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Zhang Y, Zhang N, Hu J, Liu C, Li G. Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP. BMC Gastroenterol 2024; 24:124. [PMID: 38566038 PMCID: PMC10985874 DOI: 10.1186/s12876-024-03197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Proper sedation of patients, particularly elderly individuals, who are more susceptible to sedation-related complications, is of significant importance in endoscopic retrograde cholangiopancreatography (ERCP). This study aims to assess the safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation in elderly patients undergoing ERCP, compared to a group of middle-aged patients. METHODS The medical records of 610 patients with common bile duct stones who underwent elective ERCP under deep sedation with a three-drug regimen, including midazolam, alfentanil, and propofol at Shandong Provincial Third Hospital from January 2023 to September 2023 were retrospectively reviewed in this study. Patients were categorized into three groups: middle-aged (50-64 years, n = 202), elderly (65-79 years, n = 216), and very elderly (≥ 80 years, n = 192). Intraoperative vital signs and complications were compared among these groups. RESULTS The three groups showed no significant difference in terms of intraoperative variation of systolic blood pressure (P = 0.291), diastolic blood pressure (P = 0.737), heart rate (P = 0.107), peripheral oxygen saturation (P = 0.188), bispectral index (P = 0.158), and the occurrence of sedation-related adverse events including hypotension (P = 0.170) and hypoxemia (P = 0.423). CONCLUSION The results suggest that a low-dose three-drug regimen consisting of midazolam, alfentanil, and propofol seems safe and effective for deep sedation of elderly and very elderly patients undergoing ERCP procedures. However, further studies are required to verify these findings and clarify the benefits and risks of this method.
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Affiliation(s)
- Yanping Zhang
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Ning Zhang
- Department of Cardiopulmonary rehabilitation, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Jing Hu
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Changlin Liu
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Guanjun Li
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China.
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Armstrong-Hough M, Lin P, Venkatesh S, Ghous M, Hough CL, Cook SH, Iwashyna TJ, Valley TS. Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial. Ann Am Thorac Soc 2024; 21:620-626. [PMID: 38324712 PMCID: PMC10995555 DOI: 10.1513/annalsats.202307-600oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/05/2024] [Indexed: 02/09/2024] Open
Abstract
Rationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.
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Affiliation(s)
- Mari Armstrong-Hough
- Department of Epidemiology and
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York
| | - Paul Lin
- Institute for Healthcare Policy and Innovation
| | | | - Muhammad Ghous
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Stephanie H. Cook
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York
| | - Theodore J. Iwashyna
- Department of Medicine and Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland; and
| | - Thomas S. Valley
- Institute for Healthcare Policy and Innovation
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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Chen B, Lu L, Zhai J, Hua Z. Effect of moderate versus deep sedation on recovery following outpatient gastroscopy in older patients: a randomized controlled trial. Surg Endosc 2024; 38:1273-1282. [PMID: 38102399 DOI: 10.1007/s00464-023-10642-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Although gastrointestinal endoscopy with sedation is increasingly performed in older patients, the optimal level of sedation remains open to debate. In this study, our objective was to compare the effects of moderate sedation (MS) and deep sedation (DS) on recovery following outpatient gastroscopy in elderly patients. METHODS In this randomized, partially blinded, controlled trial, we randomly divided 270 patients older than 60 years who were scheduled for elective outpatient gastroscopy into the MS or DS group based on the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). Secondary outcomes included the duration of the total hospital stay, frequency of retching, bucking, and body movements during the examination, endoscopist and patient satisfaction, and sedation-associated adverse events during the procedure. RESULTS A total of 264 patients completed the study, of whom 131 received MS and 133 received DS. MS was associated with a shorter PACU stay [16.15 ± 9.01 min vs. 20.02 ± 11.13 min, P < 0.01] and total hospital stay [27.32 ± 9.86 min vs. 30.82 ± 12.37 min, P < 0.05], lesser hypoxemia [2.3% (3/131) vs. 12.8% (17/133), P < 0.01], use of fewer vasoactive drugs (P < 0.001), and more retching (P < 0.001). There was no difference in the incidence of bucking and body movements or endoscopist and patient satisfaction between the two groups. CONCLUSION Compared to deep sedation, moderate sedation may be a preferable choice for American Society of Anesthesiologists (ASA) Grade I-III elderly patients undergoing outpatient gastroscopies, as demonstrated by shorter PACU stays and total hospital stays, lower sedation-associated adverse events, and similar levels of endoscopist and patient satisfaction.
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Affiliation(s)
- Bing Chen
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China
| | - Lin Lu
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China
| | - Jie Zhai
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China
| | - Zhen Hua
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China.
