Health Status Perception and Psychological Sequelae in Buried Victims: An Observational Study on Survivors of the Earthquake in Amatrice (Italy), Three Years Later

INTRODUCTION

The extrication from rubble is particularly critical for the survival of the victims of an earthquake. Early repeated infusion of sedative agents (SAs) in the acute trauma phase may interfere with neural processes leading to posttraumatic stress disorder (PTSD).

STUDY OBJECTIVE

This study aimed to analyze the psychological status reported by the buried victims of the earthquake in Amatrice (August 24, 2016; Italy) by considering type of the SAs administered during the extrication maneuvers.

METHODS

This was an observational study on data from 51 patients directly rescued under the rubble during the earthquake in Amatrice. During extrication maneuvers, a moderate sedation was administered by titrating ketamine (0.3-0.5mg/kg) or morphine (0.1-0.15mg/kg) with respect to the Richmond Agitation and Sedation Scale (RASS; between -2 and -3) in buried victims.Three years following the rescue, the survivors were interviewed on their perceived health status and stress using a questionnaire which consisted of 17 items: the standard four-item set of healthy days core questions (CDC HRQOL-4); the 12-item General Health Questionnaire (GHQ-12); and in addition, survivors were asked if they had a diagnosis for anxiety, depression, or for PTSD.

RESULTS

The study analyzed data from the complete clinical documentation of 51 survivors; 30 were males and 21 females, with an average age of 52 years. Twenty-six (26) subjects were treated with ketamine, while 25 were treated with morphine, during the extrication procedures. Concerning the quality-of-life analysis, only 10 survivors out of 51 perceived their health status as good; the others reported psychological disorders. The GHQ-12 scores showed that all survivors had psychological distress with a mean total score of 22.2 (SD = 3.5). Eighteen (18) victims declared to have had a diagnosis of generalized anxiety (35%), while 29 were treated for depression (57%) and PTSD (57%) by a specialist. With regards to the perceived distress level and the anxiety disorder, this analysis showed significant associations with SAs used during extrication, with a better performance for ketamine than for morphine.

CONCLUSION

These findings suggest investigating whether early sedation with ketamine directly in the disaster setting may promote the prophylaxis and reduce the risk of developing trauma-related disorders (TRDs) on the buried victims of major natural disasters in future studies.

Comparative Effectiveness of Midazolam, Propofol, and Dexmedetomidine in Patients With or at Risk for Acute Respiratory Distress Syndrome: A Propensity Score-Matched Cohort Study

Background: Sedatives are commonly used in patients with or at risk for acute respiratory distress syndrome (ARDS) during mechanical ventilation. To systematically compare the outcomes of sedation with midazolam, propofol, and dexmedetomidine in patients with or at risk for ARDS.

Methods: We developed a dataset of real-world data to enable the comparison of the effectiveness and safety of sedatives and the associated outcomes from the MIMIC-III database and the eICU Collaborative Research database. We performed a systematic study with six cohorts to estimate the relative risks of outcomes among patients administered different sedatives. Propensity score matching was performed to generate a balanced 1:1 matched cohort and to identify potential prognostic factors. The outcomes included hospital mortality, duration of mechanical ventilation, length of intensive care unit stay, length of hospitalization, and likelihood of being discharged home.

Results: We performed 60 calibrated analyses among all groups and outcomes with 17,410 eligible patients. Sedation with dexmedetomidine was associated with a lower in-hospital mortality rate than sedation with midazolam and propofol or sedation without dexmedetomidine (p < 0.001). When compared with no sedation, the use of midazolam, propofol or dexmedetomidine was associated with a longer ICU stay and longer hospitalization duration (p < 0.01). Patients treated with midazolam were relatively less likely to be discharged home (p < 0.05).

Conclusion: Patients treated with dexmedetomidine had a reduced risk of mortality. These data suggest that dexmedetomidine may be the preferred sedative in patients with or at risk for ARDS.

Propofol for gastrointestinal endoscopy

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.

Comparison of dexmedetomidine with on-demand midazolam versus midazolam alone for procedural sedation during endoscopic submucosal dissection of gastric tumor

OBJECTIVE

Endoscopic submucosal dissection (ESD) is commonly performed as a treatment for gastric neoplasms. However, sedation with midazolam (MDZ) often does not reach satisfactory sedation levels during the procedure and the drug may suppress respiration and blood pressure. This study aimed to investigate the safety and efficacy of dexmedetomidine (DEX) with on-demand MDZ (the DEX group) in comparison with MDZ alone (the MDZ group) as a sedative during ESD of gastric neoplasms.

METHODS

Eighty patients undergoing ESD for gastric tumor were randomly assigned to one of two treatment regimens (40 patients in each). We investigated the depth of sedation by using a Modified Observers Assessment Alertness/Sedation score, the number of patients' reactions interfering with the procedure, sedation related-adverse events and the degree of satisfaction of patients and doctors.

RESULTS

There was no statistically significant difference between the two groups regarding their age, gender, body mass index, American Society of Anesthesiologists physical status classification and the characteristics of the tumor. Appropriate sedation rate and the degree of satisfaction of the doctors were significantly higher in the DEX group than in the MDZ group. Patients' reactions interfering with the procedure were more numerous in the MDZ group than in the DEX group. There was no significant difference in adverse events between the two groups.

CONCLUSIONS

DEX with on-demand MDZ for sedation during gastric ESD is as safe as MDZ alone and the sedation effect of DEX with MDZ is superior to that of MDZ alone.

Instruments for monitoring intensive care unit sedation

Although many promising objective methods (measuring systems) are available, there are no truly validated instruments for monitoring intensive care unit (ICU) sedation. Auditory evoked potentials can be used only for research in patients with a deep level of sedation. Other measuring systems require further development and validation to be useful in the ICU. Continuing research will provide an objective system to improve the monitoring and controlling of this essential treatment for ICU patients. Subjective methods (scoring systems) that are based on clinical observation have proven their usefulness in guiding sedative therapy. The Glasgow Coma Score modified by Cook and Palma (GCSC) achieves good face validity and reliability, which assures its clinical utility for routine practice and research. Other scales, in particular the Ramsay Scale, can be recommended preferably for clinical use. An accurate use of available instruments can improve the sedative treatment that we deliver to our patients.