Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

Caring for the Patient During Bedside Bronchoscopy in the Critical Care Setting

BACKGROUND

Bedside bronchoscopy is a pivotal diagnostic and therapeutic tool often used with critically ill patients in the critical care setting. Bronchoscopy allows for direct visualization of the airways and lung parenchyma and can be useful in evaluating different bronchopulmonary diseases including foreign bodies, tumors, infectious and inflammatory conditions, airway stenosis, and bronchopulmonary hemorrhage.

OBJECTIVE

This article explores bedside bronchoscopy in critically ill patients. Covering key areas from preprocedure preparation care, it emphasizes the nurse's role, procedural techniques, and adaptations. The focus extends to nurses' roles with emerging bedside bronchoscopy technologies and provides insight on implications for clinical practice.

CONCLUSION

Bedside bronchoscopy serves as a vital tool in critical care, enabling both diagnosis and treatment of various pulmonary conditions. Nurses play a pivotal role in ensuring procedural success and patient safety, from preprocedure preparation to postprocedure monitoring. As technology evolves, nurses must adapt, embracing opportunities for ongoing learning and interdisciplinary collaboration, while also advocating for patient-centered care and ethical considerations in the integration of advanced technologies.

Adverse events in patients with obstructive sleep apnea undergoing procedural sedation in ambulatory settings: An updated systematic review and meta-analysis

OBJECTIVE

Patients with obstructive sleep apnea (OSA) may be at increased risk for adverse events during procedural sedation, however, there remains a gap in the literature quantifying these risks. This systematic review and meta-analysis aimed to evaluate the risk of peri-procedural adverse events in OSA patients undergoing procedural sedation in ambulatory settings, compared to those without OSA.

METHODS

Four databases were systematically searched for studies published from January 1, 2011 to January 4, 2024. The inclusion criteria were: adult patients with OSA undergoing procedural sedation in ambulatory settings, peri-procedural adverse events reported, and control group included. The primary outcome was the incidence of peri-procedural adverse events amongst patients with vs without OSA.

RESULTS

Nineteen studies (27,973 patients) were included. The odds of respiratory adverse events were significantly increased for patients with OSA (OR 1.65, 95 % CI 1.03-2.66, P = 0.04). Furthermore, the odds of requiring an airway maneuver/intervention were significantly greater for patients with OSA (OR 3.28, 95 % CI 1.43-7.51, P = 0.005). The odds of cardiovascular adverse events were not significantly increased for patients with OSA.

CONCLUSION

Patients with OSA undergoing procedural sedation in ambulatory settings had 1.7-fold greater odds of respiratory adverse events and 3.3-fold greater odds of requiring airway maneuvers/interventions.

Remimazolam for procedural sedation: A systematic review with meta-analyses and trial sequential analyses

BACKGROUND

Midazolam and propofol are frequently used for procedural sedation. Remimazolam may provide a more controllable sedation with fewer adverse effects.

OBJECTIVE

To assess the sedation success rate and respiratory and cardiovascular complications of remimazolam versus placebo and other sedatives in adults undergoing procedural sedation.

DESIGN

A systematic review of randomised controlled trials (RCTs) with meta-analyses, trial sequential analyses (TSA), and GRADE evaluations of the certainty of evidence.

DATA SOURCES

We searched Medline, Embase, CENTRAL, BIOSIS, CINAHL, and Web of Science Core Collection from their inception to 22 June 2024.

ELIGIBILITY CRITERIA

RCTs allocating participants undergoing procedural sedation to remimazolam versus placebo or any active comparator.

RESULTS

We included 63 trials randomising 13 953 participants. All included trial results were judged to be at high risk of bias. The sedation success rate was similar with remimazolam versus active comparators, relative risk (RR) 1.04, [97.5% confidence interval (CI), 0.96 to 1.14; TSA-adjusted CI, 0.95 to 1.18], P   =  0.26, GRADE: very low. Subgroup analyses indicated that remimazolam versus midazolam increased sedation success rate, while the risks were similar with remimazolam versus comparators. Remimazolam versus active comparators decreased the risk of respiratory complications, RR 0.47, (97.5% CI, 0.36 to 0.61; TSA-adjusted CI, 0.35 to 0.61), P  < 0.01; and cardiovascular complications, RR 0.46, (97.5% CI, 0.37 to 0.56; TSA-adjusted CI, 0.38 to 0.57), P  < 0.01. Subgroup analyses indicated that remimazolam versus propofol reduced respiratory and cardiovascular complications, while the risks were similar versus midazolam.

CONCLUSION

Remimazolam seems to provide a similar sedation success rate as other active comparators (propofol, ciprofol, midazolam, dexmedetomidine, etomidate), although subgroup analyses indicated that remimazolam increased sedation success rate compared to midazolam. Remimazolam compared to propofol may decrease the risk of respiratory and cardiovascular complications. The certainty of the evidence was very low to low, and firm conclusions could not be drawn.

Comparison of sedation with pentazocine or pethidine hydrochloride for endoscopic ultrasonography in outpatients: A single-center retrospective study

Objectives

Endoscopic ultrasonography (EUS) plays an important role in the diagnosis of pancreatobiliary diseases. However, an appropriate sedation method for EUS has not been established. Therefore, this study aimed to examine the safety and complications of sedation with pentazocine or pethidine hydrochloride for outpatient diagnostic EUS.

Methods

We retrospectively reviewed 1302 consecutive cases in our department that underwent outpatient diagnostic EUS between April 2019 and September 2021. Until June 2020, EUS was performed under sedation with midazolam and pentazocine (pentazocine group) in principle; after June 2020, sedation with midazolam and pethidine hydrochloride (pethidine hydrochloride group) was used. A cohort of patients with comparable backgrounds was identified using propensity score matching.

Results

A total of 486 cases were included in this study. Sedation-related adverse events during the endoscopic procedures were not significantly different between the groups. The median time spent in the recovery room after EUS was significantly shorter in the pethidine hydrochloride group than in the pentazocine group (69 versus vs. 77 min; p < 0.001). The frequency of nausea or vomiting after EUS was significantly lower in the pethidine hydrochloride group than in the pentazocine group (0% [0/486] vs. 6.2% [29/486]; p < 0.001). The frequency of readmission to the recovery room after discharge was significantly lower in the pethidine group than in the pentazocine group (0 [0%] vs. 18 [3.7%], respectively; p < 0.001).

Conclusions

The combination of midazolam and pethidine hydrochloride is a more favorable anesthetic than the combination of midazolam and pentazocine for diagnostic EUS in outpatients.

ED50 and ED95 of remimazolam for loss of consciousness in young children

BACKGROUND

The optimal single i.v. bolus dose of remimazolam for induction of general anaesthesia in children is not defined. We aimed to determine the 50% (ED50) and 95% (ED95) effective doses of remimazolam for inducing loss of consciousness in children.

METHODS

A total of 120 children, aged 1-12 yr, were divided into three groups, with 40 children in each group: toddler (1 to <3 yr), preschool (≥3 to <6 yr), and school-age group (≥6 to <12 yr). Each child received a single i.v. bolus of remimazolam, with doses determined using a biased coin design up-and-down method. The primary outcome was the ED50 and ED95 of remimazolam for inducing loss of consciousness. Secondary outcomes included the incidence of hypotension, respiratory depression, and adverse events.

RESULTS

The ED50 and ED95 of remimazolam were 0.42 mg kg-1 (95% confidence interval [CI] 0.37-0.44) and 0.57 mg kg-1 (95% CI 0.48-0.59), respectively, in the toddler group; 0.41 mg kg-1 (95% CI 0.35-0.47) and 0.57 mg kg-1 (95% CI 0.50-0.59), respectively, in the preschool group; and 0.30 mg kg-1 (95% CI 0.28-0.34) and 0.43 mg kg-1 (95% CI 0.37-0.44), respectively, in the school-age group. No significant cases of hypotension, respiratory depression, bradycardia, or other adverse events occurred in any of the three groups.