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Hunt A, Olin S, Whittemore JC, Esteller-Vico A, Springer C, Giori L. The effects of selected sedatives on basal and stimulated serum cortisol concentrations in healthy dogs. PeerJ 2024; 12:e16955. [PMID: 38406286 PMCID: PMC10885794 DOI: 10.7717/peerj.16955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Background Hormone assessment is typically recommended for awake, unsedated dogs. However, one of the most commonly asked questions from veterinary practitioners to the endocrinology laboratory is how sedation impacts cortisol concentrations and the adrenocorticotropic hormone (ACTH) stimulation test. Butorphanol, dexmedetomidine, and trazodone are common sedatives for dogs, but their impact on the hypothalamic-pituitary-adrenal axis (HPA) is unknown. The objective of this study was to evaluate the effects of butorphanol, dexmedetomidine, and trazodone on serum cortisol concentrations. Methods Twelve healthy beagles were included in a prospective, randomized, four-period crossover design study with a 7-day washout. ACTH stimulation test results were determined after saline (0.5 mL IV), butorphanol (0.3 mg/kg IV), dexmedetomidine (4 µg/kg IV), and trazodone (3-5 mg/kg PO) administration. Results Compared to saline, butorphanol increased basal (median 11.75 µg/dL (range 2.50-23.00) (324.13 nmol/L; range 68.97-634.48) vs 1.27 µg/dL (0.74-2.10) (35.03 nmol/L; 20.41-57.93); P < 0.0001) and post-ACTH cortisol concentrations (17.05 µg/dL (12.40-26.00) (470.34 nmol/L; 342.07-717.24) vs 13.75 µg/dL (10.00-18.90) (379.31 nmol/L; 275.96-521.38); P ≤ 0.0001). Dexmedetomidine and trazodone did not significantly affect basal (1.55 µg/dL (range 0.75-1.55) (42.76 nmol/L; 20.69-42.76); P = 0.33 and 0.79 µg/dL (range 0.69-1.89) (21.79 nmol/L; 19.03-52.14); P = 0.13, respectively, vs saline 1.27 (0.74-2.10) (35.03 nmol/L; 20.41-57.93)) or post-ACTH cortisol concentrations (14.35 µg/dL (range 10.70-18.00) (395.86 nmol/L; 295.17-496.55); (P = 0.98 and 12.90 µg/dL (range 8.94-17.40) (355.86 nmol/L; 246.62-480); P = 0.65), respectively, vs saline 13.75 µg/dL (10.00-18.60) (379.31 nmol/L; 275.86-513.10). Conclusion Butorphanol administration should be avoided prior to ACTH stimulation testing in dogs. Further evaluation of dexmedetomidine and trazodone's effects on adrenocortical hormone testing in dogs suspected of HPA derangements is warranted to confirm they do not impact clinical diagnosis.
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Affiliation(s)
- Adam Hunt
- Department of Small Animal Clinical Sciences, University of Tennessee, College of Veterinary Medicine, Knoxville, TN, United States of America
| | - Shelly Olin
- Department of Small Animal Clinical Sciences, University of Tennessee, College of Veterinary Medicine, Knoxville, TN, United States of America
| | | | - Alejandro Esteller-Vico
- University of Tennessee, College of Veterinary Medicine, Department of Biomedical and Diagnostic Sciences, TN, United States of America
| | - Cary Springer
- Research Computing Support, Office of Information Technology, University of Tennessee–Knoxville, Knoxville, TN, United States of America
| | - Luca Giori
- University of Tennessee, College of Veterinary Medicine, Department of Biomedical and Diagnostic Sciences, TN, United States of America
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Wei J, Zhang X, Min K, Zhou H, Shi X, Deng H, Mo W, Wei H, Gu Y, Lv X. Supraglottic Jet Oxygenation and Ventilation to Minimize Hypoxia in Patients Receiving Flexible Bronchoscopy Under Deep Sedation: A 3-Arm Randomized Controlled Trial. Anesth Analg 2024; 138:456-464. [PMID: 37874765 DOI: 10.1213/ane.0000000000006678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
BACKGROUND Hypoxia often occurs due to shared airway and anesthetic sedation-induced hypoventilation in patients receiving flexible bronchoscopy (FB) under deep sedation. Previous evidence has shown that supraglottic jet oxygenation and ventilation (SJOV) via Wei nasal jet tube (WNJ) reduces the incidence of hypoxia during FB. This study aimed to investigate the extent to which SJOV via WNJ could decrease the incidence of hypoxia in patients under deep sedation as compared to oxygen supplementation via WNJ alone or nasal catheter (NC) for oxygen supplementation during FB. METHODS This was a single-center 3-arm randomized controlled trial (RCT). Adult patients scheduled to undergo FB were randomly assigned to 3 groups: NC (oxygen supplementation via NC), low-pressure low-flow (LPLF) (low-pressure oxygen supplementation via WNJ alone), or SJOV (high-pressure oxygen supplementation via WNJ). The primary outcome was hypoxia (defined as peripheral saturation of oxygen [Sp o2 ] <90% lasting more than 5 seconds) during FB. Secondary outcomes included subclinical respiratory depression or severe hypoxia, and rescue interventions specifically performed for hypoxia treatment. Other evaluated outcomes were sore throat, xerostomia, nasal bleeding, and SJOV-related barotraumatic events. RESULTS One hundred and thirty-two randomized patients were included in 3 interventions (n = 44 in each), and all were included in the final analysis under intention to treat. Hypoxia occurred in 4 of 44 patients (9.1%) allocated to SJOV, compared to 38 of 44 patients (86%) allocated to NC, with a relative risk (RR) for hypoxia, 0.11; 98% confidence interval (CI), 0.02-0.51; P < .001; or to 27 of 44 patients (61%) allocated to LPLF, with RR for hypoxia, 0.15; 95% CI, 0.04-0.61; P < .001, respectively. The percentage of subclinical respiratory depression was also significantly diminished in patients with SJOV (39%) compared with patients with NC (100%) or patients with LPLF (96%), both P < .001. In SJOV, no severe hypoxia event occurred. More remedial interventions for hypoxia were needed in the patients with NC. Higher risk of xerostomia was observed in patients with SJOV. No severe adverse event was observed throughout the study. CONCLUSIONS SJOV via WNJ effectively reduces the incidence of hypoxia during FB under deep sedation.
