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Mac Giolla Phadraig C, Ahmad Fisal AB, Bird J, Kammer PV, Fleischmann I, Geddis-Regan A. A scoping review of interventions and outcome measures in trials of dental behavior support. SPECIAL CARE IN DENTISTRY 2024; 44:676-685. [PMID: 38110713 DOI: 10.1111/scd.12949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Dental behavior support (DBS) describes all techniques used by dental professionals to ensure that dental care is safe, effective, and acceptable. There is a need to standardize outcome measures across DBS techniques to reduce heterogeneity, limit selective reporting, promote consistency, and optimize outcomes across DBS research. A comprehensive review of existing measures is a prerequisite to understanding potential outcomes related to the area of interest. AIM This review had three aims: first, to identify the outcome measures (OMs) reported in trials of dental behavior support; second, to categorize the component DBS techniques reported within interventions according to emerging agreed terminology; and, third, to map outcome measures to intervention type. METHODS A scoping review of trials evaluating DBS techniques was undertaken from 2012 to 2022. The review was prospectively registered. Studies were identified through Medline, Embase, and PsycINFO. Study abstracts were screened by two reviewers. Data were extracted by single selector. Outcome measures were sorted according to measurement domains (physiological, behavioral, psychological, and treatment). Responses were assimilated and summed to produce a refined list of distinguishable outcome measures. Intervention types were categorized according to accepted descriptors. Frequencies were presented; associations between outcome domain and DBS type were also reported (Chi-square test of independence). RESULTS A total of 344 trials were included in the review from an initial 14,793 titles / title and abstracts screened. Most involved children (n = 215), most were from India (n = 104), involving basic dental care (n = 117). The median number of outcome measures per trial was four (range = 1-12); 1,317 individual outcomes were reported, categorized as: psychological (n = 501, 38.0%); physiological (n = 491, 37.3%), behavioral (n = 123, 9.3%) or, treatment-related (n = 202, 15.3%). DBS interventions were split between 239 (45.7%) pharmacological and 283 (54.1%) non-pharmacological; 96.6% of interventions mapped to accepted descriptors. A significant relationship was noted between the type of intervention and the outcome domain reported. CONCLUSION The findings demonstrate massive variation in outcome measures of DBS interventions that likely lead to unnecessary heterogeneity, selective reporting, and questionable relevance in the literature. A large range of DBS interventions were mapped according to BeSiDe list. There is a need for consensus on a core outcome set across the spectrum of DBS techniques.
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Affiliation(s)
| | - Aisyah Binti Ahmad Fisal
- Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, Universiti Malaya, Kuala Lumpur, Malaysia
| | - James Bird
- Sheffield Teaching Hospitals NHS Foundation Trust and School of Clinical Dentistry, The University of Sheffield, Sheffield, UK
| | | | - Isabel Fleischmann
- Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
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Moritz NMP, Moritz JE, Parma GOC, Dexter F, Traebert J. Cross-cultural adaptation and validation of the Iowa Satisfaction with Anesthesia Scale for use in Brazil: a cross-sectional study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744471. [PMID: 37952775 PMCID: PMC11148495 DOI: 10.1016/j.bjane.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/30/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND The Iowa Satisfaction with Anesthesia Scale (ISAS) was developed to assess the satisfaction of patients undergoing sedation with monitored anesthesia care. This study aimed to cross-culturally adapt the ISAS instrument and evaluate the acceptability, validity, and reliability of the proposed Brazilian version (ISAS-Br). METHODS The cross-cultural adaptation process involved translation, synthesis, back-translation, expert committee review, pre-testing, and final review of the ISAS-Br. A cross-sectional study was conducted, involving 127 adult individuals undergoing ambulatory surgeries with moderate/deep sedation. The acceptability, reliability, and construct validity of the scale were assessed. RESULTS The cross-cultural adaptation process did not require significant changes to the final version of the scale. The ISAS-Br demonstrated excellent acceptability, with a completion rate of 99% and an average completion time of 4.6 minutes. Exploratory factor analysis revealed three factors: emotional well-being, physical comfort, and anxiety relief, with respective composite reliability coefficient values of 0.874, 0.580, and 0.428. The test-retest reliability of the ISAS-Br, measured by the intraclass correlation coefficient, was 0.67 (95% confidence interval [95% CI] 0.42 to 0.83), and the Bland-Altman plot showed satisfactory agreement between the measurements. CONCLUSION The proposed Brazilian version of the ISAS underwent successful cross-cultural adaptation according to international standards. It demonstrated good acceptability and reliability, regarding the assessment of temporal stability. However, the ISAS-Br exhibited low internal consistency for some factors, indicating that this instrument lacks sensitivity to assess the satisfaction of deeply sedated patients. Further studies are necessary to explore the hypotheses raised based on the knowledge of its psychometric properties.
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Affiliation(s)
- Nicole Morem Pilau Moritz
- Universidade do Sul de Santa Catarina, Programa de Pós-Graduação em Ciências da Saúde, Palhoça, SC, Brazil; Hospital Universitário da Universidade Federal de Santa Catarina, Departamento de Anestesia, Florianópolis, SC, Brazil.
| | | | | | - Franklin Dexter
- University of Iowa, Department of Anesthesia, Iowa City, United States of America
| | - Jefferson Traebert
- Universidade do Sul de Santa Catarina, Programa de Pós-Graduação em Ciências da Saúde, Palhoça, SC, Brazil
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Jackson SS, Lee JJ, Jackson WM, Price JC, Beers SR, Berkenbosch JW, Biagas KV, Dworkin RH, Houck CS, Li G, Smith HAB, Ward DS, Zimmerman KO, Curley MAQ, Horvat CM, Huang DT, Pinto NP, Salorio CF, Slater R, Slomine BS, West LL, Wypij D, Yeates KO, Sun LS. Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop. Pediatr Crit Care Med 2024; 25:e193-e204. [PMID: 38059739 DOI: 10.1097/pcc.0000000000003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia. DESIGN Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions. SETTING A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus. SUBJECTS Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium. CONCLUSIONS These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.