CONCLUSIONS

A single i.v. bolus of remimazolam at estimated doses of 0.45-0.60 mg kg-1 for children aged 1-6 yr and 0.35-0.45 mg kg-1 for those aged 6-12 yr effectively induces loss of consciousness in children.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT06061159).

Sedation with ketamine, propofol, and dexmedetomidine in pediatric emergency departments

OBJECTIVES

Describe current practices and variation in procedural sedation with ketamine, propofol and dexmedetomidine in pediatric emergency departments (EDs).

METHODS

This was a retrospective study of 40 hospitals in the Pediatric Health Information System from 2016 to 2022, including ED visits for children under 18 years old who received sedation with ketamine, propofol, or dexmedetomidine. We described institutional variation in choice of sedation medication, as well as the differences in both frequency and diagnoses associated with procedural sedation by age.

RESULTS

There were 189,086 ED encounters included in the study. Ketamine was given in 177,502 (94 %) encounters, propofol in 22,916 (12 %), and dexmedetomidine in 3240 (1.7 %). Ketamine was the primary medication used in nearly all institutions, with only a few outliers using propofol or dexmedetomidine. The highest number of sedations occurred in young children (aged 1-7 years), and the number of ED sedation encounters decreased with each year of age beyond 5 years. Notably, infants under 1 year of age were infrequently sedated (1.4 % of all sedations). The most common diagnoses associated with sedation encounters were fractures/dislocations (60 %), followed by lacerations (19 %), and abscesses (5.8 %). Diagnoses varied with age; fractures/dislocations were more common in older age groups, while lacerations and abscesses were disproportionately more common in younger children.

CONCLUSIONS

In nearly all institutions, use of ketamine was far more common than use of propofol or dexmedetomidine. The most common diagnoses associated with ED sedation were orthopedic injuries, though diagnoses varied with age. These results illustrate current sedation practices with ketamine, propofol and dexmedetomidine in the pediatric ED and may inform future standardization efforts.

Procedural sedation competencies: a review and multidisciplinary international consensus statement on knowledge, skills, training, and credentialing

Procedural sedation is practised by a heterogeneous group of practitioners working in a wide array of settings. However, there are currently no accepted standards for the competencies a sedation practitioner should have, the content of sedation training programmes, and guidelines for credentialing. The multidisciplinary International Committee for the Advancement of Procedural Sedation sought to develop a consensus statement on the following: which competencies should medical or dental practitioners have for procedural sedation and how are they obtained, assessed, maintained, and privileged. Using the framework of Competency-Based Medical Education, the practice of procedural sedation was defined as a complex professional task requiring demonstrable integration of different competencies. For each question, the results of a literature review were synthetised into preliminary statements. Following an iterative Delphi review method, final consensus was reached. Using multispeciality consensus, we defined procedural sedation competence by identifying a set of core competencies in the domains of knowledge, skills, and attitudes across physical safety, effectiveness, psychological safety, and deliberate practice. In addition, we present a standardised framework for competency-based training and credentialing of procedural sedation practitioners.

Awake Craniotomy for a Deaf Patient: A Case Report

A 45-year-old deaf man presented with a right cerebral glioma to be resected via an awake craniotomy with language mapping. Deaf patients require special consideration of their unique communication needs. We describe the anesthetic management in detail, including operating room environment accommodations of lighting, positioning, pulse oximetry probe placement, and obviating the operating room mask protocol for the sign language interpreter. We describe a novel anesthetic approach with an awake-awake-asleep technique. The patient was able to communicate and tolerated the successful procedure well. For the safety and well-being of the surgical deaf patient, the anesthesia provider must make appropriate accommodations.

Single-agent versus combination regimens containing propofol: a retrospective cohort study of recovery metrics and complication rates in a hospital-based endoscopy suite

BACKGROUND

Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy.

METHODS

We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO2 < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals.

RESULTS

Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05).

CONCLUSIONS

With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.

Nitrous oxide analgesia for rehabilitation after anterior cruciate ligament reconstruction: A randomized controlled trial

BACKGROUND

Although there is increasing emphasis on rehabilitation training after ligament reconstruction, little is known about the pain induced by the procedure itself. Procedural success may be limited by pain and anxiety. Nitrous oxide is widely used to alleviate procedural pain. However, few studies have been conducted to show the efficacy and safety of nitrous oxide for rehabilitation training.

OBJECTIVES

To explore the short-term efficacy and safety of nitrous oxide for acute pain elicited by rehabilitation training.

METHODS

A double-blinded randomized placebo-controlled trial was conducted in the department of rehabilitation medicine. People willing to participate in the trial and sign informed consent, ≥18 years old, who had acute pain (self-reported pain score ≥4) caused by rehabilitation training after anterior cruciate ligament reconstruction were recruited. Participants undergoing rehabilitation training were randomized to receive either 65 % nitrous oxide or 100 % oxygen. The primary outcome was the pain score. Secondary outcomes were sedation score, range of motion, vital signs, physician and participant satisfaction, acceptance, and side effects.

RESULTS

120 people were enrolled; 60 received nitrous oxide and 60 received oxygen. The nitrous oxide group had a significantly lower pain score than the placebo group (P < 0.001, median difference -3, 95 % CI -4 to -2, effect size η2 = 0.369) and sedation scores (P < 0.001, median difference 1, 95 % CI 1 to 1, η2 = 0.263) during the procedure. Both physician (P < 0.001) and participant (P < 0.001) satisfaction were significantly higher in the intervention group than the placebo group. Acceptance (willingness to use the same gas next time) differed between groups (P < 0.001). No serious side effects occurred.

CONCLUSION

This study provides evidence supporting the efficacy and safety of self-administered nitrous oxide to reduce procedural pain during rehabilitation training after anterior cruciate ligament reconstruction.

Association between periprocedural cerebral desaturation during transcatheter aortic valve implantation and postprocedural delirium: a prospective observational study

BACKGROUND

The aim of this study was to investigate whether the level of decrease in cerebral oxygen saturation during the valve placement phase of the transcatheter aortic valve implantation (TAVI) procedure under sedation has an effect on postoperative delirium (POD).

METHODS

The study initially assessed 50 patients between the ages of 50 and 90 years with an indication for TAVI by the cardiac team. Regional cerebral oxygen saturation (rScO2) was measured using Near-infrared spectroscopy (NIRS) before the procedure (T1), during surgical field sterilization (T2), catheter placement (T3), wire manipulation (T4), valve placement (T5) and access site artery repair (T6). Confusion Assessment Method for The Intensive Care Unit (ICU-CAM) test was performed on intensive care unit and the presence of POD was questioned. Patients were divided into two groups as those without POD (Group 1) and those with POD (Group 2).

RESULTS

The study was completed with 41 patients in total. While POD was present in 12 (29.3%) of the patients evaluated intensive care unit, POD was not observed in 29 (70.7%) patients. The rScO2 value measured at T5 was significantly lower in Group 2 compared to Group 1 (p < 0.001).

CONCLUSIONS

In our study, the rate of POD after TAVI was as high as 29.3%. Low rScO2 during valve placement was associated with delirium. Our findings indicate that NIRS devices could be a useful tool for assessing the risk of POD during the TAVI procedure; however, further research is needed to validate their routine clinical use.

Effect of high flow nasal cannula oxygenation on incidence of hypoxia during sedated gastrointestinal endoscopy in patients with obesity: multicentre randomised controlled trial

OBJECTIVE

To determine whether high flow nasal cannula (HFNC) oxygenation can reduce the incidence of hypoxia during sedated gastrointestinal endoscopy in patients with obesity.

DESIGN

Multicentre, randomised, parallel group trial.

SETTING

Three tertiary hospitals in Shanghai, China.

