Indications, contraindications, and safety aspects of procedural sedation

Prospective Randomized Comparison of Opioid-Based Versus Non-Opioid-Based Anaesthetic Protocols for Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA)

Background: The evolution of interventional pulmonology has necessitated the refinement of anesthetic techniques to ensure the safety and efficacy of procedures such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), particularly when performed outside the conventional operating room setting. The management of anesthesia in patients with significant comorbidities, classified as American Society of Anesthesiologists (ASA) class III, presents distinct challenges. In this context, the transtracheal block emerges as a viable alternative to total intravenous anesthesia (TIVA) for these high-risk procedures. Objectives: This study aims to evaluate the comparative safety and efficacy of opioid-based intravenous analgesia versus a regimen combining sedative agents with transtracheal block in the administration of anesthesia for EBUS TBNA in high-risk patients. Design: We conducted a randomized observational study involving 57 elective EBUS-TBNA patients classified as ASA class III. Methods: Participants were allocated into two cohorts: one receiving intravenous opioid analgesia and the other receiving a combination of sedative agents with transtracheal block. Collected data encompassed patient demographics, medical history, incidence of adverse events during anesthesia, indicators of sympathetic nervous system activation, patient satisfaction levels, and the procedural conditions as assessed by the operator. Results: Opioid anesthesia was associated with increased desaturation (95.7% vs. 60.6%; p < 0.05) and higher pain-related sympathetic responses (VAS and SCI at 40-100; p < 0.05). No differences in other adverse events, patient satisfaction, or procedural conditions were noted. Conclusions: In summary, the study indicates that transtracheal block combined with sedatives may be a safer anesthetic alternative to opioid-based regimens for high-risk EBUS-TBNA patients, reducing desaturation and pain-related sympathetic activity without affecting satisfaction or procedural efficacy.

Association of anaesthesia-directed sedation with unplanned discharge to a nursing home following non-ambulatory interventional radiology and endoscopic procedures: a retrospective cohort study

INTRODUCTION

Interventional radiology procedures and endoscopies are performed commonly worldwide, often necessitating pharmacological sedation to optimise patient comfort. It is unclear to what extent non-anaesthetists should provide procedural sedation.

METHODS

We studied adult patients who previously lived independently and underwent a non-ambulatory interventional radiology or gastroenterology procedure under anaesthetist-directed or non-anaesthetist-directed sedation at a large healthcare network. The primary outcomes were postprocedural adverse discharge to a nursing home and postprocedural duration of hospital stay.

RESULTS

Among 22,868 patients included, 15,168 (66.3%) and 7700 (33.7%) underwent anaesthetist-directed sedation and non-anaesthetist-directed sedation, respectively. Of all patients receiving anaesthetist-directed sedation, 9.2% experienced adverse discharge to a nursing home compared with 21.3% undergoing non-anaesthetist-directed sedation. Anaesthetist-directed sedation was associated with reduced risk of adverse discharge to a nursing home (adjusted relative risk 0.54, 95%CI 0.45-0.63, p < 0.001, adjusted risk difference -4.6%, 95%CI -5.8 to -3.4, p < 0.001) and a shorter postprocedural duration of hospital stay (median (IQR [range]) 2 (1-6 [0-315]) days vs. 5 (2-12 [0-268]) days; adjusted model estimate 0.84, 95%CI 0.79-0.89, p < 0.001). The lower risk of adverse discharge to a nursing home and shorter duration of hospital stay in patients undergoing anaesthetist-directed sedation was reproduced in an instrumental variable analysis (adjusted risk difference -4.3%, 95%CI -8.4 to -0.1, p = 0.043; and -1.41 days, 95%CI -1.43 to -1.41 days, p < 0.001, respectively). Among patients undergoing anaesthetist-directed sedation the mean (SD) proportion of missing blood pressure measurements was lower (0.7 (4.9) % vs. 8.0 (14.6) %, p < 0.001), which mediated the effect of anaesthetist-directed sedation on adverse discharge.