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Affiliation(s)
- Shawn S Jackson
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jennifer J Lee
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - William M Jackson
- Department of Anesthesiology, Montefiore Medical Center, New York, NY
| | - Jerri C Price
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Sue R Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - John W Berkenbosch
- Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Katherine V Biagas
- Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Robert H Dworkin
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | - Constance S Houck
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Heidi A B Smith
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Denham S Ward
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher M Horvat
- Departments of Critical Care Medicine, Pediatrics and Biomedical Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David T Huang
- Departments of Critical Care Medicine, Emergency Medicine, Clinical and Translational Science, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neethi P Pinto
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cynthia F Salorio
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebeccah Slater
- Department of Paediatric Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Beth S Slomine
- Center for Brain Injury Recovery, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leanne L West
- International Children's Advisory Network, Atlanta, GA
| | - David Wypij
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Keith O Yeates
- Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Lena S Sun
- Departments of Pediatrics and Anesthesiology, Columbia University Irving Medical Center, New York, NY
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Nakagawa H, Hanamoto H, Kozu F, Yokoe C, Maegawa H, Kudo C, Niwa H. Initial loading of dexmedetomidine and continuous propofol sedation for prevention of delayed recovery: A randomized controlled trial. J Am Dent Assoc 2023; 154:1008-1018.e2. [PMID: 37725033 DOI: 10.1016/j.adaj.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Sedation with continuous dexmedetomidine and bolus midazolam administration provides a lower incidence of unacceptable patient movement during procedures but requires a longer recovery time. The authors aimed to compare recovery time and unacceptable patient movement during sedation with initial loading of dexmedetomidine followed by continuous propofol infusion with those during sedation with continuous dexmedetomidine and bolus midazolam administration. METHODS In this prospective randomized controlled trial, 54 patients undergoing dental surgery and requiring intravenous sedation were assigned to either the dexmedetomidine and propofol group (n = 27, dexmedetomidine administered at 6 μg/kg/h for 5 minutes, followed by continuous propofol infusion using a target-controlled infusion) or the dexmedetomidine and midazolam group (n = 27, dexmedetomidine administered at 0.2-0.7 μg/kg/h continuously after the same initial loading dose with bolus midazolam). A bispectral index of 70 through 80 was maintained during the procedure. Patient movement that interfered with the procedure and time from the end of sedation to achieving a negative Romberg sign were assessed. RESULTS Times from the end of sedation to achieving a negative Romberg sign in the dexmedetomidine and propofol group (median, 14 minutes [interquartile range, 12-15 minutes]) were significantly shorter (P < .001) than in the dexmedetomidine and midazolam group (median, 22 minutes [interquartile range, 17.5-30.5 minutes]). The incidence of unacceptable patient movement was comparable between groups (n = 3 in the dexmedetomidine and propofol group, n = 4 in the dexmedetomidine and midazolam group; P = .999). CONCLUSIONS Sedation with a single loading dose of dexmedetomidine followed by continuous propofol infusion can prevent delayed recovery without increasing unacceptable patient movement. PRACTICAL IMPLICATIONS The combination of dexmedetomidine and propofol may provide high-quality sedation for ambulatory dental practice. This clinical trial was registered in the University Hospital Medical Information Network Clinical Trials Registry. The registration number is UMIN000039668.
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Marchesini V, Disma N. Outcomes in pediatric anesthesia: towards a universal language. Curr Opin Anaesthesiol 2023; 36:216-221. [PMID: 36728715 DOI: 10.1097/aco.0000000000001232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW The identification of valid, well defined and relevant outcomes is fundamental to provide a reliable and replicable measure that can be used to improve quality of clinical care and research output. The purpose of this review is to provide an update on what the pediatric anesthesia research community is pursuing on standardized and validated outcomes. RECENT FINDINGS Several initiatives by different research groups have been established during the last years. They all aim to find validated outcomes using the standardized methodology of COMET ( https://www.comet-initiative.org/ ). These initiatives focus on clinical and research outcomes on the field of anesthesia, perioperative medicine, pain and sedation in pediatric age. SUMMARY Clinical outcomes are measurements of changes in health, function or quality of life and they help evaluating quality of care. In order for them to be relevant in quantifying quality improvement, they need to be well defined, standardized and consistent across trials. A great effort from researchers has been made towards the identification of set of outcomes with these features.
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Affiliation(s)
- Vanessa Marchesini
- Pediatric Intensive Care Unit, Royal Melbourne Children's Hospital, Parkville
- Anesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Nicola Disma
- Unit for Research in Anesthesia, Department of Pediatric Anesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
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Hewson DW, Worcester F, Sprinks J, Smith MD, Buchanan H, Breedon P, Hardman JG, Bedforth NM. Patient-maintained versus anaesthetist-controlled propofol sedation during elective primary lower-limb arthroplasty performed under spinal anaesthesia: a randomised controlled trial. Br J Anaesth 2022; 128:186-197. [PMID: 34852928 PMCID: PMC8787772 DOI: 10.1016/j.bja.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/03/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patient-maintained propofol TCI sedation (PMPS) allows patients to titrate their own target-controlled infusion (TCI) delivery of propofol sedation using a handheld button. The aim of this RCT was to compare PMPS with anaesthetist-controlled propofol TCI sedation (ACPS) in patients undergoing elective primary lower-limb arthroplasty surgery under spinal anaesthesia. METHODS In this single-centre open-label investigator-led study, adult patients were randomly assigned to either PMPS or ACPS during their surgery. Both sedation regimes used Schnider effect-site TCI modelling. The primary outcome measure was infusion rate adjusted for weight (expressed as mg kg-1 h-1). Secondary outcomes measures included depth of sedation, occurrence of sedation-related adverse events and time to medical readiness for discharge from the postanaesthsia care unit (PACU). RESULTS Eighty patients (48 female) were randomised. Subjects using PMPS used 39.3% less propofol during the sedation period compared with subjects in group ACPS (1.56 [0.57] vs 2.57 [1.33] mg kg-1 h-1; P<0.001), experienced fewer discrete episodes of deep sedation (0 vs 6; P=0.0256), fewer airway/breathing adverse events (odds ratio [95% confidence interval]: 2.94 [1.31-6.64]; P=0.009) and were ready for discharge from PACU more quickly (8.94 [5.5] vs 13.51 [7.2] min; P=0.0027). CONCLUSIONS Patient-maintained propofol sedation during lower-limb arthroplasty under spinal anaesthesia results in reduced drug exposure and fewer episodes of sedation-related adverse events compared with anaesthetist-controlled propofol TCI sedation. To facilitate further investigation of this procedural sedation technique, PMPS-capable TCI infusion devices should be submitted for regulatory approval for clinical use. CLINICAL TRIAL REGISTRATION ISRCTN29129799.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care Medicine, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Frank Worcester