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Affiliation(s)
- Juan Wei
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaowei Zhang
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Anesthesiology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Keting Min
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Graduate School, Wannan Medical College, Wuhu, China
| | - Huanping Zhou
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xuan Shi
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Huimin Deng
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Mo
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Graduate School, Wannan Medical College, Wuhu, China
| | - Huafeng Wei
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yang Gu
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xin Lv
- From the Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Schiedat F, Fischer J, Aweimer A, Schöne D, El-Battrawy I, Hanefeld C, Mügge A, Kloppe A. Success and safety of deep sedation as a primary anaesthetic approach for transvenous lead extraction: a retrospective analysis. Sci Rep 2023; 13:22964. [PMID: 38151554 PMCID: PMC10752869 DOI: 10.1038/s41598-023-50372-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/19/2023] [Indexed: 12/29/2023] Open
Abstract
There is a rising number in complications associated with more cardiac electrical devices implanted (CIED). Infection and lead dysfunction are reasons to perform transvenous lead extraction. An ideal anaesthetic approach has not been described yet. Most centres use general anaesthesia, but there is a lack in studies looking into deep sedation (DS) as an anaesthetic approach. We report our retrospective experience for a large number of procedures performed with deep sedation as a primary approach. Extraction procedures performed between 2011 and 2018 in our electrophysiology laboratory have been included retrospectively. We began by applying a bolus injection of piritramide followed by midazolam as primary medication and would add etomidate if necessary. For extraction of leads a stepwise approach with careful traction, locking stylets, dilator sheaths, mechanical rotating sheaths and if needed snares and baskets has been used. A total of 780 leads in 463 patients (age 69.9 ± 12.3, 31.3% female) were extracted. Deep sedation was successful in 97.8% of patients. Piritramide was used as the main analgesic medication (98.5%) and midazolam as the main sedative (94.2%). Additional etomidate was administered in 15.1% of cases. In 2.2% of patients a conversion to general anaesthesia was required as adequate level of DS was not achieved before starting the procedure. Sedation related complications occurred in 1.1% (n = 5) of patients without sequalae. Deep sedation with piritramide, midazolam and if needed additional etomidate is a safe and feasible strategy for transvenous lead extraction.
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Affiliation(s)
- Fabian Schiedat
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University, Bochum, Germany.
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Academic Hospital of the Ruhr University Bochum, Gelsenkirchen, Germany.
| | - Julian Fischer
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Academic Hospital of the Ruhr University Bochum, Gelsenkirchen, Germany
| | - Assem Aweimer
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University, Bochum, Germany
| | - Dominik Schöne
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Academic Hospital of the Ruhr University Bochum, Gelsenkirchen, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University, Bochum, Germany
- Department of Molecular and Experimental Cardiology, Institut Für Forschung Und Lehre (IFL), Ruhr-University, Bochum, Germany
| | - Christoph Hanefeld
- Department of Cardiology at Katholische Kliniken Bochum of the Ruhr University, Bochum, Germany
| | - Andreas Mügge
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University, Bochum, Germany
- Department of Cardiology at Katholische Kliniken Bochum of the Ruhr University, Bochum, Germany
| | - Axel Kloppe
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Academic Hospital of the Ruhr University Bochum, Gelsenkirchen, Germany
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Vural Ç, Kocaoğlu MH, Akbarihamed R, Demirel A. A Retrospective Investigation of Patient- and Procedure-Related Factors Associated with Cardiorespiratory Complications in Pediatric Dental Patients Undergoing Deep Sedation. Pediatr Dent 2023; 45:511-519. [PMID: 38129752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Purpose: The purposes of this retrospective study were to investigate the incidence of cardiac and respiratory complications in pediatric patients undergoing dental procedures with deep propofol sedation and examine the factors that may lead to the development of these complica- tions. Methods: This study was carried out using the records of 421 pediatric patients who received dental treatment with deep sedation. Previously recorded cardiac/respiratory complications were noted. In addition, factors such as age, gender, body mass index (BMI), propofol induction/ infusion/total dose, operation duration, and the presence of comorbidities, which were investigated whether they affect these complications, were also noted. Data were analyzed with Mann-Whitney U, chi-square, and Fisher exact tests using univariable and multivariable logistic regression analyses. A level of five percent was considered to indicate statistical significance. Results: There were no significant differences between the cases with and without complications in terms of gender, age, BMI, total propofol dose, and operation time (P=0.887, P=0.827, P=0.213, P=0.581, and P=0.081, respectively). According to the multivariable logistic regression analysis, trisomy 21, heart disease, and asthma were found to be significant risk factors for the development of these complications (odds ratios equal 9.776, 3.257, and 14.646, respectively, 95 percent confidence interval; 3.807-25.100, 1.095-9.690, 4.110-52.188, respectively). Conclusion: Considering the limitations of this study, to minimize cardio-respiratory complications it is recommended that patients with comorbidities should not be managed with deep sedation and an open airway.
