Validation of the Ramsay scale for invasive procedures under deep sedation in pediatrics

Cross-cultural adaptation of the State Behavioral Scale to Brazilian Portuguese

OBJECTIVE

To perform a cross-cultural adaptation of the State Behavioral Scale to Brazilian Portuguese, assess its psychometric quality and use the scale to evaluate the level of sedation of patients on mechanical ventilation in the pediatric intensive care unit of a tertiary care hospital.

METHODS

After receiving authorization by the main author, the State Behavioral Scale was adapted according to the following steps: translation of the original version into Portuguese; synthesis of the Portuguese versions; evaluation by a committee of judges; reverse translation by native speakers of the source language; synthesis of retroversions; pretest; and evaluation of psychometric quality.

RESULTS

The adapted scale was administered to 20 patients by four evaluators, who performed daily evaluations in pairs simultaneously and independently. The intraclass correlation coefficient was 0.939 (p < 0.001) for the State Behavioral Scale and 0.976 (p < 0.001) for the COMFORT-B scale. The two scales were strongly correlated, with Spearman coefficients ranging from 0.884 to 0.908 (p < 0.001). In the study sample, most children (n = 43 observations; 48.9%) had scores of -1 (responsive to light touch or voice) or 0 (awake and able to calm down), which corresponded to light sedation.

CONCLUSION

The translated and adapted version of the State Behavioral Scale showed high interrater agreement and high correlation with the COMFORT-B scale. The application of the scale showed an adequate level of sedation in most patients.

Study on the sedative effect and safety of oral midazolam combined with dexmedetomidine nasal drops in children during magnetic resonance imaging examination

Background

Magnetic resonance imaging (MRI) is a crucial non-invasive diagnostic tool for pediatric diseases, requiring patients to remain still, often with the use of sedatives. Midazolam and dexmedetomidine are commonly used for sedation in children, but their combined effect needs further study. This study aims to evaluate the safety and effectiveness of combining intranasal dexmedetomidine (ID) with oral midazolam (OM) in children undergoing MRI, and assess its clinical feasibility.

Methods

A prospective, randomized controlled trial was conducted with 196 pediatric patients undergoing MRI from January 2022 to December 2023. Patients were randomly assigned to a control group (OM alone) or an observation group (OM + ID), with 98 cases each. Total sedation time, wake-up time, onset time, and adverse reactions were evaluated. Sedation effectiveness was assessed using the Ramsay Sedation Score.

Results

The observation group had significantly longer total sedation time (P = 0.039) and higher one-time sedation success rate (P = 0.038) compared to the control group. The Ramsay score indicated better sedation effects in the observation group (P < 0.05). Adverse events were similar between groups and resolved with rest.

Conclusion

Combining ID with OM provides effective sedation for pediatric MRI, with an acceptable safety profile, supporting its use in clinical practice.

The Impact of Listening to Quran Recitation during Pain-Inducing Procedure among Patients Receiving Mechanical Ventilation Support: An Interventional Study

Background

Pain experienced by intubated patients is caused by several extrinsic sources, including nursing care procedures such as endotracheal suctioning. Several nonpharmacological therapies, including listening to Quran recitation, have never been tested for their pain relief effects among intubated patients, despite these therapies being cost-effective, easy to implement, and free of adverse effects. This study aimed to examine the pain-relieving effect of listening to Quran recitation during pain-inducing procedures in patients receiving mechanical ventilation support.

Materials and Methods

This pilot study used an experimental design with 32 intubated patients at King Abdullah University Hospital in Irbid, Jordan. The Behavioral Pain Scale and Ramsay Sedation Scale were used to assess pain levels and sedation, and physiologic parameters were monitored before and during endotracheal suctioning.

Results

The findings showed significant differences in Behavioral Pain Scale (BPS) scores and heart rate measures between the intervention and control groups after controlling for the level of sedation. The patients in the intervention group scored lower pain and HR measures than those in the control group (F5,26 = 11.47, p < 0.001).

Conclusions

The findings showed significant improvement in the levels of pain and heart rate measures among intubated patients who are exposed to Quran recitation. Complementary medicine is essential to the healthcare plans of critically ill patients and their families. Holy Quran recitation has been reported to be a useful nonpharmacological intervention for critically ill Muslim patients.