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK
| | - James Sprinks
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK
| | - Murray D Smith
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Heather Buchanan
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Philip Breedon
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care Medicine, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Anaesthesia & Critical Care Research Group, Injury, Inflammation and Recovery Sciences Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nigel M Bedforth
- Department of Anaesthesia and Critical Care Medicine, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Implementing capnography to help improve patient safety during procedural sedation: quality improvement in a high-volume gastroenterology department. Eur J Gastroenterol Hepatol 2021; 33:e522-e528. [PMID: 33905213 DOI: 10.1097/meg.0000000000002144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Respiratory compromise is a major cause of adverse events during procedural sedation; continuous monitoring is vital for identifying and halting decompensation. We performed a quality improvement investigation to assess patient safety during procedural sedation in gastroenterology and the impact of implementing capnography monitoring. PATIENTS AND METHODS Sedation-related adverse events and interventions were prospectively recorded during the endoscopic procedure and in recovery. Assuming rates in published literature, power analysis determined that at least 1332 patients were required to show a 20% improvement in patient safety. Recorded sedation-related adverse events (mild and severe oxygen desaturations, bradycardia and tachycardia) and interventions were anonymized and aggregated to evaluate the quality improvement. Patient safety under current care was determined before capnography (Medtronic) was implemented in combination with training. RESULTS Between February 2018 and April 2018, a baseline (1092 patients) for outcomes under current care was completed, with 11.45 events per 100 procedures recorded. Between May 2018 and July 2018, 1044 procedures including capnography monitoring were performed with 5.08 events per 100 procedures recorded. The distribution of American Society of Anesthesiologists scores and procedure types between baseline and capnography were comparable. The absolute difference between baseline and capnography was -6.4 events per 100 procedures [95% confidence interval (CI), -4.1 to -8.7; P ≤ 0.0001]. The 55% reduction in adverse events surpassed the 20% improvement in patient safety set as the goal of this quality improvement. After multivariate regression, the adjusted odds ratio for events after implementation of capnography was 0.46 (95% CI, 0.32-0.66). CONCLUSIONS Addition of capnography to current care significantly decreased procedure-related safety events.
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Viana KA, Moterane MM, Green SM, Mason KP, Costa LR. Amnesia after Midazolam and Ketamine Sedation in Children: A Secondary Analysis of a Randomized Controlled Trial. J Clin Med 2021; 10:jcm10225430. [PMID: 34830712 PMCID: PMC8625279 DOI: 10.3390/jcm10225430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/13/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
The incidence of peri-procedural amnesia following procedural sedation in children is unclear and difficult to determine. This study aimed to apply quantitative and qualitative approaches to better understand amnesia following dental sedation of children. After Institutional Review Board Approval, children scheduled for sedation for dental procedures with oral midazolam (OM), oral midazolam and ketamine (OMK), or intranasal midazolam and ketamine (IMK) were recruited for examination of peri-procedural amnesia. Amnesia during the dental session was assessed using a three-stage method, using identification of pictures and an animal toy. On the day following the sedation, primary caregivers answered two questions about their children’s memory. One week later, the children received a semi-structured interview. Behavior and level of sedation during the dental session were recorded. Quantitative data were analyzed using descriptive statistics and comparison tests. Qualitative data were analyzed using content analysis. Triangulation was used. Thirty-five children (age: 36 to 76 months) participated in the quantitative analysis. Most children showed amnesia for the dental procedure (82.9%, n = 29/35) and remembered receiving the sedation (82.1%, n = 23/28 for oral administration; 59.3%, n = 16/27 for intranasal administration). The occurrence of amnesia for the dental procedure was slightly higher in the oral midazolam group compared with the other groups (44.8%, n = 13/29 for OM, 13.8%, n = 4/29 for OMK, and 41.4%, n = 12/29 for IMK). Twenty-eight children participated in the qualitative approach. The major theme identified was that some children could remember their procedures in detail. We conclude that peri-procedural amnesia of the dental procedure was common following sedation.
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Affiliation(s)
- Karolline A. Viana
- Dentistry Graduate Program, Faculdade de Odontologia, Universidade Federal de Goiás, Goiânia 74000-000, Goiás, Brazil;
- Correspondence: ; Tel./Fax: +55-62-3209-6325
| | - Mônica M. Moterane
- Dentistry Graduate Program, Faculdade de Odontologia, Universidade Federal de Goiás, Goiânia 74000-000, Goiás, Brazil;
| | - Steven M. Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Luciane R. Costa
- Department of Oral Health, Faculdade de Odontologia, Universidade Federal de Goiás, Goiânia 74000-000, Goiás, Brazil;
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Lee JJ, Price JC, Gewandter J, Kleykamp BA, Biagas KV, Naim MY, Ward D, Dworkin RH, Sun LS. Design and reporting characteristics of clinical trials investigating sedation practices in the paediatric intensive care unit: a scoping review by SCEPTER (Sedation Consortium on Endpoints and Procedures for Treatment, Education and Research). BMJ Open 2021; 11:e053519. [PMID: 34649849 PMCID: PMC8522672 DOI: 10.1136/bmjopen-2021-053519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To conduct a scoping review of sedation clinical trials in the paediatric intensive care setting and summarise key methodological elements. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and grey references including ClinicalTrials.gov from database inception to 3 August 2021. STUDY SELECTION All human trials in the English language related to sedation in paediatric critically ill patients were included. After title and abstract screening, full-text review was performed. 29 trials were eligible for final analysis. DATA EXTRACTION A coding manual was developed and pretested. Trial characteristics were double extracted. RESULTS The majority of trials were single centre (22/29, 75.9%), parallel group superiority (17/29, 58.6%), double-blinded (18/29, 62.1%) and conducted in an academic setting (29/29, 100.0%). Trial enrolment (≥90% planned sample size) was achieved in 65.5% of trials (19/29), and retention (≥90% enrolled subjects) in 72.4% of trials (21/29). Protocol violations were reported in nine trials (31.0%). The most commonly studied cohorts were mechanically ventilated patients (28/29, 96.6%) and postsurgical patients (11/29, 37.9%) with inclusion criteria for age ranging from 0±0.5 to 15.0±7.3 years (median±IQR). The median age of enrolled patients was 1.7 years (IQR=4.4 years). Patients excluded from trials were those with neurological impairment (21/29, 72.4%), complex disease (20/29, 69.0%) or receipt of neuromuscular blockade (10/29, 34.5%). Trials evaluated drugs/protocols for sedation management (20/29, 69.0%), weaning (3/29, 10.3%), daily interruption (3/29, 10.3%) or protocolisation (3/29, 10.3%). Primary outcome measures were heterogeneous, as were assessment instruments and follow-up durations. CONCLUSIONS There is substantial heterogeneity in methodological approach in clinical trials evaluating sedation in critically ill paediatric patients. These results provide a basis for the design of future clinical trials to improve the quality of trial data and aid in the development of sedation-related clinical guidelines.