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Affiliation(s)
- Çağıl Vural
- Faculty of Dentistry, Ankara University, Ankara, Turkey
| | | | | | - Akif Demirel
- Faculty of Dentistry, Ankara University, Ankara, Turkey
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Gandhi HA, Olson G, Lee H, Zouaidi K, Yansane A, Walji M, Kalenderian E, Tokede B. Assessing the safety of deep sedation in outpatient pediatric oral health care. J Am Dent Assoc 2023; 154:975-983.e1. [PMID: 37676186 DOI: 10.1016/j.adaj.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/12/2023] [Accepted: 07/24/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Children are the patient subgroup with the lowest error tolerance regarding deep sedation (DS)-supported care. This study assessed the safety of DS-supported pediatric dental treatment carried out in an outpatient setting through retrospective review of patient charts. METHODS An automated script was developed to identify charts of pediatric patients who underwent DS-supported dental procedures from 2017 through 2019 at a dental clinic. Charts were assessed for the presence of sedation-related adverse events (AEs). A panel of experts performed a second review and confirmed or refuted the designation of AE (by the first reviewer). AEs were classified with the Tracking and Reporting Outcomes of Procedural Sedation system. RESULTS Of the 175 DS cases, 19 AEs were identified in 15 cases (8.60%). Using the Tracking and Reporting Outcomes of Procedural Sedation classification system, 7 (36.84%) events were related to the airway and breathing category, 9 (47.37%) were related to sedation quality (including a dizzy patient who fell at the checkout desk and sustained a head laceration), and 3 (15.79%) were classified as an allergy. CONCLUSION This study suggests an AE (whether relatively minor or of potentially major consequence) occurs in 1 of every 12 DS cases involving pediatric patients, performed at an outpatient dental clinic. Larger studies are needed, in addition to root cause analyses. PRACTICAL IMPLICATIONS As dentists increasingly pivot in the use of DS services from in-hospital to outpatient settings, patients expect comparable levels of safety. This work helps generate evidence to drive targeted efforts to improve the safety and reliability of pediatric outpatient sedation.
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Li X, Wei J, Shen N, Lu T, Xing J, Mai K, Li J, Hei Z, Chen C. Modified Manual Chest Compression for Prevention and Treatment of Respiratory Depression in Patients Under Deep Sedation During Upper Gastrointestinal Endoscopy: Two Randomized Controlled Trials. Anesth Analg 2023; 137:859-869. [PMID: 37010960 DOI: 10.1213/ane.0000000000006447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND We aimed to determine the preventive and therapeutic efficacy of modified manual chest compression (MMCC), a novel noninvasive and device-independent method, in reducing oxygen desaturation events in patients undergoing upper gastrointestinal endoscopy under deep sedation. METHODS A total of 584 outpatients who underwent deep sedation during upper gastrointestinal endoscopy were enrolled. In the preventive cohort, 440 patients were randomized to the MMCC group (patients received MMCC when their eyelash reflex disappeared, M1 group) or control group (C1 group). In the therapeutic cohort, 144 patients with oxygen desaturation of a Sp o2 < 95% were randomized to MMCC group (patients who subsequently received MMCC, M2 group) or the conventional treatment group (C2 group). The primary outcomes were the incidence of desaturation episodes with an Sp o2 < 95% for the preventive cohort and the time spent below 95% Sp o2 for the therapeutic cohort. Secondary outcomes included the incidence of gastroscopy withdrawal and diaphragmatic pause. RESULTS In the preventive cohort, MMCC reduced the incidence of desaturation episodes <95% (14.4% vs 26.1%; RR, 0.549; 95% confidence interval [CI], 0.37-0.815; P = .002), gastroscopy withdrawal (0% vs 2.29%; P = .008), and diaphragmatic pause at 30 seconds after propofol injection (74.5% vs 88.1%; RR, 0.846; 95% CI, 0.772-0.928; P < .001). In the therapeutic cohort, patients who received MMCC had a significantly shorter time spent below 95% Sp o2 (40 [20-69] seconds vs 91 [33-152] seconds, median difference [95% CI], -39 [-57 to -16] seconds, P < .001), a lower incidence of gastroscopy withdrawal (0% vs 10.4%, P = .018), and more enhanced diaphragmatic movement at 30 seconds after Sp o2 <95% (1.11 [0.93-1.4] cm vs 1.03 [0.7-1.24] cm; median difference [95% confidence interval], 0.16 [0.02-0.32] cm; P = .015). CONCLUSIONS MMCC may exert preventive and therapeutic effects against oxygen desaturation events during upper gastrointestinal endoscopy.
