative protocols and assessment tools, were used in these trials the data should be interpreted with caution.There was no evidence of a significant difference in pregnancy rate in the 12 studies which assessed this outcome, and pooled data of four trials comparing electro-acupuncture combined with paracervical block with conscious sedation and analgesia plus paracervical block showed an odds ratio (OR) of 0.96 (95% CI 0.72 to 1.29; N = 783, 4 trials) for pregnancy. High levels of women's satisfaction were reported for all modalities of conscious sedation and analgesia as assessed in 12 studies. Meta-analysis of all the studies was not attempted due to considerable heterogeneity.For the rest of the trials a descriptive summary of the outcomes was presented.

AUTHORS' CONCLUSIONS

The evidence from this review of 21 randomised controlled trials did not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte recovery. The simultaneous use of more than one method of sedation and pain relief resulted in better pain relief than one modality alone. The various approaches and techniques reviewed appeared to be acceptable and were associated with a high degree of satisfaction in women. As women vary in their experience of pain and in coping strategies, the optimal method may be individualised depending on the preferences of both the women and the clinicians and resource availability.

The effect of pre-procedure anxiety on sedative requirements for sedation during colonoscopy

This study investigated the effects of pre-procedural anxiety (assessed using the Beck Anxiety Inventory) on sedative requirements in 135 patients undergoing sedation for colonoscopy. Deep sedation was defined as loss of consciousness and no response to colonoscopy, and was achieved by target-controlled infusion of propofol. Patients' characteristics, baseline haemodynamic profiles, Beck Anxiety Inventory scores, effect-site propofol concentration at loss of consciousness and characteristics of recovery were recorded. No correlations were found between Beck Anxiety Inventory scores and effect-site propofol concentration at loss of consciousness or baseline haemodynamic profiles. There was no statistical difference in the characteristics of recovery among patients with different levels of anxiety. In conclusion, in patients receiving deep sedation for colonoscopies, the level of pre-procedural anxiety did not relate to the sedative requirement or post-procedural recovery characteristics.

Rapid injection of propofol reduces vascular pain and facilitates Laryngeal Mask Airway insertion

STUDY OBJECTIVE

To compare the clinical efficacy of a rapid injection of propofol in regard to pain and ability to facilitate Laryngeal Mask Airway (LMA) insertion.

DESIGN

Randomized, single-blinded, placebo-controlled study.

SETTING

University hospital.

PATIENTS

120 ASA physical status 1 and 2 patients undergoing elective orthopedic surgeries.

INTERVENTIONS

Patients were randomly allocated to one of 4 groups. Group A patients were pretreated with normal saline followed by propofol 2.0 mg/kg at 3.3 mg/sec. Group B patients were pretreated with lidocaine 0.5 mg/kg followed by propofol 2.0 mg/kg at 3.3 mg/sec. In Group C, patients were pretreated with lidocaine 1.0 mg/kg followed by propofol 2.0 mg/kg at 3.3 mg/sec. In Group D, patients were pretreated with normal saline followed by propofol 2.0 mg/kg at 50 mg/sec.

MEASUREMENTS

Pain on injection was measured using a 4-point scale. Scale and success rate of smooth LMA insertion also were recorded.

MAIN RESULTS

Rapid injection was less painful than after pretreatment with lidocaine 0.5 mg/kg, but was similar to slow injection after pretreatment with lidocaine 1.0 mg/kg. Rapid injection facilitated LMA insertion, unlike slow injection with lidocaine 0.5 mg/kg pretreatment, and was similarly successful to slow injection after pretreatment with lidocaine 1.0 mg/kg.

CONCLUSIONS

The rapid administration of propofol reduces pain and facilitates LMA insertion versus slow administration of propofol.

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia

BACKGROUND

Psychological factors are thought to drive inter-patient variations in anaesthetic and analgesic requirements. This cross-sectional study investigated whether preoperative psychological factors can predict anaesthetic requirements and postoperative pain.

METHODS

Before total thyroidectomy, 100 consecutive women completed the Spielberger's State-Trait Anxiety Inventory (STAI) and the pain sensitivity questionnaire (PSQ). Target-controlled propofol was administered for induction of anaesthesia, and sevoflurane-oxygen-air was given to maintain equal depths of anaesthesia, as determined by bispectral index (BIS) monitoring.

RESULTS

Patients with higher anxiety scores (state and trait) required greater amounts of propofol to reach light (BIS=85) and moderate (BIS=75) levels of sedation, but only trait anxiety was significantly associated with propofol requirements in reaching a deep level of sedation (BIS=65). The MAC-hour of sevoflurane was significantly correlated only with PSQ scores. The postoperative pain intensity was significantly correlated with both STAI and PSQ.

CONCLUSIONS

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Anaesthetic and analgesic doses could be modified based on the patient's preoperative anxiety and pain sensitivity.