PARTICIPANTS

1000 adult patients with obesity (body mass index ≥28) who were scheduled for gastrointestinal endoscopy.

INTERVENTIONS

Participants were randomly allocated to receive regular nasal cannula oxygenation or HFNC oxygenation during a sedated procedure with propofol and low dose sufentanil.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of hypoxia (75%≤SpO2<90% for <60 s) during the procedure. Secondary outcomes included the incidences of subclinical respiratory depression (90%≤SpO2<95% for any duration) and severe hypoxia (SpO2<75% for any duration or 75%≤SPO2<90% for >60 s) during the procedure.

RESULTS

From 6 May 2021 to 26 May 2023, 984 patients (mean age 49.2 years; 36.9% (n=363) female) completed the study and were analysed. Compared with regular nasal cannula oxygenation, HFNC oxygenation reduced the incidence of hypoxia from 21.2% (103/487) to 2.0% (10/497) (difference -19.14, 95% confidence interval -23.09 to -15.36; P<0.001), subclinical respiratory depression from 36.3% (177/487) to 5.6% (28/497) (difference -30.71, -35.40 to -25.92; P<0.001), and severe hypoxia from 4.1% (20/487) to 0% (0/497) (difference -4.11%, -6.26 to -2.48; P<0.001). Other sedation related adverse events did not differ between the two groups.

CONCLUSIONS

In patients with obesity, oxygenation via HFNC during sedated gastrointestinal endoscopy significantly reduced the incidences of hypoxia, subclinical respiratory depression, and severe hypoxia without increasing other adverse events.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04500392.

Dental Anesthesia Guidelines and Regulations of US States and Major Professional Organizations: A Review

This summary reviews guidelines and regulations pertaining to dental anesthesia across the United States, including guidelines of the American Dental Association (ADA), American Association of Oral and Maxillofacial Surgeons (AAOMS), and American Society of Anesthesiologists (ASA). The analysis addresses a range of requirements, including definitions of anesthesia and requirements for training and certification across professional societies and the 50 US states, with a focus on office-based settings. Strikingly, substantial variation exists among state rules and regulations and the ADA, AAOMS, and ASA guidelines with implications for variations of care, outcomes, and patient safety. We examined definitions of sedation and general anesthesia, patient selection and evaluation, fasting requirements, emergency preparedness, drug administration, monitoring, equipment, procedure selection, education and training requirements, permit requirements, life support certifications, reporting of adverse events, and inspection requirements. This comprehensive analysis serves to educate dental practitioners and office staff, patients, primary care providers, and state dental boards about the regulatory landscape of dental anesthesia. Our findings establish a foundation for future research and policy development aimed at improving consistency, best practices, and safety in dental anesthesia practices.

Establishing the first ever pediatric procedural sedation clinic in a low-income country: Assessment of the safety and efficacy

BACKGROUND

Pediatric sedation clinics are rare in low-income countries. Our aim is to describe the establishment of the first-ever pediatric sedation clinic in Ethiopia and provide an assessment of its safety and efficacy over the 5 years since its establishment.

METHODS

A multi-phase approach was undertaken. In the first phase, we analyzed barriers to procedural pain management through repeated focus group discussions with stakeholders. Subsequently, we conducted a modified sedation provider course from the Society for Pediatric Sedation (SPS) with pre and post-training testing to document course effectiveness. Finally, we developed a procedural sedation clinic at Tikur Anbessa Specialized Hospital. In the second phase, we prospectively collected outcome data over a 5-year period from patients receiving procedural sedation at the clinic. This included assessing the efficacy of sedation and documenting any adverse events that occurred during the procedures.

RESULT

One hundred three providers completed the procedural sedation course. There was a 13.4% improvement in knowledge between baseline and post-course testing. A total of 2,820 patients underwent procedural sedation over the 5-year period from 2016 through 2021, and data selected from 475 (16.8%) patients were analyzed. The most common procedure performed was bone marrow aspiration/biopsy in 384 subjects (80.8%). The most common procedural sedation used was the combination of ketamine and propofol in 60.6%. The mean pain score during the procedure was 0.28/10, which was significantly lower than the pre-procedural pain score (p-value < 0.001). A total of 9 (1.9%) patients had adverse events and there was no mortality.

CONCLUSION

Based on our experience, development of a safe and effective sedation clinic is possible in resource-limited settings as evidenced by low procedural pain scores, and low adverse events rates. Provider training based on a modification of the SPS course improved overall procedural sedation knowledge.

Point-counterpoint: should sedation be used for image-guided biopsies?

Cross-sectional interventional radiology procedures can be performed using a range of techniques with approaches varying across institutions. One area in which practices for these procedures may differ is in the use of moderate sedation. This perspective discusses the pros and cons of using moderate sedation for deep organ biopsies commonly experienced in radiology departments.

Dream of the Endless: Special Considerations in Procedural Sedation

Procedural sedation and analgesia (PSAA) is integral to facilitating painful and anxiety-inducing medical procedures in the emergency department (ED). Optimal PSAA enhances procedural success and improves both patient and provider satisfaction. The selection of appropriate sedative and analgesic agents, routes, and dosages, which depend on various patient- and procedure-specific factors is a complex process. Alternative routes of administration, such as intranasal, intramuscular, and oral, are all options, each with their own inherent benefits and limitations. It is important for providers to take into account patient-specific considerations, including age, medical history, body weight composition, and pregnancy, which can significantly impact PSAA effectiveness and safety. Implementation strategies targeted to minimize medication errors and optimize workflow are also important considerations in PSAA. By adopting a comprehensive and evidence-based approach, health care providers can navigate the intricacies of PSAA and ensure the best possible care for patients in the ED.

Comparative Study of Remimazolam and Midazolam During Sedated Upper Gastrointestinal Endoscopy: A Propensity Score Matching Analysis

AIM

This study aimed to compare the use of remimazolam and midazolam in upper gastrointestinal endoscopy in Japan as a sub-analysis of data from an investigator-initiated clinical trial of remimazolam.

METHODS AND RESULTS

Patients in two groups were matched using propensity score matching. We evaluated the time from the end of the gastrointestinal endoscopy until discharge, the time from the end of the procedure until awakening, and adverse events. Overall, 36 participants from the clinical trial population who underwent upper gastrointestinal endoscopy using remimazolam and 199 patients who underwent the procedure with midazolam during the same period were included in this study. Following propensity score matching, 34 patients in both groups were matched. The median time from the end of the procedure until awakening was 27.0 min (23.0-40.5 min) in the midazolam group (Group M) and 0 min (0-5.0 min) in the remimazolam group (Group R); the median time from the end of the upper gastrointestinal endoscopy until discharge was 39.0 min (35.0-52.5 min) in Group M and 5.0 min (0-5.0 min) in Group R (p < 0.01). Reported adverse events were hypotension and hypoxemia in one patient in Group R.

CONCLUSION

Compared with midazolam, remimazolam significantly shortened the time to patient awakening and duration until the patient could leave the endoscopy room. Trial Registration: The main study (REM-IICT JP1) is registered with the Japan Registry of Clinical Trails: jRCT2031200360.

Collaborative nursing education between advanced practice registered nurses

The surge in healthcare demands requires academic institutions to address and enhance the expanded education needs of Advanced Practice Registered Nurses (APRNs). Increasing cohort size while effectively and efficiently teaching students the newest best practice is particularly challenging amidst nurse faculty shortages in specialty areas. Faculty voids stem from factors such as lack of pay competitiveness with clinical positions, and a shortage of doctoral-prepared nurses seeking faculty positions. Despite efforts to recruit and retain nursing faculty, the shortage persists and necessitates innovative approaches to teaching and best utilizing the strengths of existing faculty. This article explores the collaborative teaching between Nurse Anesthesia (NA) and Adult Gerontology Nurse Practitioner (NP) programs. Teaching areas focus on airway management, sedation techniques, chest X-ray interpretation, and ultrasound skills. Students receiving synchronous or online asynchronous teaching received overwhelmingly positive feedback from faculty not in their learning specialty. Ongoing communication and collaborations between NA and NP faculty facilitate teaching and educational strategies across programs, sharing faculty expertise, and mitigating reduced faculty numbers. This innovative model benefits faculty and students and provides a platform for firsthand collaboration among advanced practice specialties that rarely interact. These interactions foster mutual respect and prepare students for effective interdisciplinary healthcare teamwork.