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Affiliation(s)
- Xiaoyun Li
- From the Department of Anaesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Tunç M, Sazak H, Öztürk A, Yılmaz A, Alagöz A. Safety of geriatric patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration with deep sedation: a retrospective study. BMC Anesthesiol 2023; 23:276. [PMID: 37587423 PMCID: PMC10428560 DOI: 10.1186/s12871-023-02241-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/11/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be performed in a wide range, from minimal sedation to general anesthesia. Advanced age increases perioperative risks related to anesthesia and is also associated with many pathological processes that further increase morbidity and mortality. The ideal sedation protocol for EBUS-TBNA has yet to be determined in geriatric patients. Deep sedation (DS) may increase the safety and performance of the procedure. There are limited studies evaluating the effectiveness and safety of EBUS-TBNA under DS in elderly patients. METHODS 280 patients who underwent EBUS-TBNA under DS were included in this retrospective study. 156 patients aged 65 years and over (Group 1) and 124 patients under 45 (Group 2) were compared. Demographic data, comorbidities, pulmonary function tests (PFTs), hemodynamic measurements, and peripheral oxygen saturation (SpO2) before the procedure were evaluated. In addition, the duration of the EBUS-TBNA procedure, sedation agents and dosages, recovery time, and complications related to the procedure in the 24 h and applied medications and treatments were recorded. RESULTS There was no difference in body mass index, EBUS-TBNA procedure duration, and recovery time between geriatric and young patients(p > 0.05). The proportion of female patients, pre-anesthesia SpO2, and PFTs were found to be significantly lower in geriatric patients(p < 0.05). ASA classification, frequency of comorbidities, and initial mean arterial pressure were found to be significantly higher in the geriatric group(p < 0.05). The propofol-ketamine combination was the most preferred sedative in both groups. The dose of propofol used in the regimen in which propofol was administered alone was found to be lower in the elderly group (p < 0.05). The increase in the HR was significant in Group 2 in the T4 and T5 periods with respect to T1 when the differences were compared (p < 0.05). As a complication, the frequency of high blood pressure during the procedure was higher in the elderly group (p < 0.05). CONCLUSIONS The EBUS-TBNA procedure performed under DS was safe in elderly and young patients. Our study showed that the procedure and recovery times were similar in the elderly and young groups. The incidence of temporary high blood pressure during the procedure was higher in the elderly patients. The other complication rates during the procedure were similar in groups. Decreased propofol dose in the regimen using propofol alone has shown us that anesthetists are more sensitive to the administration of sedative agents in geriatric patients, taking into account comorbidities and drug interactions.
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Affiliation(s)
- Mehtap Tunç
- Department of Anesthesiology and Reanimation, University of Health Sciences, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey.
| | - Hilal Sazak
- Department of Anesthesiology and Reanimation, University of Health Sciences, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey
| | - Ayperi Öztürk
- Department of Anesthesiology and Reanimation, University of Health Sciences, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey
| | - Aydın Yılmaz
- Department of Interventional Pulmonology, University of Health Sciences, Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - Ali Alagöz
- Department of Anesthesiology and Reanimation, University of Health Sciences, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey
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Iacopino S, Colella J, Dini D, Mantovani L, Sorrenti PF, Malacrida M, Filannino P. Sedation strategies for pulsed-field ablation of atrial fibrillation: focus on deep sedation with intravenous ketamine in spontaneous respiration. Europace 2023; 25:euad230. [PMID: 37494101 PMCID: PMC10434732 DOI: 10.1093/europace/euad230] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/20/2023] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
AIMS A standardized sedation protocol for pulsed-field ablation (PFA) of atrial fibrillation (AF) through irreversible cellular electroporation has not been well established. We report our experience of a protocol for deep sedation with ketamine in spontaneous respiration during the PFA of AF. METHODS AND RESULTS All consecutive patients undergoing PFA for AF at our center were included. Our sedation protocol involves the intravenous administration of fentanyl (1.5 mcg/kg) and midazolam (2 mg) at low doses before local anesthesia with lidocaine. A ketamine adjunct (1 mg/kg) was injected about 5 minutes before the first PFA delivery. We enrolled 66 patients (age = 59 ± 9 years, 78.8% males, body mass index = 28.8 ± 5 kg/m2, fluoroscopy time = 21[15-30] min, skin-to-skin time = 75[60-100] min and PFA LA dwell time = 25[22-28] min). By the end of the procedure, PVI had been achieved in all patients by means of PFA alone. The mean time under sedation was 56.4 ± 6 min, with 50 (76%) patients being sedated for less than 1 hour. A satisfactory Ramsey Sedation Scale level before ketamine infusion was achieved in all patients except one (78.8% of the patients with rank 3; 19.7% with rank 2). In all procedures, the satisfaction level was found to be acceptable by both the patient and the primary operator (Score = 0 in 98.5% of cases). All patients reported none or mild pain. No major procedure or anesthesia-related complications were reported. CONCLUSION Our standardized sedation protocol with the administration of drugs with rapid onset and pharmacological offset at low doses was safe and effective, with an optimal degree of patient and operator satisfaction. CLINICAL TRIAL REGISTRATION Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA). URL: http://clinicaltrials.gov/Identifier: NCT05617456.
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Affiliation(s)
- Saverio Iacopino
- Electrophysiology Unit, GVM Care&Research, Maria Cecilia Hospital, Cotignola, 48033 RA, Italy
| | - Jacopo Colella
- Electrophysiology Unit, GVM Care&Research, Maria Cecilia Hospital, Cotignola, 48033 RA, Italy
| | - Daniele Dini
- Electrophysiology Unit, GVM Care&Research, Maria Cecilia Hospital, Cotignola, 48033 RA, Italy
| | - Lorenzo Mantovani
- Electrophysiology Unit, GVM Care&Research, Maria Cecilia Hospital, Cotignola, 48033 RA, Italy
| | | | - Maurizio Malacrida
- Medical Education & Scientific Affairs, Boston Scientific, 20134, Milan, Italy
| | - Pasquale Filannino
- Electrophysiology Unit, GVM Care&Research, Maria Cecilia Hospital, Cotignola, 48033 RA, Italy
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12
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Pacheco de Vasconcelos SR, Alcántara Montero A, Fernández Bermejo M. Green discoloration of the urine following sedation with propofol for colonoscopy. Rev Esp Enferm Dig 2023; 115:393-394. [PMID: 36177819 DOI: 10.17235/reed.2022.9125/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Propofol (2,6-diisopropylphenol) is the most widely used drug for endoscopic procedures under deep sedation. We present the clinical case of an 83-year-old man who underwent a colonoscopy under sedation with propofol, observing a green discolouration of the urine during the procedure.