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Affiliation(s)
| | - Jerri C Price
- Anesthesiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Gewandter
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Bethea A Kleykamp
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine V Biagas
- Pediatrics, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Maryam Y Naim
- Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Denham Ward
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert H Dworkin
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Lena S Sun
- Anesthesiology and Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
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Ward DS, Absalom AR, Aitken LM, Balas MC, Brown DL, Burry L, Colantuoni E, Coursin D, Devlin JW, Dexter F, Dworkin RH, Egan TD, Elliott D, Egerod I, Flood P, Fraser GL, Girard TD, Gozal D, Hopkins RO, Kress J, Maze M, Needham DM, Pandharipande P, Riker R, Sessler DI, Shafer SL, Shehabi Y, Spies C, Sun LS, Tung A, Urman RD. Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III. Crit Care Med 2021; 49:1684-1693. [PMID: 33938718 PMCID: PMC8439670 DOI: 10.1097/ccm.0000000000005049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.
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Affiliation(s)
- Denham S Ward
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anthony R Absalom
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Leanne M Aitken
- School of Health Sciences, University of London, London, United Kingdom
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia
| | - Michele C Balas
- Center of Healthy Aging, Self-Management, and Complex Care, The Ohio State University, College of Nursing, Columbus, OH
| | | | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Douglas Coursin
- Departments of Anesthesiology and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Talmage D Egan
- Department of Anesthesiology, University of Utah, Salt Lake City, UT
| | - Doug Elliott
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pamela Flood
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Gilles L Fraser
- Department of Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - David Gozal
- Division of Anesthesiology and CCM, Hadassah Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ramona O Hopkins
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT
| | - John Kress
- Department of Medicine, Section of Pulmonary and Critical Care, The University of Chicago, Chicago, IL
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Pratik Pandharipande
- Department of Anesthesiology and the Critical Illness, Vanderbilt University Medical Center, Nashville, TN
| | - Richard Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Steven L Shafer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences - Department of Intensive Care Medicine - Critical Care Research, Melbourne, VIC, Australia
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Charité Mitte & Campus Virchow-Klinikum, Berlin, Germany
| | - Lena S Sun
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Avery Tung
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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11
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Chua GCC, Cyna AM. Satisfaction measures in pediatric anesthesia and perioperative care. Paediatr Anaesth 2021; 31:746-754. [PMID: 33899988 DOI: 10.1111/pan.14197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/21/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
Patient satisfaction is routinely used to assess the quality of care in medicine. In the field of anesthesia, research has been primarily directed toward developing satisfaction measures in adults with little attention paid to the pediatric population. Satisfaction in pediatric anesthesia and perioperative care is poorly understood. We have identified existing satisfaction measures in pediatric perioperative care and examined their similarities and differences. A search of relevant published trials up to January 2021 identified 17 studies using 14 unique satisfaction measures of perioperative care in children. Eleven of these assessed satisfaction multidimensionally while three assessed overall satisfaction of parents with their child's anesthesia. Of the six dimensions of satisfaction identified, all were duplicated to some degree across studies. The dimensions were: "staff rapport and communication" and "anesthetic and nursing quality of care" in eight satisfaction measures; "information giving" in seven measures; "postoperative symptom control" in six; "hospital experience" in five; and "involvement in decision-making" in three. The most important items from the parents' perspective were: "staff rapport and communication;" "information giving;" and "decision-making". No study examined all dimensions of satisfaction. Although all studies questioned parents, only three asked satisfaction questions of the child. No study was analyzed the child's direct responses. In three studies, parental involvement in decision-making was reported to be important as a satisfaction measure of their child's perioperative care. Of the few existing satisfaction measures evaluated, there is no accepted standard in current practice. Future studies identifying the important determinants of satisfaction in pediatric perioperative care, perhaps also using a Delphi approach with parents, might allow for the development of a patient-focused standardized measure in this setting.
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Affiliation(s)
- Graham C C Chua
- The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Allan M Cyna
- Department of Children's Anaesthesia, Women's and Children's Hospital, North Adelaide, SA, Australia.,Discipline of Acute Care Medicine, University of Adelaide Health Sciences, Adelaide, SA, Australia
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12
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Conway A, Chang K, Mafeld S, Sutherland J. Midazolam for sedation before procedures in adults and children: a systematic review update. Syst Rev 2021; 10:69. [PMID: 33673878 PMCID: PMC7936483 DOI: 10.1186/s13643-021-01617-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Midazolam is used for sedation before diagnostic and therapeutic medical procedures by several routes including oral, intravenous, intranasal and intramuscular. This is an update of a Cochrane review published in 2016, which aimed to determine the evidence on the effectiveness of midazolam for sedation when administered before a diagnostic or therapeutic procedure in adults and children. METHODS We searched CENTRAL, MEDLINE, Embase and two trials registers up to May 2020 together with reference checking to identify additional studies. We imposed no language restrictions. Randomized controlled trials of midazolam in comparison with placebo or other medications used for sedation were included. Two authors independently extracted data and assessed risk of bias for each included study. RESULTS Eight new trials were included in this update, which resulted in changed conclusions for the intravenous midazolam versus placebo, oral midazolam versus chloral hydrate and oral midazolam versus placebo comparisons. Effect estimates for all outcomes within the intravenous midazolam versus placebo (7 trials; 633 adults and 32 children) are uncertain due to concerns about imprecision and risk of bias. Midazolam resulted in a higher level of sedation than placebo (mean difference (MD) 1.05; 95% confidence interval (95% CI) 0.69 to 1.41; 1 study; 100 adults). There was no difference in anxiety (RR 0.43, 95% CI 0.09 to 1.99; I2 = 75%; 2 studies; 123 adults). Risk of difficulty performing procedures was lower in the midazolam group (RR 0.5; 95% CI 0.29 to 0.86; I2 = 45%; 3 studies; 191 adults and 32 children). There was no difference in discomfort (RR 0.51; 95% CI 0.25 to 1.04; I2 = 0%; 2 studies; 190 