DISCUSSION

Among patients undergoing a non-ambulatory interventional radiology procedure or a gastrointestinal endoscopy, anaesthetist-directed sedation is associated with a reduced risk of adverse discharge to a nursing home and a shorter duration of hospital stay.

The Role of Behavioral Management in Enhancing Clinical Care and Efficiency, Minimizing Social Disruption, and Promoting Welfare in Captive Primates

Medical procedures necessary for routine care can induce stress in both the veterinary and human clinical situations. In the research environment, nonhuman primates undergo procedures like physical examination, blood sampling, and intravenous drug or fluid administration either as a part of routine veterinary care or during the modeling of clinical disease and interventions under study. Behavioral management techniques, such as training for cooperation, allow caregivers to train primates to voluntarily engage in various medical procedures. This approach reduces stress and anxiety associated with necessary procedures, thereby enhancing efficiency and minimizing the invasiveness of medical care. Consequently, veterinary evaluation and care can be provided without compromise, resulting in enhanced clinical outcomes and overall better health. In this study, we explored the impact of the behavioral management program implemented at our center on a subset of animals undergoing routine veterinary care, focusing on the overall experience, including animal welfare, scientific rigor, and efficiency in terms of economics and time. We investigated its impact on key factors, such as the total procedure and recovery time, incidence of side effects, and welfare indicators, revealing a significant positive influence on animal care. Furthermore, through case studies, we illustrate how behavioral management facilitates timely medical care and monitoring, effectively mitigating stressors that could otherwise impair health and welfare, enabling the provision of care that would have otherwise been unachievable. A thoughtfully designed primate behavioral management program, integrating cooperation and participation with veterinary care, forms the cornerstone of superior animal welfare, enhanced clinical care, and more accurate scientific outcomes.

Effect of remimazolam vs propofol in high-risk patients undergoing upper gastrointestinal endoscopy: a non-inferiority randomized controlled trial

BACKGROUND

Procedural sedation is essential for optimizing upper gastrointestinal endoscopy, particularly in high-risk patients with multiple underlying diseases. Respiratory and circulatory complications present significant challenges for procedural sedation in this population. This non-inferiority randomized controlled trial aims to investigate the safety and comfort of remimazolam compared to propofol for procedural sedation during upper gastrointestinal endoscopy in high-risk patients.

METHODS

A total of 576 high-risk patients scheduled to undergo upper gastrointestinal endoscopy are planned to be enrolled in this study and randomly allocated to either the remimazolam or propofol group. The primary outcome measure is a composite endpoint, which includes (1) achieving a Modified Observer's Alertness/Sedation scale (MOAA/S) score ≤ 3 before endoscope insertion, (2) successful completion of the endoscopic procedure, (3) the absence of significant respiratory instability during the endoscopy and treatment, and (4) the absence of significant circulatory instability during the examination. The noninferiority margin was 10%. Any adverse events (AEs) that occur will be reported.

DISCUSSION

This trial aims to determine whether remimazolam is non-inferior to propofol for procedural sedation during upper gastrointestinal endoscopy in high-risk patients, regarding success rate, complication incidence, patient comfort, and satisfaction. TRIAL REGISTRATION {2A AND 2B}: Chinese Clinical Trial Registry ClinicalTrials.gov ChiCTR2200066527. Registered on 7 December 2022.

Sedated Colonoscopy may not be Beneficial for Polyp/Adenoma Detection

BACKGROUND

Sedated colonoscopy has been increasingly selected. However, the effect of sedated colonoscopy on polyp/adenoma detection rate (PDR/ADR) remains controversial among studies.