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13
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Althoff FC, Agnihotri A, Grabitz SD, Santer P, Nabel S, Tran T, Berzin TM, Sundar E, Xu X, Sawhney MS, Eikermann M. Outcomes after endoscopic retrograde cholangiopancreatography with general anaesthesia versus sedation. Br J Anaesth 2020; 126:191-200. [PMID: 33046219 DOI: 10.1016/j.bja.2020.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/20/2020] [Accepted: 08/08/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND We tested the primary hypothesis that use of general anaesthesia vs sedation increases vulnerability to adverse discharge (in-hospital mortality or new discharge to a nursing facility) after endoscopic retrograde cholangiopancreatography (ERCP). METHODS In this retrospective cohort study, adult patients undergoing ERCP with general anaesthesia or sedation at a tertiary care hospital were included. We calculated adjusted absolute risk differences between patients receiving general anaesthesia vs sedation using provider preference-based instrumental variable analysis. We also used mediation analysis to determine whether intraoperative hypotension during general anaesthesia mediated its effect on adverse discharge. RESULTS Among 17 538 patients undergoing ERCP from 2007 through 2018, 16 238 received sedation and 1300 received GA. Rates of adverse discharge were 5.8% (n=938) after sedation and 16.2% (n=210) after general anaesthesia. Providers' adjusted mean predicted probabilities of using general anaesthesia for ERCP ranged from 0.2% to 63.2% of individual caseloads. Utilising provider-related variability in the use of general anaesthesia for instrumental variable analysis resulted in an 8.6% risk increase (95% confidence interval, 4.5-12.6%; P<0.001) in adverse discharge among patients receiving general anaesthesia vs sedation. Intraoperative hypotensive events occurred more often during general anaesthesia and mediated 23.8% (95% confidence interval, 3.9-43.7%: P=0.019) of the primary association. CONCLUSIONS These results suggest that use of sedation during ERCP facilitates reduced adverse discharge for patients for whom general anaesthesia is not clearly indicated. Intraoperative hypotension during general anaesthesia for ERCP partly mediates the increased vulnerability to adverse discharge.
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Affiliation(s)
- Friederike C Althoff
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Abhishek Agnihotri
- Department of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Stephanie D Grabitz
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah Nabel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tuyet Tran
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tyler M Berzin
- Department of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Eswar Sundar
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mandeep S Sawhney
- Department of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Essen-Duisburg University, Medical Faculty, Essen, Germany.
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Barends CRM, Driesens MK, van Amsterdam K, Struys MMRF, Absalom AR. Moderate-to-Deep Sedation Using Target-Controlled Infusions of Propofol and Remifentanil: Adverse Events and Risk Factors: A Retrospective Cohort Study of 2937 Procedures. Anesth Analg 2020; 131:1173-1183. [PMID: 32925338 DOI: 10.1213/ane.0000000000004593] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In the University Medical Center Groningen in Groningen, the Netherlands, moderate-to-deep sedation is provided by nursing staff trained and supervised by the anesthesia department using protocol-based target-controlled infusions (TCIs) of propofol and remifentanil. The aim of this retrospective cohort study was to investigate the incidence of events with potential adverse health consequences within this service model and the risk factors for the occurrence of these events. METHODS We retrospectively interrogated a database containing the computerized anesthetic records of 2937 procedures where moderate-to-deep sedation was provided using TCI administration of propofol and remifentanil between May 2014 and October 2017. The primary outcome measures were the incidence of sedation-related events with potential adverse health consequences and risk factors for the occurrence of such events. The events under investigation were unplanned intensive care unit (ICU) admission, need for cardiopulmonary resuscitation (CPR), death on the day of the procedure due to sedation-related events, cardiovascular events (arrhythmias, hypertension, and hypotension), pulmonary events (aspiration, desaturation, unplanned tracheal intubation), anaphylactic or allergic reactions, and the termination of the procedure due to sedation-related events. Cardiovascular and pulmonary events were classified as severe, significant, or moderate. Events were identified by using computer algorithms to search the computerized records from all included procedures. RESULTS Data from 2937 procedures were analyzed. No patients suffered catastrophic events (death, need for CPR, or unplanned ICU admission). Thirty-two severe sedation-related events occurred in 32 procedures. Severe desaturation (0.6%; 95% confidence interval [CI], 0.4-0.9) and severe hypertension (0.2%; 95% CI, 0.04-0.37) were the most common severe events. Significant hypotension (8.8%; 95% CI, 7.73-9.77) and significant desaturation (1.6%; 95% CI, 1.12-2.02) were found to be the most common events with potential adverse health consequences. No patient suffered lasting health consequences. Average mean and maximum targeted effect-site concentrations (Cet) for propofol were 2.6 ± 0.83 and 3.3 ± 1.09 µg·mL, respectively, and for remifentanil 0.84 ± 0.18 and 0.99 ± 0.22 ng·mL, respectively. Maximum Cets of propofol were lower among patients with higher body mass index (BMI) and were higher among patients of younger age. Higher BMI was a risk factor for desaturation. Increased age and lower BMI were risk factors for hypotension. Longer procedure time was a risk factor for both desaturation and hypotension. CONCLUSIONS Moderate-to-deep sedation by propofol and remifentanil TCI has a low incidence of catastrophic and severe events.