adults). Five trials with 336 children were included in the oral midazolam versus chloral hydrate comparison. Midazolam was less likely to result in moderate sedation (RR 0.30, 95% CI 0.11 to 0.82; I2 = 64%; 2 studies, 228 participants). This effect estimate is highly uncertain due to concerns about the risk of bias, imprecision and inconsistency. There was no difference in ratings of anxiety (SMD - 0.26; 95% CI - 0.75 to 0.23; I2 = 0%; 2 studies; 68 participants). Midazolam increased risk of incomplete procedures (RR 4.01; 95% CI 1.92 to 8.40; I2 = 0%; 4 studies, 268 participants). This effect estimate is uncertain due to concerns about the risk of bias. There were four trials with 359 adults and 77 children included in the oral midazolam versus placebo comparison. Midazolam reduced ratings of anxiety (SMD - 1.01; 95% CI - 1.86 to - 0.16; I2 = 92%; 4 studies; 436 participants). It is unclear if midazolam has an effect on difficulty performing procedures. Meta-analysis was not performed because there was only one incomplete procedure in the midazolam group in one of the trials. Midazolam reduced pain in one study with 99 adults (MD - 2; 95% CI - 2.5 to - 1.6; moderate quality). The effect estimate is uncertain due to concerns about the risk of bias. CONCLUSION The additional evidence arising from inclusion of new studies in this updated review has not produced sufficient high-quality evidence to determine whether midazolam produces more effective sedation than other medications or placebo in any specific population included in this review. For adults, there was low-quality evidence that intravenous midazolam did not reduce the risk of anxiety or discomfort/pain in comparison to placebo, but the sedation level was higher. By combining results from adults and children, there was low-quality evidence of a large reduction in the risk of procedures being difficult to perform with midazolam in comparison to placebo. The effect estimates for this comparison are uncertain because there was concern about risk of bias and imprecision. There is moderate-quality evidence suggesting that oral midazolam produces less-effective sedation than chloral hydrate for completion of procedures for children undergoing non-invasive diagnostic procedures. Ratings of anxiety were not different between oral midazolam and chloral hydrate. The extent to which giving oral midazolam to adults or children decreases anxiety during procedures compared with placebo is uncertain due to concerns about risk of bias and imprecision. There was moderate-quality evidence from one study that oral midazolam reduced the severity of discomfort/pain for adults during a brief diagnostic procedure in comparison with placebo.
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Affiliation(s)
- Aaron Conway
- Peter Munk Cardiac Centre, University Health Network, 585 University Ave, Toronto, ON, M5G 2N2, Canada. .,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. .,School of Nursing, Queensland University of Technology (QUT), Brisbane, Australia.
| | - Kristina Chang
- Peter Munk Cardiac Centre, University Health Network, 585 University Ave, Toronto, ON, M5G 2N2, Canada
| | - Sebastian Mafeld
- Interventional Radiology, JDMI, Toronto General Hospital, Toronto, Canada
| | - Joanna Sutherland
- Rural Clinical School, University of New South Wales, Coffs Harbour, NSW, Australia.,Department of Anaesthesia, Coffs Harbour Health Campus, Coffs Harbour, NSW, Australia
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13
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Hewson DW, Hardman JG, Bedforth NM. Patient-maintained propofol sedation for adult patients undergoing surgical or medical procedures: a scoping review of current evidence and technology. Br J Anaesth 2020; 126:139-148. [PMID: 32917377 PMCID: PMC7844373 DOI: 10.1016/j.bja.2020.07.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/04/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022] Open
Abstract
Patient-maintained propofol sedation (PMPS) is the delivery of procedural propofol sedation by target-controlled infusion with the patient exerting an element of control over their target-site propofol concentration. This scoping review aims to establish the extent and nature of current knowledge regarding PMPS from both a clinical and technological perspective, thereby identifying knowledge gaps to guide future research. We searched MEDLINE, EMBASE, and OpenGrey databases, identifying 17 clinical studies for analysis. PMPS is described in the context of healthy volunteers and in orthopaedic, general surgical, dental, and endoscopic clinical settings. All studies used modifications to existing commercially-available infusion devices to achieve prototype systems capable of PMPS. The current literature precludes rigorous generalisable conclusions regarding the safety or comparative clinical effectiveness of PMPS, however cautious acknowledgement of efficacy in specific clinical settings is appropriate. Based on the existing literature, together with new standardised outcome reporting recommendations for sedation research and frameworks designed to assess novel health technologies research, we have made recommendations for future pharmacological, clinical, behavioural, and health economic research on PMPS. We conclude that high-quality experimental clinical trials with relevant comparator groups assessing the impact of PMPS on standardised patient-orientated outcome measures are urgently required.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nigel M Bedforth
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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14
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The effectiveness of a low-dose esketamine versus an alfentanil adjunct to propofol sedation during endoscopic retrograde cholangiopancreatography. Eur J Anaesthesiol 2020; 37:394-401. [DOI: 10.1097/eja.0000000000001134] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Sforzi I, Bressan S, Saffirio C, De Masi S, Bussolin L, Da Dalt L, De Iaco F, Shavit I, Krauss B, Barbi E. The development of a Consensus Conference on Pediatric Procedural Sedation in the Emergency Department in Italy: from here where to? Ital J Pediatr 2020; 46:57. [PMID: 32357893 PMCID: PMC7195721 DOI: 10.1186/s13052-020-0812-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/30/2020] [Indexed: 01/14/2023] Open
Abstract
Background In Italy, as in many European countries, Pediatric Emergency Medicine is not formally recognized as a pediatric subspecialty, hindering nation-wide adoption of standards of care, especially in the field of procedural sedation and analgesia (PSA) in the Emergency Department (ED). For this reason PSA in Italy is mostly neglected or performed very heterogeneously and by different providers, with no reference standard. We aimed to describe the procedures and results of the first multidisciplinary and multi-professional Consensus Conference in Italy on safe and effective pediatric PSA in Italian EDs. Methods The preparation, organization and conduct of the Consensus Conference, held in Florence in 2017, followed the recommended National methodological standards. Professionals from different specialties across the country were invited to participate. Results Overall 86 recommendations covering 8 themes (pre-sedation evaluation, pharmacologic agents, monitoring, equipment and discharge checklists, training, non-pharmacologic techniques, the adult ED setting, impact on hospitalizations) were developed, taking into account the Italian training system and healthcare organization characteristics. Conclusion The results of the first multidisciplinary and multi-professional Consensus Conference in Italy are meant to provide up-to-date national guidance to improve the standard of care of children undergoing painful and stressful procedures in the ED. The recommendations will be periodically updated as new relevant evidence is published.