An unusual surgical complication: Slipped molar lodged in vocal cords and its anesthetic management

Background

Extraction of wisdom tooth is one of the most common surgical interventions, as it is more prone for impaction. Due to the pain and anxiety associated with the procedure, it is common to do this procedure under conscious sedation. However unexpected events do occur during the procedure and one such complication along with the prompt management is discussed here.

Case report

This case report details an unusual occurrence of a third molar tooth slipping during dental extraction and becoming lodged at the base of the vocal cords. The patient, a 52-year-old man with a history of hypertension, underwent the procedure under conscious sedation. The case report highlights the importance of preparedness and multidisciplinary coordination in managing rare complications during dental procedures under conscious sedation. The accidental aspiration of a molar tooth into the airway required prompt and effective intervention, using dexmedetomidine for sedation, fibre-optic bronchoscopy for visualization, and a range of retrieval instruments. Using video-assisted laryngoscopy and fibre-optic laryngoscopy proved indispensable in locating and safely retrieving the foreign body without resorting to more invasive procedures.

Conclusion

This case highlights the importance of anaesthesiologist's role in emergency management and comprehensive preparedness in dental practice.

Procedural sedation in the emergency department by Italian emergency physicians: results of the SEED SIMEU registry

BACKGROUND AND IMPORTANCE

Effective and safe procedural sedation is pivotal for the quality of care in the emergency department (ED).

OBJECTIVES

The aim of this work is to evaluate the feasibility, effectiveness, and safety procedural sedation performed by emergency physicians in the ED setting in Italy.

DESIGN/SETTING AND PARTICIPANTS/INTERVENTION

Following a specific training of the staff and with the adoption of a standardized protocol, a registry of procedural sedations performed on adult patients in 10 Italian EDs was compiled from 2019 to 2022; the following basic data were recorded: demographic and clinical information, procedure's indication, administered drugs, predefined, and actual sedation level.

OUTCOME MEASURES AND ANALYSIS

Effectiveness was evaluated considering three parameters: successful completion of the procedure, absence of procedural pain, and no memory of the procedure; adverse events were classified according to the World Society of Intravenous Anaesthesia criteria and evaluated taking into account clinical and procedural variables.

MAIN RESULTS

The study included 1349 patients (median age 68 years, male 64%). Sedation was performed for electrical cardioversion (66.3%), orthopedic procedures (23.2%), or other procedures (10.5%). Propofol (67%) and midazolam (24.2%) were the two most frequently used sedatives and 70.6% of the patients achieved a deep level of sedation.Procedural failure occurred in 4.6% of cases, with no significant differences between procedure types or drugs used. Recall of the procedure and procedural related pain were reported by 2.9% and 2.6% of patients, respectively, and were more frequently related to orthopedic procedures, midazolam use - if compared with propofol, and lower levels of sedation.A total of 135 adverse events were observed, with an overall incidence of 10%: 38 minimal adverse events (2.8%), 38 minor adverse events (2.8%), and 59 moderate adverse events (4.4%). There were no adverse events requiring unplanned hospital admission or escalation of care, and no sentinel adverse events were observed. All adverse events were resolved with simple and noninvasive treatments. The incidence of adverse events was greater with higher American Society of Anesthesiologists class, intermediate/difficult airway, and deeper sedation levels.

CONCLUSION

Procedural sedation performed in Italian EDs by emergency physicians, with propofol as main sedative, was effective and safe, and has comparable adverse event rates with previous international studies.

Intraoperative virtual reality for older patients undergoing total knee arthroplasty: study protocol for a randomized clinical trial

BACKGROUND

In an aging surgical patient population, preventing complications such as oversedation has taken increasing priority in perioperative care. Intraoperative use of virtual reality (VR) may decrease sedative requirements. We hypothesize that the use of immersive VR during total knee arthroplasty (TKA) will lead to decreased propofol requirements, improved patient-reported satisfaction, and reduced postoperative opioid requirements compared to active and usual care controls.

METHODS

This is a single-center, randomized clinical trial of older (age > 60) patients undergoing TKA. Participants will be randomized into three groups (2:2:1): VR immersion, music, and sham VR plus usual care. All patients will receive a regional block and spinal anesthesia. Patients in the immersive VR and music groups will use patient-controlled sedation (PCS) with propofol, while those in the sham VR group will act as the standard of care control group and will receive monitored anesthesia care (MAC) with propofol infusion.

STATISTICAL ANALYSIS

Analyses will be conducted using IBM SPSS Statistics Version 25, considering a two-sided p-value < 0.05 to be statistically significant. The primary outcome is the intraoperative dose of propofol (mg kg-1 min-1). Secondary outcomes include patient satisfaction, post-anesthesia care unit (PACU) length of stay, postoperative pain scores and analgesic requirements, functional outcomes, postoperative delirium, and postoperative neurocognition.

DISCUSSION

VR used as a non-pharmacological adjunct to regional and spinal anesthesia during TKA may reduce sedative requirements while maintaining patient satisfaction. If true, this approach to minimizing sedation may impact clinical outcomes including perioperative complications and length of stay for older patients, while maintaining a high degree of patient satisfaction.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov on January 29, 2021. The registration number is NCT04748549.

Dental sedation permit requirements for physician anesthesiologists in the United States and the European Union: a review

PURPOSE OF REVIEW

This review addresses the dental sedation permit requirements for physician anesthesiologists in the United States and the European Union (EU). The regulatory landscape for office-based anesthesia, including dental settings, is often described as the 'Wild West' of patient safety, making it crucial to outline the similarities and differences in dental anesthesia regulations and offer practical guidelines for regulators.

RECENT FINDINGS

There is virtually no literature that addresses the issue of dental sedation permits for physicians. By summarizing the variation in language and terminology from state to state, this review highlights the inconsistencies and gaps in dental regulations. The review also highlights the limited specific guidance on the permit process for physicians administering dental anesthesia.

SUMMARY

By comparing dental anesthesia regulations and guidelines across all U.S. states and the EU, the review aims to offer practical guidelines for regulators to institute an oversight process that is fair to physician anesthesiologists and does not impede their ability to practice in the dental office setting. This framework for credentialing and permitting physicians in dental office-based anesthesia settings is informed by existing safety recommendations and best practices.