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Affiliation(s)
- Clemens R M Barends
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mendy K Driesens
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kai van Amsterdam
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michel M R F Struys
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Anesthesia and Peri-operative Medicine, Ghent University, Ghent, Belgium
| | - Anthony R Absalom
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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15
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Tian L, Luan H, Zhu P, Zhang Z, Bao H. A randomized controlled trial for measuring effects on cognitive functions of adding ketamine to propofol during sedation for colonoscopy. Medicine (Baltimore) 2020; 99:e21859. [PMID: 32899015 PMCID: PMC7478513 DOI: 10.1097/md.0000000000021859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of adding ketamine to propofol on cognitive functions in patients undergoing sedation for colonoscopy. METHODS In this randomized, double-blinded, and controlled study, 200 patients were randomly allocated to ketamine/propofol admixture group (Group KP, n = 100), and propofol group (Group P, n = 100). Patients in Group KP received 0.25 mg/kg of ketamine and 0.5 mg/kg of propofol. Patients in Group P received 0.5 mg/kg propofol. Cognitive functions were measured using CogState battery before and after the colonoscopy procedure. Ninety five patients in Group KP and 92 patients in Group P had completed the CogStates tests and were included in the data analysis. RESULTS Compared with before procedure baseline, the performance on detection and identification tasks were significantly impaired after the procedure in both Group KP (P = .004, P = .001) and Group P patients (P = .005, P < .001). However, one-card learning accuracy and One-back memory was only impaired in Group KP patients (P = .006, P = .040) after the endoscopy but left intact in Group P patients. Group KP patients showed more severe impairment in one-card learning accuracy compared with Group P patients (P = .044). Group KP patients have better 5 minutes MAP (P = .005) and were also less likely to suffer from complications such as respiratory depression (P = .023) and hypotension (P = .015). OAA/S scores, BIS, MAP, complications, recovery times, and endoscopist and patient satisfaction were similar between the 2 groups. CONCLUSION Although adding ketamine to propofol for sedation in colonoscopy provided fewer complications such as respiratory depression and hypotension, it also causes more impairment in cognitive functions.
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Affiliation(s)
- Liang Tian
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Hengfei Luan
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Pin Zhu
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Zhiyuan Zhang
- Department of Pathology, Basic Medical Sciences of Nanjing Medical University
| | - Hongguang Bao
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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Chiang MH, Luo SD, Lin HC, Hou SY, Ke TY, Chen CC, Hung KC, Wu SC. A novel algorithm to predict oxygen desaturation in sedated patients with obstructive sleep apnea utilizing polysomnography: A STROBE-compliant article. Medicine (Baltimore) 2020; 99:e21915. [PMID: 32846859 PMCID: PMC7447357 DOI: 10.1097/md.0000000000021915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This retrospective study aimed at identifying the predictors of oxygen desaturation (OD) (i.e., SpO2 < 95%) in patients with obstructive sleep apnea (OSA) requiring deep sedation and developing an algorithm to predict OD.We studied 66 OSA patients undergoing propofol-induced deep sedation for drug-induced sleep endoscopy (DISE). The patients were divided into prediction (n = 35) and validation (n = 31) groups. Patient characteristics and polysomnographic parameters were analyzed with receiver operating characteristic curve and Chi-squared test to identify significant predictors of OD for developing an algorithm in the prediction group. The predictive accuracy, sensitivity, positive predictive value, and negative predictive value of the algorithm were determined in the validation group.Six polysomnographic predictors of OD were identified, including Apnea-Hypopnea Index of total sleep time (AHI-TST), AHI at the stage of rapid eye movement (AHI-REM), percentage of time with oxygen saturation <90% (mO2 < 90%), average SpO2, lowest SpO2, and desaturation index. Stepwise multiple logistic regression analysis demonstrated that low average SpO2 (<95.05%) and high AHI-REM (>16.5 events/h) were independent predictors of OD. The algorithm thus developed showed that patients with an average SpO2 < 95.05% and those with an average SpO2 ≥ 95.05% together with an AHI-REM > 16.5 events/h would be at risk of OD under sedation. The predictive accuracy, sensitivity, positive predictive value, and negative predictive value were 84%, 100%, 83%, 100%, respectively.For patients with OSA, average SpO2 and AHI-REM may enable clinicians to predict the occurrence of oxygen desaturation under deep sedation. Future large-scale studies are needed to validate the findings.