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Affiliation(s)
- Idanna Sforzi
- Pediatric Emergency Department and Trauma Center, Meyer Children's Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Claudia Saffirio
- Pediatric Emergency Department and Trauma Center, Meyer Children's Hospital, Viale Pieraccini 24, 50139, Florence, Italy
| | - Salvatore De Masi
- Health Sciences Department, University of Florence, Meyer University Children's Hospital, Florence, Italy
| | - Leonardo Bussolin
- Pediatric Emergency Department and Trauma Center, Meyer Children's Hospital, Viale Pieraccini 24, 50139, Florence, Italy
| | - Liviana Da Dalt
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Fabio De Iaco
- Emergency Department, Martini Hospital, ASL Città di Torino, Torino, Italy
| | - Itai Shavit
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Baruch Krauss
- Division of Emergency Medicine, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Egidio Barbi
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy.,University of Trieste, Trieste, Italy
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16
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Loeffen EAH, Mulder RL, Font-Gonzalez A, Leroy PLJM, Dick BD, Taddio A, Ljungman G, Jibb LA, Tutelman PR, Liossi C, Twycross A, Positano K, Knops RR, Wijnen M, van de Wetering MD, Kremer LCM, Dupuis LL, Campbell F, Tissing WJE. Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline. Eur J Cancer 2020; 131:53-67. [PMID: 32302949 DOI: 10.1016/j.ejca.2020.02.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress. METHODS Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents. RESULTS The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures. CONCLUSION In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.
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Affiliation(s)
- Erik A H Loeffen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Oncology/Hematology, Groningen, the Netherlands.
| | - Renée L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Anna Font-Gonzalez
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Piet L J M Leroy
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bruce D Dick
- Departments of Anesthesiology and Pain Medicine, Psychiatry &Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anna Taddio
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Department of Pharmacy and Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Gustaf Ljungman
- Department of Women's and Children's Health, Pediatric Oncology, Uppsala University, Uppsala, Sweden
| | - Lindsay A Jibb
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Perri R Tutelman
- Centre for Pediatric Pain Research, IWK Health Centre Halifax, NS, Canada
| | - Christina Liossi
- Pediatric Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alison Twycross
- School of Health and Social Care, London South Bank University, London, United Kingdom
| | | | - Rutger R Knops
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marc Wijnen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - L Lee Dupuis
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Department of Pharmacy and Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Wim J E Tissing
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Oncology/Hematology, Groningen, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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17
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Chadha RM, Dexter F, Brull SJ. Lack of recall after sedation for cataract surgery and its effect on the validity of measuring patient satisfaction. Korean J Anesthesiol 2019; 73:319-325. [PMID: 31612692 PMCID: PMC7403108 DOI: 10.4097/kja.19314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We evaluated the validity of assessing patient satisfaction with the sedation regimen among patients being discharged 45 min after receiving midazolam. If most patients do not have recall, then the sedation cannot be considered complete at the time of evaluation. METHODS In this prospective cohort study, 20 patients underwent cataract surgery with nurse-administered midazolam and fentanyl. The 11-item Iowa Satisfaction with Anesthesia Scale was administered 30 min after sedation in the recovery room. Recalled items were evaluated the next morning. RESULTS Eleven patients recalled 0 themes, 4 recalled 1, 4 recalled 2, and 1 recalled 3 themes. Thus, 15/20 patients (75%) recalled 0 or 1 of the 11 themes (P = 0.021 versus half the patients). The 95% one-sided lower confidence limit for 0, 1, or 2 themes was 80% of patients (P < 0.001 versus half). Patients who received less midazolam recalled more themes (Kendall's τb = 0.43, P = 0.039). CONCLUSIONS Evaluating patient satisfaction with sedation shortly after admission to the post-anesthesia care unit is invalid because of a lack of recall; the sedation/amnesia is ongoing. Patient comfort may be assessed, but comfort is not synonymous with satisfaction; 'satisfaction' implies presence of recall. Because we studied sedation with low doses of midazolam and fentanyl, the same conclusion reliably would apply to larger doses of anxiolytics administered intraoperatively. The results match previous findings that when patients receive preoperative midazolam prior to meeting the anesthesiologist, even if the patient fully answers questions, they may have negligible recall of having met the anesthesiologist.
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Affiliation(s)
- Ryan M Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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18
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Ward DS, Williams MR, Berkenbosch JW, Bhatt M, Carlson D, Chappell P, Clark RM, Constant I, Conway A, Cravero J, Dahan A, Dexter F, Dionne R, Dworkin RH, Gan TJ, Gozal D, Green S, Irwin MG, Karan S, Kochman M, Lerman J, Lightdale JR, Litman RS, Mason KP, Miner J, O'Connor RE, Pandharipande P, Riker RR, Roback MG, Sessler DI, Sexton A, Tobin JR, Turk DC, Twersky RS, Urman RD, Weiss M, Wunsch H, Zhao-Wong A. Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations. Anesth Analg 2019; 127:1146-1154. [PMID: 29782404 DOI: 10.1213/ane.0000000000003409] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses.