Effective and safe pediatric sedation

Pediatric sedation is a crucial tool for minimizing pain and anxiety during procedures and examinations in children. However, it is not without risks. This review provides a comprehensive review of pediatric sedation, including both established practices and recent advancements. A thorough pre-procedural evaluation is crucial to mitigate these risks. Skilled healthcare professionals trained in pediatric sedation are paramount to ensure a safe and effective procedure. The choice of sedative medication depends on various factors, such as the type of procedure and the patient's medical condition. Medications, used alone or in combination, offer sedation with varying onset times and durations. Non-pharmacological approaches can complement pharmacological sedation and further reduce potential complications. Preventing sedation-related complications requires a multidisciplinary approach. This includes collaborative decision-making, vigilant monitoring throughout the procedure, and a focus on patient safety. Recovery involves ensuring the child returns to their baseline status before discharge, following established criteria. In conclusion, successful pediatric sedation hinges on a comprehensive strategy. This strategy encompasses a thorough evaluation, skilled personnel, appropriate medication selection, vigilant monitoring, and a focus on patient safety throughout the process. By following these steps, we can minimize risks and achieve successful outcomes.

A Randomised Clinical Trial to Compare the Efficacy and Safety of Dexmedetomidine-Ropivacaine Versus Fentanyl-Ropivacaine for Epidural Labour Analgesia

Background An epidural block is a superior potent approach to labour analgesia, and ropivacaine combined with fentanyl has been successfully practised for it. Dexmedetomidine, as a novel form of labour analgesia, must be researched further. Our study results give insight into the epidural block and come up with a pioneering approach for labour analgesia. Methodology A total of 68 parturients were assigned to two equal groups and received either dexmedetomidine with ropivacaine (Group RD) or fentanyl with ropivacaine (Group RF). Parturients received a loading dose and maintenance was given using a patient-controlled analgesia (PCA) pump. Analgesia onset time, labour duration, rescue dose requirement, and Visual Analogue Scale (VAS) pain scores were noted. Appearance, Pulse, Grimace, Activity and Respiration (APGAR) scores of newborns, Ramsay Sedation Scale (RSS) scores of mothers, and maternal side effects were observed. Results Group RD showed a shorter onset time of analgesia (group RD: 12.50 ± 1.31 minutes vs. group RF: 15.26 ± 1.46 min), less local anaesthetics requirement (group RD: 47.54 ±5.37 ml vs. group RF: 59.05 ± 6.62 ml), less number of bolus doses (group RD: 0.15 ± 0.36 vs. group RF: 1.21 ± 0.95), and shorter duration from the epidural administration to the delivery (group RD: 312.97 ± 42.40 minutes vs. group RF: 345.94 ±14.67 minutes) than group RF. VAS values of the RD group were significantly less than the RF group. The RSS scores were comparably low in both groups, and excessive sedation was not seen in any group. Newborn APGAR values were comparably on the higher side in the two groups. Adverse effects were observed in the two groups, like hypotension, nausea/vomiting, bradycardia, shivering, and pruritus, which were insignificant. Conclusion The RD group showed an improved analgesic effect with a quicker onset of action, reduced requirement of local anaesthetics, and lower VAS scores compared to the RF group. With ropivacaine, dexmedetomidine shows more efficacy than fentanyl during epidural block and is a safe alternative for labour pain management.

Clinical Evaluation of Oral Midazolam Containing Cyclodextrin in Pediatric Magnetic Resonance: A Retrospective Cohort Study

BACKGROUND

Reducing a child's level of anxiety before magnetic resonance imaging (MRI) procedures allows for better behavioral outcomes. The aim of this retrospective study was to evaluate anxiolytic efficacy of Midazolam/γ-cyclodextrin oral formulation.

METHODS

We retrospectively reviewed 100 medical charts of children who, between 1 February and 31 July 2022, underwent MRI under general anesthesia with or without premedication with midazolam/γ-cyclodextrin. Primary outcome was comparison of behavior to facemask positioning, while secondary endpoints were degree of drugs acceptance, anxiolytic effect evaluation, child's behavior on separation, and sevoflurane need.

RESULTS

Facemask positioning was accepted by 58% of the midazolam/γ-cyclodextrin group compared to 22% of children in the control group. The rate of acceptance was >90%. At the moment of separation from parent, none of the premedicated children needed to be restrained compared to 18% in the control group. A lower percentage of sevoflurane was needed for eye-closure at induction of anesthesia and for anesthesia maintenance. At emergence from anesthesia, 46% of children in the premedicated group compared to 66% of children in the control group showed transient agitation.