A comparison of three different target-controlled remifentanil infusion rates during target-controlled propofol infusion for oocyte retrieval

OBJECTIVE

To evaluate the effects of three different target-controlled remifentanil infusion rates during target-controlled propofol infusion on hemodynamic parameters, pain, sedation, and recovery score during oocyte retrieval.

METHODS

Sixty-nine women were scheduled for oocyte retrieval. Target-controlled propofol infusion at an effect-site concentration of 1.5 μg/mL was instituted. The patients were randomly allocated to receive remifentanil at an effect-site concentration of either 1.5 (group I, n = 23), 2 (group II, n = 23) or 2.5 ng/mL (group III, n = 23). Hemodynamic variables, sedation, pain, the Aldrete recovery score, and side effects were recorded.

RESULTS

Hemodynamic variables, sedation and pain scores and the number of patients with the maximum Aldrete recovery score 10 min after the procedure were comparable among the groups. The number of patients in group III with the maximum Aldrete recovery score 5 min after the procedure was significantly lower than that in groups I and II. One patient in group II and one patient in group III suffered from nausea.

CONCLUSION

Similar pain-free conscious sedation conditions without significant changes in hemodynamic parameters were provided by all three protocols. However, target controlled infusion of remifentanil at 1.5 or 2 ng/mL proved superior at providing early recovery compared to 2.5 ng/mL.

The patients' perspective on fertility care: a systematic review

BACKGROUND

Patient-centered reproductive medicine (PCRM) is important for quality of care, and this is increasingly being recognized. However, its scientific basis is unclear. The main research questions addressed in this review are: 'How has the patients' perspective on fertility care been examined (method and quality)?' and 'What is the perspective of patients in developed countries on fertility care?'.

METHODS

A systematic search of electronic databases was conducted and inclusion criteria with respect to eligibility and quality were applied. The methodology of the studies was critically appraised; the findings of the studies were synthesized and organized according to: patients' value clarification and assessment of service quality and dimensions of patient-centeredness. Additionally data on patient preferences and determinants of patients' perspective on care were collected.

RESULTS

In 51 selected studies, patients' perspective on fertility care was examined with (few or many item) questionnaires and/or qualitative interviews. Significant methodological problems were observed. Fertility patients attached importance to seven out of eight dimensions of patient-centeredness (Picker institute) and two new dimensions 'fertility clinic staff' and 'skills' were developed. Overall, fertility patients want to be treated like human beings with a need for: medical skills, respect, coordination, accessibility, information, comfort, support, partner involvement and a good attitude of and relationship with fertility clinic staff. Patients' preferences between procedures and demographic, medical and psychological determinants of their perspective were defined.

CONCLUSIONS

Fertility patients have 'human needs' besides their need for medical care. Evidence on PCRM is available but significant methodological limitations call for the development and validation of a European questionnaire.

HYPNOSIS TO MANAGE DISTRESS RELATED TO MEDICAL PROCEDURES: A META-ANALYSIS

This meta-analysis evaluates the effect of hypnosis in reducing emotional distress associated with medical procedures. PsycINFO and PubMed were searched from their inception through February 2008. Randomized controlled trials of hypnosis interventions, administered in the context of clinical medical procedures, with a distress outcome, were included in the meta-analysis (26 of 61 papers initially reviewed). Information on sample size, study methodology, participant age and outcomes were abstracted independently by 2 authors using a standardized form. Disagreements were resolved by consensus. Effects from the 26 trials were based on 2342 participants. Results indicated an overall large effect size (ES) of 0.88 (95% CI = 0.57-1.19) in favour of hypnosis. Effect sizes differed significantly (p < 0.01) according to age (children benefitted to a greater extent than adults) and method of hypnosis delivery, but did not differ based on the control condition used (standard care vs. attention control).

The effect of preoperative uncertainty and anxiety on short-term recovery after elective arthroplasty

AIMS AND OBJECTIVES

This study examined the effect of preoperative anxiety and uncertainty on short-term physical and mental recovery after elective arthroplasty.

BACKGROUND

Uncertainty and anxiety accompany all medical procedures. Although preoperative uncertainty plays a central role in the development of stress, only a few studies explicitly examine this issue in terms of its impact on postoperative recovery.

DESIGN

Quazi-experimental study.

METHODS

Two self-administered questionnaires were used to collect data, before and five to six days after surgery. Participants (n = 87) admitted for elective arthroplasty completed the study.

RESULTS

Preoperative anxiety negatively affected postoperative recovery variables and preoperative uncertainty negatively affected mental and physical recovery after surgery. Furthermore, postoperative symptoms were related to the patients' subjective readiness to be discharged.

CONCLUSIONS

Separately, reduction of preoperative anxiety and uncertainty could have a positive impact on postoperative recovery and on perceived readiness to be discharged.

RELEVANCE TO CLINICAL PRACTICE

The unique contribution of each preoperative variable (uncertainty and anxiety) to postoperative recovery emphasizes the need for clinical and educational interventions that separately relieve uncertainty and anxiety.