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Affiliation(s)
- Denham S Ward
- From the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Anesthesiology, Tufts School of Medicine, Boston, Massachusetts
| | - Mark R Williams
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - John W Berkenbosch
- Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Douglas Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois.,Department of Pediatrics, St John's Children's Hospital, Springfield, Illinois
| | | | - Randall M Clark
- Department of Anesthesiology, University of Colorado School of Medicine, Denver, Colorado
| | - Isabelle Constant
- Department of Anesthesiology, Hôpital Armand Trousseau, APHP, UPMC Université, Paris, France
| | - Aaron Conway
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Joseph Cravero
- Department of Anesthesia, Harvard Medical School, Department of Anesthesiology, Critical Care & Pain, Boston Children's Hospital, Boston, Massachusetts
| | - Albert Dahan
- Department of Anesthesiology, Leiden University, Leiden University Medical Center, Leiden, the Netherlands
| | - Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, The University of Iowa, Iowa City, Iowa
| | - Raymond Dionne
- Department of Pharmacology and Foundational Sciences, East Carolina University, Greenville, North Carolina
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - David Gozal
- Division of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, The Hebrew University of Jerusalem School of Medicine, Jerusalem, Israel
| | - Steven Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, California
| | - Michael G Irwin
- Department of Anesthesiology, University of Hong Kong, Hong Kong, China
| | - Suzanne Karan
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael Kochman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jerrold Lerman
- Department of Anesthesia, John R. Oishei Children's Hospital Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Jenifer R Lightdale
- Department of Pediatrics, University of Massachusetts Memorial Children's Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ronald S Litman
- Department of Anesthesiology & Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keira P Mason
- Department of Anesthesia, Harvard Medical School, Department of Anesthesiology, Critical Care & Pain, Boston Children's Hospital, Boston, Massachusetts
| | - James Miner
- Department of Emergency, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Robert E O'Connor
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Pratik Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard R Riker
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.,Department of Critical Care Medicine and Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Mark G Roback
- Department of Emergency, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anne Sexton
- CNS Clinical Affairs, Pfizer Inc, Groton, Connecticut
| | - Joseph R Tobin
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dennis C Turk
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Rebecca S Twersky
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, Josie Robertson Surgery Center, New York, New York
| | - Richard D Urman
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark Weiss
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Wunsch
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anna Zhao-Wong
- Maintenance and Support Services Organization, MedDRA, McLean, Virginia
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Engaging Stakeholders to Promote Safe Anesthesia and Sedation Care in Young Children. J Neurosurg Anesthesiol 2019; 31:125-128. [PMID: 30767936 DOI: 10.1097/ana.0000000000000547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An important aspect of any research endeavor is engaging various stakeholders to work toward the common goal of pushing knowledge forward about the question at hand. Research into pediatric anesthetic neurotoxicity could benefit greatly from interventions designed to improve the efforts and dedication of government agencies, pharmaceutical companies, research communities, and most importantly, patients. The Pediatric Anesthesia Neurodevelopment Assessment (PANDA) symposium is a biennial meeting where updates in research in the field are presented, and issues relevant to the community are discussed in round table discussions. Here, we summarize a discussion that took place at the 2018 meeting regarding new methods of engaging various stakeholders, as well as perspectives from other stakeholders. Topics discussed included an online portal to better reach patients, experiences with a public-private partnership, steps by the National Institutes of Health to improve engagement with research and improve the dissemination of results, and the experiences of the United States Food and Drug Administration attempting to improve stakeholder engagement following the passage of a new law to promote drug development. The round table discussion provided interesting insights into a critical research topic, and shared first-hand experience of attempts to improve engagement with a variety of stakeholders.
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Schick A, Driver B, Moore JC, Fagerstrom E, Miner JR. Randomized Clinical Trial Comparing Procedural Amnesia and Respiratory Depression Between Moderate and Deep Sedation With Propofol in the Emergency Department. Acad Emerg Med 2019; 26:364-374. [PMID: 30098230 DOI: 10.1111/acem.13548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 07/07/2018] [Accepted: 08/04/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to determine if there is a difference in procedural amnesia and adverse respiratory events (AREs) between the target sedation levels of moderate (MS) and deep (DS) procedural sedation. METHODS This was a prospective, randomized clinical trial of consenting adult patients planning to undergo DS with propofol between March 5, 2015, and May 24, 2017. Patients were randomized to a target sedation level of MS or DS using the American Society of Anesthesiologist's definitions. Drug doses, vital signs, observer's assessment of alertness/sedation (OAAS) score, end-tidal CO2 (ETCO2 ), and the need for supportive airway maneuvers (SAMs; bag-valve mask use, repositioning, and stimulation to induce respirations) were monitored continuously. A standardized image was shown every 30 seconds starting 3 minutes before the procedure continuing until the patient had returned to baseline after the procedure. Recall and recognition of images were assessed 10 minutes after the sedation. Subclinical respiratory depression (RD) was defined as SaO2 ≤ 91%, change in ETCO2 ≥ 10 mm Hg, or absent ETCO2 at any time. The occurrence of RD with a SAM was defined as an ARE. Patient satisfaction, pain, and perceived recollection and physician assessment of procedure difficulty were collected using visual analog scales (VASs). Data were analyzed with descriptive statistics and Wilcoxon rank-sum test. RESULTS A total of 107 patients were enrolled: 54 randomized to target MS and 53 to DS. Of the patients randomized to target MS, 50% achieved MS and 50% achieved DS. In the target DS group, 77% achieved DS and 23% achieved MS. The median total propofol dose (mg/kg) was lower in the MS group: MS 1.4 (95% confidence interval [CI] = 1.3-1.6, IQR = 1) versus DS 1.8 (95% CI = 1.6-2.0, IQR = 0.9). There were no differences in median OAAS during the procedure (MS 2.4 and DS 2.8), lowest OAAS (MS 2 and DS 2), percentage of images recalled (MS 4.7% vs. DS 3.8%, p = 0.73), or percentage of images recognized (MS 61.1% vs. DS 55%, p = 0.52). In the MS group, 41% patients had any AREs compared to 42% in the DS group (p = 0.77, 95% CI difference = -0.12 to 0.24). The total number of AREs was 23% lower in the MS group (p = 0.01, 95% CI = -0.41 to -0.04). There was no difference in patient-reported pain, satisfaction, or recollection VAS scores. Provider's rating of procedural difficulty and procedural success were similar in both groups. CONCLUSIONS Targeting MS or DS did not reliably result in the intended sedation level. Targeting MS, however, resulted in a lower rate of total AREs and fewer patients had multiple AREs with no difference in procedural recall. As seen in previous reports, patients who achieved MS had less AREs than those who achieved DS. Our study suggests that a target of MS provides adequate amnesia with less need for supportive airway interventions than a target level of DS, despite the fact that it often does not result in intended sedation level.
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Affiliation(s)
- Alexandra Schick
- Department of Emergency Medicine Hennepin County Medical Center MinneapolisMN
| | - Brian Driver
- Department of Emergency Medicine Hennepin County Medical Center MinneapolisMN
| | - Johanna C. Moore
- Department of Emergency Medicine Hennepin County Medical Center MinneapolisMN
| | - Erik Fagerstrom
- Department of Emergency Medicine Hennepin County Medical Center MinneapolisMN
| | - James R. Miner
- Department of Emergency Medicine Hennepin County Medical Center MinneapolisMN
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Mason KP, Seth N. Future of paediatric sedation: towards a unified goal of improving practice. Br J Anaesth 2019; 122:652-661. [PMID: 30916013 DOI: 10.1016/j.bja.2019.01.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.