CONCLUSIONS

Midazolam/γ-cyclodextrin showed a good profile of acceptance, satisfactory anxiolytic properties, and reduced need for anesthetics when administered to children before MRI under general anesthesia.

Correlation of Comfort Score and Narcotrend Index during Procedural Sedation with Midazolam and Propofol in Children

Background/Objectives: Precise assessment of hypnotic depth in children during procedural sedation with preserved spontaneous breathing is challenging. The Narcotrendindex (NI) offers uninterrupted information by continuous electrocortical monitoring without the need to apply a stimulus with the risk of assessment-induced arousal. This study aimed to explore the correlation between NI and the Comfort Scale (CS) during procedural sedation with midazolam and propofol and to identify an NI target range for deep sedation. Methods: A prospective observational study was conducted on 176 children (6 months to 17.9 years) undergoing procedural sedation with midazolam premedication and continuous propofol infusion. Statistical analyses included Pearson correlation of NI and CS values, logistic regression, and receiver operating curves. Results: Median NI values varied with CS and age. The correlation coefficient between CS and NI was 0.50 and slightly higher in procedure-specific subgroup analyses. The optimal NI cut-off for deep sedation was between 50 and 60 depending on the analyzed subgroup and displayed high positive predictive values for sufficient sedation throughout. Conclusion: Our study found a moderate correlation between NI and CS, demonstrating reliable identification of adequately sedated patients.

Effectiveness of perioperative low-dose esketamine infusion for postoperative pain management in pediatric urological surgery: a prospective clinical trial

BACKGROUND

Postoperative pain is common in pediatric urological surgery. The study assess the impact of perioperative intravenous infusion of low-dose esketamine on postoperative pain in pediatric urological surgery.

METHODS

Pediatric patients (n = 80) undergoing urological surgery were randomized into four groups. Patients in the control group were administered an analgesic pump containing only hydromorphone at a dose of 0.1 mg/kg (Hydromorphone Group 1, H1) or 0.15 mg/kg (Hydromorphone Group 2, H2). Patients in the experimental group were injected intravenously with 0.3 mg/kg of esketamine (Esketamine group 1, ES1) or equal volume of saline (Esketamine Group 2, ES2) during anesthesia induction. Esketamine 1.0 mg/kg and hydromorphone 0.1 mg/kg were added to the analgesic pump. Face, Leg, Activity, Crying, and Comfort (FLACC) scale or the Numerical Rating Scale (NRS) and adverse effects were recorded at 2, 6, 24, and 48 h postoperatively. Additionally, total and effective PCA button presses were recorded.

RESULTS

In comparison to the H1 group, the pain scores were notably reduced at all postoperative time points in both the ES1 and H2 groups. The ES2 group exhibited lower pain scores only at 24 and 48 h postoperatively. When compared to the H2 group, there were no significant differences in pain scores at various postoperative time points in the ES2 group. However, the ES1 group demonstrated significantly lower pain scores at 6, 24 and 48 h postoperatively, and these scores were also significantly lower than those observed in the ES2 group. The total and effective number of PCA button presses in the ES1, ES2 and H2 group were lower than that in the H1 group (P < 0.001). The incidence of adverse effects within 48 h after surgery was 15% in ES1, 22% in ES2, 58% in H1, and 42% in H2, respectively (P = 0.021).

CONCLUSIONS

The use of low-dose esketamine infusion in analgesia pump can effectively alleviates postoperative pain in pediatric urological patients, leading to a significant reduction in the number of analgesic pump button press. The combined approach of perioperative anesthesia induction and analgesia pump administration is recommended for optimal pain management in these patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry- ChiCTR2300073879 (24/07/2023).

The relationship between different bispectral index and the occurrence of dreams in elective surgery under general anesthesia: protocol for a randomized controlled clinical trial

INTRODUCTION

Dreaming reported after anesthesia remains a poorly understood phenomenon. At present, there is a hypothesis that dreaming occurs intraoperatively and is related to light or inadequate anesthesia; thus, in order to further verify the hypothesis, we choose elective surgery under general anesthesia to observe whether the generation of dreams is related to the dose of general anesthetics maintenance.

METHODS AND ANALYSIS

This randomized, double-blind controlled trial to observe whether the generation of dreams is related to the dose of general anesthetics maintenance in the elective surgery under general anesthesia. A total of 124 participants will be randomly allocated to a low bispectral index or high bispectral index group at a ratio of 1:1. The Hospital Anxiety and Depression Scale (HADS) is used to assess the anxiety and depression status of participants during the perioperative period. Ramsay score is used to assess patients' sedation level after surgery in the PACU. Modified Brice questionnaire and awareness classification are used to assess whether patients experienced dreaming during the surgery.