Outpatient Hysteroscopy: (Green-top Guideline no. 59)

All gynaecology departments should provide a dedicated outpatient hysteroscopy service to aid care of women and people with abnormal uterine bleeding, reproductive problems, and insertion/retrieval of intrauterine devices. [Grade A] Written information should be provided to the woman prior to their appointment. This should include details about the procedure, the benefits and risks, advice regarding pre-operative analgesia, as well as alternative options for care and contact details for the hysteroscopy unit. [Good Practice Point] Women should be made aware of other settings and modes of anaesthesia for hysteroscopy (e.g. under general or regional anaesthesia or intravenous sedation). [GPP] The woman should be advised that if they find the procedure too painful or distressing at any point, they must alert the clinical team who will stop the procedure immediately. The clinical team should alert the hysteroscopist if the woman appears to be in too much pain or is experiencing a vasovagal episode and therefore unable to voice the concerns so that the procedure can be stopped. [GPP] Women should be advised to take standard doses of oral non-steroidal anti-inflammatory agents (NSAIDs) one hour before their scheduled appointment. Vaginoscopy should be the standard technique for outpatient hysteroscopy unless the use of a vaginal speculum is required (e.g. for administering local cervical anaesthesia or dilating the cervix). [Grade A] When performing operative hysteroscopy, the smallest diameter hysteroscope should be used, with consideration given to the use of hysteroscopes with expandable outer working channels because they are associated with less pain. [Grade B] Mechanical hysteroscopic tissue removal systems should be preferred over miniature bipolar electrodes to remove endometrial polyps. [Grade A] Local anaesthesia should not be routinely administered prior to outpatient hysteroscopy where a vaginoscopic approach is used. It should be considered where use of a vaginal speculum is planned e.g. for cervical dilatation if anticipated, due to either cervical stenosis and/or the utilisation of larger-diameter hysteroscopes (≥5mm outer diameter). [Grade A] Saline should be instilled at the lowest possible pressure to achieve a satisfactory view. [Grade A] Conscious sedation should not be routinely used in outpatient hysteroscopic procedures. [Grade B].

EEG bispectral index sensor guidance improves accuracy and safety of procedural sedation

PURPOSE

To re-audit compliance with an amended sedation protocol following the latest national guidelines. To confirm the improved safety achieved through EEG guidance for drug administration during procedural sedation.

MATERIALS AND METHODS

Following the revision of the departmental protocol, 14 standards were set. Sedation data and outcomes in 150 consecutive patients undergoing fluoroscopic and combined endoscopic procedures were evaluated against these. Combination sedo-analgesia was titrated by the interventional radiology nurses guided by bispectral index sensor (BIS) measurements to achieve readings between 80 and 85. Doses were stratified by patient age and ASA status. Nasal oxygen was given and standard monitoring including pulse oximetry and capnography were used alongside to assess for complications, notably hypoxaemia of ≤ 94%.

RESULTS

85% were non-vascular procedures, the bulk made up of oesophageal stent insertion, gastrostomy, oesophageal dilatation of radiation strictures and biliary procedures. Mean procedure time was 32.9 minutes (10-170). Mean doses of midazolam and fentanyl were 3.99mg (±1.9) and 92.3μg (±35.4), respectively. 84% of patients were classified as having received light or moderate sedation (BIS 70-89). Three standards for patient sedation were missed, but no patient required sedation reversal or airway management, and none developed hypoxaemia.

CONCLUSIONS

BIS guidance of sedation administration allows real-time assessment of the patient's response to sedo-analgesia administered and allows prediction about the safety of further drug administration. It identifies patients waking up, allowing this to be anticipated and reduces interruptions of the procedure. It offers clear clinical advantages to interval assessment of patients' response to clinical stimuli and reduces under-as well as oversedation.

Image-guided renal parenchymal biopsies- how we do it

This paper is a multi-institutional review of image-guided renal parenchymal biopsies. Among the topics covered are indications, preprocedural considerations, biopsy technique, complications, and postprocedural management. Both native kidney and transplant kidney biopsies are considered in this review.

Safety of propofol sedation administered by interventional radiologists for radiofrequency ablation in patients with hepatocellular carcinoma

PURPOSE

To evaluate the safety of propofol sedation administered by interventional radiologists during radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Propofol sedation was administered by interventional radiologists in 72 patients (85 procedures, 93 tumors) during RFA for HCC between August 2018 and December 2020. Interventional radiologists equipped with adequate knowledge and skills in sedation and respiratory management were responsible for sedation. Sedation was carefully assessed based on vital signs, including end-tidal carbon dioxide, consciousness status, and bispectral index. The primary endpoint was the incidence of sedation-related complications, which were evaluated separately as respiratory and cardiovascular complications. Secondary endpoints were technical success rate, ablation-related complications, and local tumor control rate. Technical success was defined as completion of ablation in the planned area. Complications were evaluated using the Clavien-Dindo classification. Sedation-related complications, technical success rate, and ablation-related complications were evaluated on a procedure basis, and local tumor control was evaluated on a tumor basis.

RESULTS

Respiratory and cardiovascular complications were observed in eight (8/85, 9.4%) and two (2/85, 2.4%) patients, respectively. Four patients required the jaw thrust maneuver due to glossoptosis, whereas a decrease in oxygen saturation to < 90% was recorded in the other four patients. However, these were temporary, and none required manual ventilation or endotracheal intubation. Bradycardia (< 50 bpm) was detected in two patients; one recovered immediately without treatment, whereas the other rapidly improved after atropine sulfate administration. No severe hypotension (< 80 mmHg) was observed. The technical success rate was 100% (85/85). Grade 3 ablation-related complications were identified in three patients (3/85, 3.5%). The local tumor control rate was 95.7% (89/93).

CONCLUSION

Propofol sedation can be safely administered by interventional radiologists during RFA for HCC. Although it requires special safety considerations, it may be a sedation option during hepatic RFA.

Bispectral index monitoring for sedation in scheduled adult colonoscopy: A randomized controlled trial

BACKGROUND

Patients should be closely monitored during procedures under sedation outside the operating room, but it is unclear which type of monitoring is best. We investigated the efficacy and safety of BIS monitoring vs conventional monitoring for sedation during colonoscopy.

METHODS

We performed a double-blind clinical trial in 180 patients undergoing elective colonoscopy. Patients were randomized to 1) the BIS group or 2) a control group, in which sedation was monitored with a BIS monitor or the Ramsay Sedation Score, respectively. The primary outcome was the rate of sedation-induced adverse events in both groups. Secondary outcomes were the characteristics of patients who developed adverse events, and time during colonoscopy when these events occurred, propofol and remifentanil dosage, and patient satisfaction.

RESULTS

Univariate analysis showed fewer cardiopulmonary complications in the BIS group (41.11% vs 57.78% in controls; p = 0.02). Multivariate analysis found a significantly higher risk of adverse events in older patients (95% CI, 1.013-1.091; p = 0.0087) and in men (95% CI, 1.129-7.668; p = 0.0272). These events were observed at the hepatic flexure. No significant differences between propofol or remifentanil dosage, use of rescue medication, and patient satisfaction were observed between groups.

CONCLUSIONS

Our data suggest that BIS monitoring during sedation in scheduled colonoscopies reduces adverse respiratory events. Although its routine use in sedation does not appear to be warranted, clinicians should take steps to identify patients with a higher risk of complications who might benefit from this type of monitoring.

Development and characterization of novel fast-dissolving pentobarbital suppositories for pediatric procedural sedation and comparison with lipophilic formulations

For pediatric radiological procedures (RP), pentobarbital sodium (PNa) can be used orally or rectally to replace intravenous anesthesia. Since no commercial PNa suppositories exist, they must be prepared by compounding pharmacies. This study aims to develop fast-dissolving PNa suppositories for fast pharmacological activity during RP. We prepared gelatin (G), gelatin/polyethylene glycol 4000 (GP), and polyethylene glycol 4000 (P) suppositories, with and without pH adjustment, and assessed their dosage uniformity (DU), softening time, rupture resistance, and in-vitro dissolution. An optimal formulation was selected, and PNa release was compared to that of fat-based suppositories using dissolution tests. Additionally, the quality control process (analytical performance, safety/eco-friendliness and productivity/practical effectiveness) of these formulas were compared using a RGB method. All hydrophilic formulas (HF) met the DU requirement (AV < 8 %) except for P (AV 15.62 ± 4 %). pH adjustment enhanced G and GP suppositories resistance to 2.2 ± 0.2 kg and 2.0 ± 0.3 kg, respectively, and allowed 100 % release of PNa in under 10 min. In contrast, lipophilic formulas released less than 80 % of PNa at best after 120 min. These results show the biopharmaceutical suitability of HF for RP compared to lipophilic ones, but a pharmacokinetic study is needed to confirm data.