METHODS

In this retrospective study, the medical records of 11 504 consecutive patients who underwent colonoscopy at our department from July 1, 2021 to December 31, 2022 were collected. Patients were divided into sedated and unsedated groups according to the use of intravenous sedation during colonoscopy. Overall PDR/ADR, right-side, transverse, and left-side colon PDR/ADR, and single and multiple PDR/ADR were calculated. By adjusting for age, gender, body mass index, inpatient, screening/surveillance, cecal intubation time, colonoscopy withdrawal time ≥6 min, and an endoscopist's experience ≥5 years, multivariate logistic regression analyses were performed to evaluate the association of sedated colonoscopy with overall PDR/ADR, right-side, transverse, and left-side colon PDR/ADR, and single and multiple PDR/ADR, where the absence of PDR/ADR was used as reference. Odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated.

RESULTS

Overall, 2275 patients were included, of whom 293 and 1982 underwent sedated and unsedated colonoscopy, respectively. Multivariate logistic regression analyses showed that sedated colonoscopy was independently associated with lower overall PDR/ADR (OR = 0.640, 95% CI = 0.460-0.889, P = 0.008), right-side colon PDR/ADR (OR = 0.591, 95% CI = 0.417-0.837, P = 0.003), single PDR/ADR (OR = 0.659, 95% CI = 0.436-0.996, P = 0.048), and multiple PDR/ADR (OR = 0.586, 95% CI = 0.402-0.855, P = 0.005), but not transverse or left-side colon PDR/ADR.

CONCLUSION

Sedated colonoscopy may not be beneficial in terms of overall PDR/ADR, right-side colon PDR/ADR, and number of polyps/adenomas. Thus, it should be selectively recommended. Additionally, it should be necessary to explore how to improve the quality of sedated colonoscopy.

Dental pain perception and emotional changes: on the relationship between dental anxiety and olfaction

BACKGROUND

The purpose of the study was to determine to what extent olfactory aromatherapy reduces the intensity of dental pain and the level of dental anxiety. It also attempted to corelate between olfactory aromatherapy, stages of dental visits, and various dental procedures.

METHODS

Female patients were enrolled in a randomized controlled study. Olfactory aromatherapy was performed using lavender oils. Patients were randomly assigned to one of two groups: the lavender group, in which patients inhaled 2% lavender vapors, and the control group, in which patients inhaled water vapors. Pain score, anxiety score, and changes in vital signs were among the predictable variables. Anxiety and pain were assessed using the Modified Dental Anxiety Scale (MDAS), Speilberger State-Trait Anxiety Inventory (STAI), and visual analog scales (VAS). The vital signs were systolic (SBP) and diastolic (DBP), heart rate (HR), respiratory rate (RR), and oxygen saturation (Spo2). Variables were evaluated before inhalations, 20 min after inhalations, at the end of settings, and on the following day.

RESULTS

Each group had 175 participants. Pain and anxiety scores were significantly reduced, and all vital signs improved, except for DBP. The MDAS, STAI, and pain scores are reduced by 3.4, 4.2, and 2.4 times, respectively, compared to the control group. Olfactory aromatherapy had the greatest impact during the phase of waiting rooms.

CONCLUSION

When compared to the control group, olfactory aromatherapy reduces anxiety scores three to four times more. Pain perception is reduced by twice as much as in the control group. It also significantly reduces the anxiety associated with minor to moderately stressful dental procedures.

Effect of high-flow nasal oxygen on hypoxaemia during procedural sedation: a systematic review and meta-analysis