ETHICS AND DISSEMINATION

This randomized, double-blind controlled trial received prospective ethics committee approval at the Human Research Ethical Committee of Shengjing Hospital, Shenyang, Liaoning Province, China (Institutional Review Board registration number 2021PS664K), and was compliant with the Declaration of Helsinki. Written informed consent was obtained from all subjects participating in the trial.

Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial

INTRODUCTION

There are limited options for pain and distress management in children undergoing minor procedures, without the burden of an intravenous line insertion. Prior to this study, we conducted a dose-escalation study and identified 6 mg/kg as a potentially optimal initial dose of intranasal ketamine.

OBJECTIVE

To assess the efficacy and safety of intranasal ketamine at a dose of 6 mg/kg for procedural sedation to repair lacerations with sutures in children in the emergency department.

METHODS

We conducted a single-arm, open-label multicenter clinical trial for intranasal ketamine for laceration repair with sutures in children aged 1 to 12 years. A convenience sample of 30 patients received 6 mg/kg of intranasal ketamine for their procedural sedation. The primary outcome was the proportion (95% CI) of patients who achieved an effective procedural sedation.

RESULTS

We recruited 30 patients from April 2018 to December 2019 in two pediatric emergency departments in Canada. Lacerations repaired were mostly facial in 21(70%) patients and longer than 2 cm in 20 (67%) patients. Sedation was effective in 18/30 (60% [95% CI 45, 80]) children and was suboptimal in 5 (17%) patients but procedure was completed in them with minimal difficulties. Sedation was poor in the remaining 7 (23%) patients, with 3 (10%) of them required additional sedative agents. No serious adverse events were reported.

CONCLUSIONS

Using a single dose of 6 mg/kg of intranasal Ketamine for laceration repair led to successful sedation in 60% of patients according to our a priori definition. An additional 17% of patients were considered suboptimal, but their procedure was still completed with minimal difficulty.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03053947).

Comparison of Efficacy and Safety of Different Doses of Dexmedetomidine for Epidural Labor Analgesia

Objective

To explore the efficacy and safety of different doses of dexmedetomidine (DEX) for epidural labor analgesia (ELA).

Methods

From June 2021 to June 2022, 147 parturients who underwent ELA in our hospital were selected and divided into low- (0.5 μg/kg DEX), medium- (0.75 μg/kg DEX), and high-dose (1.0 μg/kg DEX) groups (n = 49 for each) according to the random number table method. The analgesic effect was assessed using the Ramsay sedation score and Visual Analogue Scale (VAS), and the labor duration, mean arterial pressure (MAP), and heart rate (HR) before and after analgesia, vaginal bleeding within 2 h postpartum, and delivery outcomes (the cesarean section conversion rate and the neonatal Apgar score) were statistically analyzed. Furthermore, the incidence of adverse reactions was calculated, and maternal satisfaction with delivery was investigated.

Results

After analgesia, the the Ramsay and labor duration were higher in the high-dose group than those in the low- and medium-dose groups, and the VAS scores was lowerin the high-dose group than those in the low- and medium-dose groups(P < 0.05), while no difference was identified among the three groups in terms of the cesarean section conversion rate and the neonatal Apgar score (P > 0.05). The high-dose group had the greatest fluctuations in MAP and HR levels before and after analgesia than the other two groups, with a higher incidence of adverse reactions (P < 0.05). Finally, the survey of delivery satisfaction showed no significant difference in delivery satisfaction among the three groups (P > 0.05).

Conclusion

DEX has excellent performance in ELA, which can effectively relieve the pain of puerperae and shorten the labor process. Among them, low-dose DEX has higher safety and is recommended as the first choice. Trial Registrations. This trial is registered with ML2021073.

Adoption of Dexmedetomidine in Different Doses at Different Timing in Perioperative Patients

Dexmedetomidine (Dex) is an alpha-2 agonist used for sedation during various procedures. Dex activates 2-adrenoceptors, and causes the decrease of sympathetic tone, with attenuation of the neuroendocrine and hemodynamic responses to anesthesia and surgery; it reduces anesthetic and opioid requirements; and causes sedation and analgesia.

OBJECTIVE

it was to compare the perioperative effects of different doses of Dex at different timing in patients using Dex during the perioperative period adopting a medical data classification algorithm based on optimized semi-supervised collaborative training (Tri-training).