Anesthetic Techniques for Ablation in Atrial Fibrillation: A Comparative Review

Atrial fibrillation, the most prevalent cardiac arrhythmia, has witnessed significant advancements in treatment modalities, transitioning from invasive procedures like the maze procedure to minimally invasive catheter ablation techniques. This review focuses on recent improvements in anesthetic approaches that enhance outcomes in catheter atrial fibrillation ablation. We highlight the efficacy of contact force sensing catheters with steerable introducer sheaths, which outperform traditional catheters by ensuring more effective contact time and lesion formation. Comparing general anesthesia with conscious sedation, we find that general anesthesia provides superior catheter stability due to reduced respiratory variability, resulting in more effective lesion formation, and reduced pulmonary vein reconnection. The use of high-frequency jet ventilation under general anesthesia, delivering low tidal volumes, effectively minimizes left atrial movement, decreasing catheter displacement and procedure time, and reducing recurrence in paroxysmal atrial fibrillation. An alternative, high-frequency low tidal volume ventilation using conventional ventilators, also shows improved catheter stability and lesion durability compared to traditional ventilation methods. However, a detailed comparative study of high-frequency jet ventilation, high-frequency low tidal volume ventilation, and conventional mechanical ventilation in catheter ablation for atrial fibrillation is lacking. This review emphasizes the need for such studies to identify optimal anesthetic techniques, potentially enhancing patient outcomes in atrial fibrillation treatment. Our findings suggest that careful selection of anesthetic methods, including ventilation strategies, plays a crucial role in the success of catheter ablation for atrial fibrillation, warranting further research for evidence-based practice.

Current sedation practices for non-invasive procedures in tertiary maternity and children's hospitals in China: a 5-year update

BACKGROUND

Sedation techniques can ease anxiety during medical procedures for children. Our previous report on Chinese sedation practices for non-invasive procedures in 2018 is outdated due to the rapid development of sedation services. This study provides an updated report on sedation practices for non-invasive procedures in China.

METHODS

This is a cross-sectional study. Questionnaires were sent to tertiary maternity and children's hospitals nationwide through the WeChat Mini Program. The survey questioned the location and caseloads of hospitals providing sedation services, support facilities, contraindications, fasting practices, sedation regimens, monitoring practices, staff structure, certification requirements for sedation providers and quality control data.

RESULTS

Procedural sedation for non-invasive procedures were provided in 88 of 114 hospitals. These hospitals are located across the country except Heilongjiang province and the Tibet Autonomous Region. Compared with previous reports, significant increases were found in the number of hospitals providing sedation services, dedicated sedation rooms and recovery rooms and full-time sedation providers. Most hospitals advocated the 2-4-6 rule for pre-sedation fasting. Dexmedetomidine was the most used first-choice sedative. Anaesthesiologists remain the primary sedation providers, but nurses are also important. The most mentioned qualification requirements for sedation providers were a professional title of attending doctor, ≥5 years of working experience in paediatric anaesthesia and paediatric advanced life support certification. Sedation service records were used in 83 hospitals, but only 42 and 39 recorded success rates and adverse events, respectively.

CONCLUSIONS

Sedation services for non-invasive procedures are available in most areas of China. More hospitals now provide sedation services and full-time sedation providers. Supporting facilities and sedation regimens have improved. Non-anaesthesiologist sedation providers are important at current stage, developing training programmes for them may be necessary. Attention should be focused on quality control and improvement of sedation services.

Can ketamine administration prevent intubation in patients who cannot comply with NIV due to agitation?

BACKGROUND

In patients presenting to the emergency department (ED) with acute respiratory failure, non-invasive mechanical ventilation (NIMV) is applied when conventional oxygen support is not sufficient. Patients who are agitated often have very low NIMV compliance and a transition to invasive mechanical ventilation (IMV) is often required. To avoid IMV, a suitable sedative agent can be utilized. The aim of this research is to investigate the relationship between ketamine administration to patients who are non-compliant with NIMV due to agitation and the outcome of their intubation.

METHODS

This retrospective study included patients with acute respiratory failure who were admitted to the ED from 2021 to 2022 and used Richmond Agitation Sedation Scale (RASS) to identify agitation level of patients. The relationship between ketamine administration in this patient group and NIMV compliance and intubation rate was evaluated.

RESULTS

A total of 81 patients, including 35 (43.2%) men and 46 (56.8%) women, were included in the study. Of these patients, 46 (56.8%) were intubated despite ketamine administration, while 35 (43.2%) were compliant with NIMV and were not intubated. When evaluating the RASS, which shows the agitation levels of the patients, the non-intubated group was found to be 2.17 ± 0.68, while the intubated group was 2.66 ± 0.73, and it was statistically significant that the NIMV intubated group was higher (p = 0.003).

CONCLUSION

This study showed that agitation can impair NIMV compliance in patients with acute respiratory failure. However, a significant proportion of this patient group can be avoided through IMV with proper sedative agents.

Efficacy of virtual reality therapy versus pharmacological sedation for reducing pain and anxiety during coronary catheterisation procedures: A prospective randomised controlled trial

Background and Aims

The use of virtual reality (VR) therapy has grown considerably, as it is effective for reducing pain and anxiety in different clinical areas. However, it has not been well evaluated for coronary angiography and angioplasty. This study aimed to compare VR therapy with pharmacological sedation (Sedation) for reducing pain in patients undergoing a planned coronary angiography or coronary/peripheral angioplasty.

Methods

In this prospective randomized controlled trial, patients were randomly allocated to one of two groups before catheterization: a Sedation group (injection of midazolam and fentanyl) or a VR group (Deepsen VR headset). The primary outcome measure was the maximum pain during the procedure (visual analogue scale: 0-10). The secondary outcome measures were anxiety following the procedure (Spielberger State Anxiety Inventory: 20-80), the occurrence of arterial spasm, the haemodynamic profile and patient satisfaction.

Results

The VR group (n = 63) had a mean pain rating of 2.5; for the Sedation group (n = 59) this was 1.0. This did not meet the criterion for non-inferiority. Anxiety was comparable between the two groups (VR: 25.4; Sedation: 24.7), as was the occurrence of arterial spasm (VR: 7.9%; Sedation: 8.5%; p = 0.91), but blood pressure was higher in the VR group (140.2/71.7 mmHg vs. 121.8/64.7 mmHg). There were no VR-related adverse effects, and patient satisfaction was high for both groups.

Conclusions

Virtual reality therapy was not non-inferior to pharmacological sedation for reducing pain during coronary angiography or angioplasty. However, it reduced anxiety to a comparable level. Virtual reality therapy represents an alternative to pharmacological sedation, which is well accepted by patients.

Bone Biopsies: Practical Considerations and Technical Tips

Percutaneous image-guided needle biopsies are a safe and minimally invasive method of obtaining tissue of bone lesions. Radiologists are an integral part of a multidisciplinary team (MDT) approach to patient care in obtaining tissue for both pathologic diagnosis and advanced genetic/molecular testing. By utilizing image guidance, radiologists can target bone lesions with a very low complication rate. This review will discuss our approach to image-guided biopsies of bone lesions. Radiologists should be familiar with patient selection and imaging workup prior to performing biopsies, as well as the importance of coordinating the biopsy approach and sampling with the patient's clinical team. Management of bleeding and thrombotic risk in patients undergoing bone biopsies is also an important preprocedural consideration and will be discussed. The majority of bone biopsies are performed utilizing moderate sedation for patient analgesia and comfort, but close attention should be paid to patient comorbidities and potential interacting medications. Although computed tomography guidance remains the mainstay of image-guided biopsy, there are some circumstances in which ultrasound or fluoroscopic guidance may be beneficial. New advances in powered drill technology have made tissue sampling of bone lesions particularly sclerotic bone lesions both safer and faster with increased tissue yield. Finally, we will discuss image-guided biopsy of difficult anatomic regions that require special techniques to yield tissue safely.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI)

BACKGROUND

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.