We conducted a systematic review to evaluate the effect of high-flow nasal oxygen and conventional oxygen therapy during procedural sedation amongst adults and children. We searched MEDLINE, EMBASE and CINAHL for randomised controlled trials that reported the effects of high-flow nasal oxygen during procedural sedation. The primary outcome measure was hypoxaemia and the secondary outcomes were minimum oxygen saturation; hypercarbia; requirement for airway manoeuvres; and procedure interruptions. The quality of evidence was assessed using the revised Cochrane risk-of bias tool and grading of recommendations, assessment, development and evaluation (GRADE). Nineteen randomised controlled trials (4121 patients) including three in children were included. Administration of high-flow nasal oxygen reduced hypoxaemia, risk ratio (95%CI) 0.37 (0.24-0.56), p < 0.001; minor airway manoeuvre requirements, risk ratio (95%CI) 0.26 (0.11-0.59), p < 0.001; procedural interruptions, risk ratio (95%CI) 0.17 (0.05-0.53), p = 0.002; and increased minimum oxygen saturation, mean difference (95%CI) 4.1 (2.70-5.50), p < 0.001; as compared with the control group. High-flow nasal oxygen had no impact on hypercarbia, risk ratio (95%CI) 1.24 (0.97-1.58), p = 0.09, I²  = 0%. High-flow nasal oxygen reduced the incidence of hypoxaemia regardless of the procedure involved, degree of fractional inspired oxygen, risk-profile of patients and mode of propofol administration. The evidence was ascertained as moderate for all outcomes except for procedure interruptions. In summary, high-flow nasal oxygen compared with conventional oxygenation techniques reduced the risk of hypoxaemia, increased minimum oxygen saturation and reduced the requirement for airway manoeuvres. High-flow nasal oxygen should be considered in patients at risk of hypoxaemia during procedural sedation.

Sedation-Led chEmotherapy Evades Pain (S.L.E.E.P.)

Chemotherapy and other invasive therapies are often limited by side effects, pain and negative experiences that can limit adherence to the therapy itself. Such negative components add to the patient's depressive state due to the disease. This research project proposes the use of deep sedation during chemotherapy sessions or other disabling therapies in the treatment of tumors or other severe diseases. The proposed protocol provides for an ad hoc hospitalization which could be during the night, during the day or limited to a few hours. Administration during sleep eliminates the memory and the negative impact the treatment has on the rest of the patient's daily life. This approach also agrees with the evidence of the circadian rhythm of cellular repair processes, which is greater at sunrise and sunset and linked to a good quantity and quality of sleep. In conclusion, this project aims to reduce the negative impact and increase the adherence to and efficacy of the therapy itself.

Clinical outcomes of patients undergoing percutaneous left atrial appendage occlusion in general anaesthesia or conscious sedation: data from the prospective global Amplatzer Amulet Occluder Observational Study

OBJECTIVE

To evaluate the safety and efficacy of percutaneous left atrial appendage occlusion (LAAO) using conscious sedation (CS).

BACKGROUND

Several percutaneous structural heart disease interventions are safely and efficiently performed using CS instead of general anaesthesia (GA). This concept has not been evaluated in a large multicenter cohort of patients undergoing LAAO.

METHODS

Patients from the prospective, global Amplatzer Amulet Occluder Observational Study were divided into two groups (GA vs CS). Baseline information, periprocedural and postprocedural efficacy and complications, as well as outcomes through 7 days post implant were compared.

RESULTS

Patients undergoing transesophageal-guided implants were categorised by GA (n=607, 64%) or CS (n=342, 36%) usage. Mean age was 75 years in both groups. LAAO technical success was achieved in 99% of both groups. The procedure duration (GA: 35±22 min vs CS: 27±19 min, p<0.001), total amount of contrast medium (GA: 105±81 mL vs CS: 86±66 mL, p<0.001) and fluoroscopic time (GA: 13±9 min vs CS: 12±13 min, p<0.001) were less in CS cases. Procedure-related or device-related serious adverse events during the first 7 days were numerically higher in the CS group (GA: 4.9% vs CS: 7.6%, p=0.114). Peridevice residual flow was absent or ≤5 mm 1-3 months after the procedure in 99.7% of the GA and in 100% of the CS group (p=1.000).

CONCLUSIONS

In a large global study, LAAO with the Amplatzer Amulet occluder is safe and feasible using CS. Procedure duration and total amount of contrast were less with CS than GA cases.

TRIAL REGISTRATION NUMBER

NCT02447081; Results.

Induction and maintenance of procedural sedation in adults: focus on remimazolam injection

Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.