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Affiliation(s)
- Keira P Mason
- Harvard Medical School, Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, USA.
| | - Neena Seth
- Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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Silva-Jr JM, Katayama HT, Nogueira FAM, Moura TB, Alves TL, de Oliveira BW. Comparison of dexmedetomidine and benzodiazepine for intraoperative sedation in elderly patients: a randomized clinical trial. Reg Anesth Pain Med 2019; 44:319-324. [DOI: 10.1136/rapm-2018-100120] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/28/2018] [Indexed: 11/04/2022]
Abstract
Background and objectivesElderly individuals have a greater sensitivity to sedation, and the most commonly used drugs for sedation are benzodiazepines, which exhibit some complication. Therefore, this study aimed to compare the use of dexmedetomidine and midazolam regarding proper sedation and postoperative complications in elderly individuals who require intraoperative sedation.MethodsThis study was a parallel-randomized clinical trial, which included 120 patients aged >70 years undergoing regional anesthesia and sedation. The exclusion criteria consisted of bradycardia, heart failure, respiratory failure, a Glasgow Coma Scale ≤14, liver failure and refusal to participate. Patients were divided into two groups: the first group received midazolam (MDZ), while the second group received dexmedetomidine (DEX). The doses were titrated to achieve an intraoperative Richmond Agitation-Sedation Scale (RASS) score between −3 and −1. Incidences of complications were recorded.ResultsDuring a 120 min follow-up, the depth of sedation (RASS score) revealed variations less often in the DEX group (p=0.002). Patients in the DEX group (n=67) had lower rates of intraoperative complications (19.4% vs 73.6%, p<0.001). Intraoperatively, the incidence rates of psychomotor agitation (15.1% vs 1.5%, p=0.005), arterial hypotension (28.3% vs 3.0%, p<0.001) and respiratory depression (73.6% vs 0%, p<0.001) were higher in the MDZ group (n=53). During postanesthesia care, the incidence rates of shivering (p<0.001), residual sedation (p=0.04) and use of supplemental oxygen (p<0.001) were significantly lower in the DEX group.ConclusionsThe use of DEX for sedation during surgery provides better control over the depth of sedation and produces fewer complications in elderly individuals.Trial registration numberNCT02878837.
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Abstract
There is a continued mandate for practicing evidence-based medicine and the prerequisite rigorous analysis of the comparative effectiveness of alternative treatments. There is also an increasing emphasis on delivering value-based health care. Both these high priorities and their related endeavors require correct information about the outcomes of care. Accurately measuring and confirming health care outcomes are thus likely now of even greater importance. The present basic statistical tutorial focuses on the germane topic of psychometrics. In its narrower sense, psychometrics is the science of evaluating the attributes of such psychological tests. However, in its broader sense, psychometrics is concerned with the objective measurement of the skills, knowledge, and abilities, as well as the subjective measurement of the interests, values, and attitudes of individuals-both patients and their clinicians. While psychometrics is principally the domain and content expertise of psychiatry, psychology, and social work, it is also very pertinent to patient care, education, and research in anesthesiology, perioperative medicine, critical care, and pain medicine. A key step in selecting an existing or creating a new health-related assessment tool, scale, or survey is confirming or establishing the usefulness of the existing or new measure; this process conventionally involves assessing its reliability and its validity. Assessing reliability involves demonstrating that the measurement instrument generates consistent and hence reproducible results-in other words, whether the instrument produces the same results each time it is used in the same setting, with the same type of subjects. This includes interrater reliability, intrarater reliability, test-retest reliability, and internal reliability. Assessing validity is answering whether the instrument is actually measuring what it is intended to measure. This includes content validity, criterion validity, and construct validity. In evaluating a reported set of research data and its analyses, in a similar manner, it is important to assess the overall internal validity of the attendant study design and the external validity (generalizability) of its findings.
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Affiliation(s)
- Thomas R. Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Catherine Cubbin
- Steve Hicks School of Social Work at the University of Texas at Austin, Austin, Texas
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Abstract
PURPOSE OF REVIEW Procedures are increasingly being performed in the acute care setting, outside of the operating rooms (OR). This article aims to review the current literature on out-of-OR procedural sedation with a focus on the ICU and emergency department, highlighting the following topics: multidisciplinary team approach, choice of pharmacologic agent, sedation scales, current safety guidelines, anticipating complications, appropriate monitoring and necessary resources. RECENT FINDINGS Subjective assessment of sedation using sedation scales is controversial. Addition of ketamine and dexmedetomidine to propofol for sedation improves patient and proceduralist satisfaction. The short-acting benzodiazepine remimazolam shows promise in initial phase 2 trials. Use of capnography for monitoring during sedation is being challenged by new literature from the emergency department setting. Hypoxia is the most common adverse event with procedural sedation, and the risk of pulmonary aspiration is low. SUMMARY Multimodal/synergistic sedation under a multidisciplinary team provides the best patient satisfaction. Collection and analysis of physiological data and outcomes of patients undergoing procedural sedation is necessary to maintain compliance with regulatory bodies. There is a paucity of comprehensive guidelines for conducting research in procedural sedation; therefore, it is being currently addressed by the Sedation Consortium.
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Williams MR, Nayshtut M, Hoefnagel A, McKeown A, Carlson DW, Cravero J, Lightdale J, Mason KP, Wilson S, Turk DC, Dworkin RH, Ward DS. Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials. Anesth Analg 2018; 126:956-967. [DOI: 10.1213/ane.0000000000002456] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ward DS, Williams MR, Turk DC, Dworkin RH, Sessler DI, Dexter F. Recommendations for Procedural Sedation Clinical Trials. Anesth Analg 2017; 125:703-704. [DOI: 10.1213/ane.0000000000002225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dionne RA. Raise the bar for safe sedation, not barriers for access to care. J Am Dent Assoc 2017; 148:133-137. [DOI: 10.1016/j.adaj.2016.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/06/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
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Who Should Provide Investigators With Direction on How to Conduct Clinical Trials of Procedural Sedation? Anesth Analg 2017; 124:722-723. [PMID: 28207442 DOI: 10.1213/ane.0000000000001853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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