AIMS

To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.

METHODS

An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.

RESULTS

Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability.

CONCLUSIONS

This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

Sedation of Adults with Orally Administered Midazolam in Dentistry - A Retrospective Study

OBJECTIVE

The use of midazolam (MZ) has increased in dentistry, but the effect in adults is sparsely studied. The aim of this study was to investigate doses, effects, and side effects of orally administered MZ as a sedative for adults in a dental care organization.

MATERIAL AND METHODS

A retrospective record review was performed including all adult patients in the dental care organization ≥20 years receiving MZ, identified through a logbook for addictive drugs, during 2020. From patients' records, the following data were extracted: age, gender, medical history, reason for sedation, performed treatments, doses, effects, and side effects of MZ.  Results: In total, 265 patients on 418 occasions had been sedated, which constituted 2.3 sedations per 1,000 visits and 3.3 sedations per 1,000 treated patients. Mean age was 40.8 years and 67.7% were females. The most common reason for sedation was anxiety. Mean dose in primary dental clinics was 7.9 mg and in specialist clinics, 6.8 mg (p < 0.001). Older patients (>70 years) had lower doses than younger (p < 0.001), while no difference was found between ages 55-70 years and those who were younger. Dental treatment was completed in 91.9% of occasions, and side effects were registered in 2.2%. Successful dental treatment was related to type of treatment performed.

CONCLUSIONS

Sedation is rarely used, particularly in primary dental care, and the use varies widely between clinics. MZ administered by dentists seems to be safe and effective. A sedation record should be used to make patient data such as weight and medical conditions available.

Co-administration of midazolam and psilocybin: differential effects on subjective quality versus memory of the psychedelic experience

Aspects of the acute experience induced by the serotonergic psychedelic psilocybin predict symptomatic relief in multiple psychiatric disorders and improved well-being in healthy participants, but whether these therapeutic effects are immediate or are based on memories of the experience is unclear. To examine this, we co-administered psilocybin (25 mg) with the amnestic benzodiazepine midazolam in 8 healthy participants and assayed the subjective quality of, and memory for, the dosing-day experience. We identified a midazolam dose that allowed a conscious psychedelic experience to occur while partially impairing memory for the experience. Furthermore, midazolam dose and memory impairment tended to associate inversely with salience, insight, and well-being induced by psilocybin. These data suggest a role for memory in therapeutically relevant behavioral effects occasioned by psilocybin. Because midazolam blocks memory by blocking cortical neural plasticity, it may also be useful for evaluating the contribution of the pro-neuroplastic properties of psychedelics to their therapeutic activity.

Prehospital emergency anesthesia: A single-center retrospective analysis of guideline adherence and unexpected incidents

Although prehospital emergency anesthesia (PHEA), with a specific focus on intubation attempts, is frequently studied in prehospital emergency care, there is a gap in the knowledge on aspects related to adherence to PHEA guidelines. This study investigates adherence to the "Guidelines for Prehospital Emergency Anesthesia in Adults" with regard to the induction of PHEA, including the decision making, rapid sequence induction, preoxygenation, standard monitoring, intubation attempts, adverse events, and administration of appropriate medications and their side effects. This retrospective study examined PHEA interventions from 01/01/2020 to 12/31/2021 in the city of Aachen, Germany. The inclusion criteria were adult patients who met the indication criteria for the PHEA. Data were obtained from emergency medical protocols. A total of 127 patients were included in this study. All the patients met the PHEA indication criteria. Despite having a valid indication, 29 patients did not receive the PHEA. 98 patients were endotracheally intubated. For these patients, monitoring had conformed to the guidelines. The medications were used according to the guidelines. A significant increase in oxygen saturation was reported after anesthesia induction (p < 0.001). The patients were successfully intubated endotracheally on the third attempt. Guideline adherence was maintained in terms of execution of PHEA, rapid sequence induction, preoxygenation, monitoring, selection, and administration of relevant medications. Emergency physicians demonstrated the capacity to effectively respond to cardiorespiratory events. Further investigations are needed on the group of patients who did not receive PHEA despite meeting the criteria. The underlying causes of decision making in these cases need to be evaluated in the future.

Collaborative nursing education between advanced practice registered nurses

The surge in healthcare demands due to the explosion of growth in the aging adult population demands that academic institutions address enhanced education of Advanced Practice Registered Nurses (APRNs). This is particularly challenging amidst nurse faculty shortages in specialty areas, stemming from factors such as lack of pay competitiveness with clinical positions, and doctoral-prepared nurses seeking faculty positions. Despite efforts to address the shortages, recruitment challenges persist, necessitating innovative approaches. This article explores the interprofessional collaborative teaching between Nurse Anesthesia (NA) and Adult Gerontology Nurse Practitioner (NP) programs, focusing on airway management, sedation techniques, chest X-ray interpretation, and ultrasound skills. To date, this collaboration between NA and NP faculty has proven effective. Both synchronous and online asynchronous teaching have received overwhelmingly positive student feedback. Ongoing communication and collaborations between NA and NP faculty facilitate teaching and educational strategies across programs, sharing faculty expertise, and mitigating reduced faculty numbers. This innovative model benefits faculty and students and provides a platform for firsthand interprofessional collaboration, fostering mutual respect and preparing students for effective interdisciplinary healthcare teamwork.

Pediatric Procedural Sedation

Pediatric procedural sedation (PPS), formerly known as conscious sedation, is often used outside the operating room for various procedures. Twenty years ago, nearly all cases of PPS were performed by pediatric intensivists, dentists, emergency medicine physicians, and anesthesiologists, due to the urgent nature of procedures in their settings. However, with the emergence of pediatric hospital medicine as a board-certified subspecialty, many children's hospitals have created dedicated PPS teams. These teams, composed of highly trained physicians and ancillary staff, are well-suited for procedures, quality measures, and multidisciplinary care. The wider availability of sedation outside the operating room allows other pediatric subspecialties, such as surgery and oncology, to use PPS in ensuring safe and timely interventions for their patients. This article will cover PPS as an alternative to anesthesia for otherwise healthy children and aim to answer frequent questions that arise regarding medications, risks, and candidacy for PPS. [Pediatr Ann. 2024;53(9):e324-e329.].

Recommendations for pharmacogenetic testing in clinical practice guidelines in the US

PURPOSE

Pharmacogenetic testing can identify patients who may benefit from personalized drug treatment. However, clinical uptake of pharmacogenetic testing has been limited. Clinical practice guidelines recommend biomarker tests that the guideline authors deem to have demonstrated clinical utility, meaning that testing improves treatment outcomes. The objective of this narrative review is to describe the current status of pharmacogenetic testing recommendations within clinical practice guidelines in the US.

SUMMARY

Guidelines were reviewed for pharmacogenetic testing recommendations for 21 gene-drug pairs that have well-established drug response associations and all of which are categorized as clinically actionable by the Clinical Pharmacogenetics Implementation Consortium. The degree of consistency within and between organizations in pharmacogenetic testing recommendations was assessed. Relatively few clinical practice guidelines that provide a pharmacogenetic testing recommendation were identified. Testing recommendations for HLA-B*57:01 before initiation of abacavir and G6PD before initiation of rasburicase, both of which are included in drug labeling, were mostly consistent across guidelines. Gene-drug pairs with at least one clinical practice guideline recommending testing or stating that testing could be considered included CYP2C19-clopidogrel, CYP2D6-codeine, CYP2D6-tramadol, CYP2B6-efavirenz, TPMT-thiopurines, and NUDT15-thiopurines. Testing recommendations for the same gene-drug pair were often inconsistent between organizations and sometimes inconsistent between different guidelines from the same organization.