METHODS

495 patients requiring surgical treatment in Xingtai People's Hospital were randomly selected as the study subjects. The patients were divided into group A (used before induction), group B (used during induction), and group C (used after induction) according to different induction timing, with 165 cases in each group. Then, groups A, B, and C were divided into groups A1, B1, and C1 (0.4 μg/(kg·h) rate), groups A2, B2, and C2 (0.6 μg/(kg·h) rate), and groups A3, B3, and C3 (0.8 μg/(kg·h) rate) according to the dose used, with 55 cases in each group. Intraoperative anesthesia and postoperative adverse reactions were compared among the 9 groups.

RESULTS

the similarity between the Tri-training algorithm optimized by Naive Bayes (NB) classification algorithm and the actual classification (93.49%) was clearly higher than that by decision tree (DT) and K-nearest neighbor (kNN) classification algorithm (76.21%, 74.31%); heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) values decreased obviously after Dex used in groups B1, C1, B2, C2, B3, and C3 (P <0.05), but did not change significantly in groups A1, A2, and A3 (P >0.05); the proportion of patients with satisfactory Ramsay score in group A3 was distinctly superior than that in groups A1, A2, B1, B2, B3, C1, C2, and C3 (P <0.05); the incidence of adverse reactions in group A3 was significantly inferior than that in groups A1, A2, B1, B2, B3, C1, C2, and C3 (P <0.05).

CONCLUSION

the optimization effect of NB classification algorithm was the best, and the injection of Dex at the injection rate of 0.8 μg/(kg·h) before induction of anesthesia could apparently improve the fluctuation of HR, SBP, and DBP during perioperative period, and effectively reduce the occurrence of adverse reactions in patients, with better sedative effect on patients.

Effect of ketorolac tromethamine combined with dezocine prior administration on hemodynamics and postoperative analgesia in patients undergoing laparoscopic hernia repair

OBJECTIVE

To observe the effect of Ketorolac tromethamine combined with dezocine prior administration on hemodynamics and postoperative sedation in patients undergoing laparoscopic hernia repair.

METHODS

100 male patients aged 60 to 80 years old, a line to elective laparoscopic inguinal hernia repair, were randomly divided into four groups: control group (Group A) and dezocine group (Group B), ketorolac tromethamine group (Group C), ketorolac tromethamine combined with dezocine group (Group D). Patients were administrated with 0.1 mg/kg dezocine in Group B, 0.5 mg/kg ketorolac in Group C, 0.1 mg/kg dezocine, and 0.5 mg/kg ketorolac in Group D, and with an equal dose of normal saline in group A. The heart rate (HR) and mean arterial pressure (MAP) of patients in 4 groups were recorded at each time point as follows, T0 (enter the operating room), T1 (before skin resection), 10 min after pneumoperitoneum (T2), mesh placement (T3), and laryngeal mask extraction (T4). Operation time, awakening time (time from drug withdrawal to consciousness recovery), the dosage of propofol, sufentanil, remifentanil, and intraoperative vasoactive drug dosage were recorded to compare. Visual analog scale score and sedation Ramsay score were evaluated 1, 6, 12, and 24 hours after extubation.

RESULTS

There was no significant difference in operation time, anesthesia recovery time, sufentanil dosage, and vasoactive drugs among all groups. The amount of propofol in Group B and D was less than that in Group A and C (P < .05), and there was no difference between Group B and D, A and C (P > .05). The amount of remifentanil in Group B, C, and D was less than that in Group A (P < .05), and Group D was less than B and C (P < .05). After extubation, HR and MAP were significantly higher than before (P < .05). Compared with T0, HR and MAP increased in each group at T4, but MAP and HR in Group D increased the least (P < .05). There were significant differences between Group B, C, D, and A, MAP and HR fluctuated little during extubation (P < .05), but there was a significant difference between Group D and B, C (P < .05). Visual analog scale scores of Group B, C, and D were lower than those of A at 1, 6, and 12 hours after surgery (P < .05), and there was a significant difference between Group D, and B, C (P < .05). Ramsay scores in Group B and D were higher than those in A and C at 1 and 6 hours after the operation (P < .05). There was no difference in the incidence of adverse reactions among groups.

CONCLUSION

The prophylactic use of ketorolac tromethamine and dezocine before laparoscopic inguinal hernia repair can reduce hemodynamic disorder during anesthesia recovery, increase postoperative sedative and analgesic effects.