CONCLUSION

A standardized approach to evaluating the evidence of clinical utility for pharmacogenetic testing may increase the inclusion and consistency of pharmacogenetic testing recommendations in clinical practice guidelines, which could benefit patients and society by increasing clinical use of pharmacogenetic testing.

Addressing weight bias in reproductive medicine: a call to revisit body mass index restrictions for in vitro fertilization treatment

The prevalence of obesity has doubled among reproductive-age adults in the US over the past 40 years and is projected to impact half of the population by 2030. Obesity is associated with a twofold to threefold increase in infertility, largely because of anovulation, and is associated with a lower rate of pregnancy with ovulation induction among anovulatory women. As a result of these trends and associations, in vitro fertilization (IVF) care will need to be adapted to provide safe, effective, and equitable access for patients with obesity. Research over the past 10 years has demonstrated safe sedation practices and effective procedure modifications for oocyte retrievals and embryo transfers in patients with obesity undergoing IVF treatment. We encourage IVF medical directors to revisit body mass index restrictions for IVF treatment in favor of individualized patient risk assessments to minimize weight bias and provide timely access to safe and effective IVF care for patients with obesity and infertility.

Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance

The imbalance in anesthesia workforce supply and demand has been exacerbated post-COVID due to a surge in demand for anesthesia care, especially in non-operating room anesthetizing sites, at a faster rate than the increase in anesthesia clinicians. The consequences of this imbalance or labor shortage compromise healthcare facilities, adversely affect the cost of care, worsen anesthesia workforce burnout, disrupt procedural and surgical schedules, and threaten academic missions and the ability to educate future anesthesiologists. In developing possible solutions, one must examine emerging trends that are affecting the anesthesia workforce, new technologies that will transform anesthesia care and the workforce, and financial considerations, including governmental payment policies. Possible practice solutions to this imbalance will require both short- and long-term multifactorial approaches that include increasing training positions and retention policies, improving capacity through innovations, leveraging technology, and addressing financial constraints.

Emerging Technologies

In this article, an array of new developments in burn care, from diagnosis to post-burn reconstruction and re-integration, will be discussed. Multidisciplinary advances have allowed the implementation of technologies that provide more accurate assessments of burn depth, improved outcomes when treating full-thickness burns, and enhanced scar tissue management. Incorporating these new treatment modalities into current practice is essential to improving the standard of burn care and developing the next generation of burn wound management methodologies.

Continuous Capnography for Early Detection of Respiratory Compromise During Gastroenterological Procedural Sedation and Analgesia

Gastroenterology nurses working across a variety of clinical settings are responsible for periprocedural monitoring during moderate to deep procedural sedation and analgesia (PSA) to identify signs of respiratory compromise and intervene to prevent cardiorespiratory events. Pulse oximetry is the standard of care for respiratory monitoring, but it may delay or fail to detect abnormal ventilation during PSA. Continuous capnography, which measures end-tidal CO2 as a marker of alveolar ventilation, has been endorsed by a number of clinical guidelines. Large clinical trials have demonstrated that the addition of continuous capnography to pulse oximetry during PSA for various gastroenterological procedures reduces the incidence of hypoxemia, severe hypoxemia, and apnea. Studies have shown that the cost of adding continuous capnography is offset by the reduction in adverse events and hospital length of stay. In the postanesthesia care unit, continuous capnography is being evaluated for monitoring opioid-induced respiratory depression and to guide artificial airway removal. Studies are also examining the utility of continuous capnography to predict the risk of opioid-induced respiratory depression among patients receiving opioids for primary analgesia. Continuous capnography monitoring has become an essential tool to detect early signs of respiratory compromise in patients receiving PSA during gastroenterological procedures. When combined with pulse oximetry, it can help reduce cardiorespiratory adverse events, improve patient outcomes and safety, and reduce health care costs.

Thoracic impedance pneumography in propofol-sedated patients undergoing percutaneous endoscopic gastrostomy (PEG) placement in gastrointestinal endoscopy: A prospective, randomized trial

STUDY OBJECTIVE

To assess the efficacy of an ECG-based method called thoracic impedance pneumography to reduce hypoxic events in endoscopy.

DESIGN

This was a single center, 1:1 randomized controlled trial.

SETTING

The trial was conducted during the placement of percutaneous endoscopic gastrostomy (PEG).

PATIENTS

173 patients who underwent PEG placement were enrolled in the present trial. Indication was oncological in most patients (89%). 58% of patients were ASA class II and 42% of patients ASA class III.

INTERVENTIONS

Patients were randomized in the standard monitoring group (SM) with pulse oximetry and automatic blood pressure measurement or in the intervention group with additional thoracic impedance pneumography (TIM). Sedation was performed with propofol by gastroenterologists or trained nurses.

MEASUREMENTS

Hypoxic episodes defined as SpO2 < 90% for >15 s were the primary endpoint. Secondary endpoints were minimal SpO2, apnea >10s/>30s and incurred costs.

MAIN RESULTS

Additional use of thoracic impedance pneumography reduced hypoxic episodes (TIM: 31% vs SM: 49%; p = 0.016; OR 0.47; NNT 5.6) and elevated minimal SpO2 per procedure (TIM: 90.0% ± 8.9; SM: 84.0% ± 17.6; p = 0.007) significantly. Apnea events >10s and > 30s were significantly more often detected in TIM (43%; 7%) compared to SM (1%; 0%; p < 0.001; p = 0.014) resulting in a time advantage of 17 s before the occurrence of hypoxic events. As a result, adjustments of oxygen flow were significantly more often necessary in SM than in TIM (p = 0.034) and assisted ventilation was less often needed in TIM (2%) compared with SM (9%; p = 0.053). Calculated costs for the additional use of thoracic impedance pneumography were 0.13$ (0.12 €/0.11 £) per procedure.

CONCLUSIONS

Additional thoracic impedance pneumography reduced the quantity and extent of hypoxic events with less need of assisted ventilation. Supplemental costs per procedure were negligible.

KEY WORDS

thoracic impedance pneumography, capnography, sedation, monitoring, gastrointestinal endoscopy, percutaneous endoscopic gastrostomy.

Perspectives and Practice in Eastern and Western Medicine for Pain Management in Rehabilitation Training after Orthopedic Trauma Surgery: A Qualitative Study

BACKGROUND

Despite the increasing emphasis on rehabilitation training after orthopedic surgery, little is known about the pain caused by the procedure itself. Clinical practice is driven by beliefs in pain management.

AIMS

This study aimed to explore the perspective of pain management during rehabilitation training after orthopedic trauma in China and its influencing factors from different perspectives in traditional Chinese medicine and Western medicine, respectively.

DESIGN

A phenomenological qualitative study involving semi-structured interviews.

SETTINGS

  METHODS: A qualitative study was conducted with 16 medical workers working in the Rehabilitation Medicine Department in eastern China from July 2022-February 2023. A directed method to thematic analysis was used to code the transcribed data and identify themes.

RESULTS

Four main themes emerged. (1) Inconsistent perspectives and practice: Chinese doctors majoring in Western medicine felt sympathy, helpless, and had a lack of knowledge and misconception about pain. Traditional Chinese medicine deemed that pain is a protective mechanism and attached importance to holism and unique means. (2) Consistent outcome: Insufficient pain management will have a series of negative consequences for patients' recovery, forming a vicious cycle. (3) Expectations: Though they are not optimistic about traditional analgesics, enhancement, cooperation and ideal analgesic methods still be expressed, and (4) Concept transformation: Conducting nitrous oxide is a process not only to promote analgesic technology but also to promote the awareness and concept of pain management.

CONCLUSIONS

Our study emphasized that medical workers should be aware of the importance of pain management at the same time while treating the disability. The study provides insight into pain management experiences within different educational backgrounds. The findings enable professionals to recognize the importance of pain management and its influencing factors to provide feasible and effective pain management strategies.