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Affiliation(s)
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Hsin-Ching Lin
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | | | | | | | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology
- Department of Anesthesiology, Xiamen Changgung Hospital, Xiamen, Fujian, China
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17
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Pappal RD, Roberts BW, Winkler W, Yaegar LH, Stephens RJ, Fuller BM. Awareness and bispectral index (BIS) monitoring in mechanically ventilated patients in the emergency department and intensive care unit: a systematic review protocol. BMJ Open 2020; 10:e034673. [PMID: 32139489 PMCID: PMC7059542 DOI: 10.1136/bmjopen-2019-034673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Accidental awareness with recall is one of the most feared complications for patients undergoing general anaesthesia and can lead to post-traumatic stress disorder in up to 70% of patients experiencing it. To reduce the incidence of awareness with recall, the bispectral index monitor is recommended for patients receiving total intravenous anaesthetics, especially those receiving neuromuscular blockers. While extensive investigation into awareness and bispectral index monitoring has occurred for operating room patients, this has not extended to other clinical arenas where sedated and mechanically ventilated patients are cared for, namely the intensive care unit and emergency department. The purpose of this systematic review is to assess the world's literature to determine the incidence of awareness with paralysis in mechanically ventilated patients and the impact of bispectral index monitoring for reducing this complication. METHODS AND ANALYSIS Randomised trials and non-randomised studies are eligible for inclusion. With aid from a medical librarian, an electronic search will include Ovid Medline, Embase.com, Scopus, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. To find data published in abstract form, literature from professional society conferences (2010-2019) will be manually searched. Two authors will independently review search results and consensus will be reached with assistance from a third author, as needed. Heterogeneity and publication bias will be assessed and reported. If possible and appropriate, a meta-analysis of the data will be conducted for quantitative data analysis. ETHICS AND DISSEMINATION The proposed systematic review does not require ethical approval, as it is conducted at the study level and does not involve individual patient-level data. Results will be disseminated by data sharing via academically established means, presentation at local and national scientific meetings and publication as a peer-reviewed manuscript. PROSPERO REGISTRATION NUMBER The protocol has been submitted to International Prospective Register of Systematic Reviews and is awaiting registration.
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Affiliation(s)
- Ryan D Pappal
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian W Roberts
- Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Winston Winkler
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Lauren H Yaegar
- Bernard Becker Medical Library, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Robert J Stephens
- Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian M Fuller
- Emergency Medicine and Anesthesiology, Washington University, Saint Louis, Missouri, USA
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Vinclair M, Schilte C, Roudaud F, Lavolaine J, Francony G, Bouzat P, Bosson JL, Payen JF. Using Pupillary Pain Index to Assess Nociception in Sedated Critically Ill Patients. Anesth Analg 2019; 129:1540-1546. [PMID: 31743173 DOI: 10.1213/ane.0000000000004173] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pupillary reflex dilation is a reliable indicator of response to noxious stimulation. In a proof of concept study, we investigated the performance of pupillary pain index, a new score derived from pupillary reflex dilation measurements, to predict nociceptive response to endotracheal suctioning in sedated critically ill patients. METHODS Twenty brain-injured and 20 non-brain-injured patients were studied within 48 hours of admission (T1) in the intensive care unit and at 48-72 hours later (T2). Video-based pupillometer was used to determine pupillary reflex dilation during tetanic stimulation. The tetanic stimulation (100 Hz) was applied to the skin area innervated by the ulnar nerve and was stepwise increased from 10 to 60 mA until pupil size had increased by 13% compared to baseline. The maximum intensity value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception). The Behavioral Pain Scale response to endotracheal suctioning was measured thereafter. RESULTS Behavioral Pain Scale responses to endotracheal suctioning and pupillary pain index scores were positively correlated at T1 and T2 (both P < .01). After adjustments for repeated measurements and group of patients, the area under the receiver operating characteristic curve of pupillary pain index to predict Behavioral Pain Scale response to endotracheal suctioning was of 0.862 (95% CI, 0.714-0.954). In the combined set of patients, a pupillary pain index score of ≤4 could predict no nociceptive response to endotracheal suctioning with a sensitivity of 88% (95% CI, 68%-97%) and a specificity of 79% (95% CI, 66%-88%). By contrast with endotracheal suctioning, tetanic stimulation had no effect on intracranial pressure in the brain-injured group. CONCLUSIONS These results are a proof of concept. The nociceptive response to endotracheal suctioning could be accurately predicted using the determination of pupillary pain index score in sedated critically ill patients whether they have brain injury or not.
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Affiliation(s)
- Marc Vinclair
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Clotilde Schilte
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Florian Roudaud
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Julien Lavolaine
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Gilles Francony
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Pierre Bouzat
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
- Institut National de la Santé et de la Recherche Médicale, U1216, F-38000 Grenoble, France
- Université Grenoble Alpes, Grenoble Institut des Neurosciences, F-38000 Grenoble, France
| | - Jean-Luc Bosson
- Clinical Research Centre, Institut National de la Santé et de la Recherche Médicale 003, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
- Université Grenoble Alpes, Centre National de la Recherche Scientifique-Mathématiques et Applications, Grenoble Unité Mixte de Recherche, 5525-ThEMAS, F-38000 Grenoble, France
| | - Jean-Francois Payen
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
- Institut National de la Santé et de la Recherche Médicale, U1216, F-38000 Grenoble, France
- Université Grenoble Alpes, Grenoble Institut des Neurosciences, F-38000 Grenoble, France
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Abstract
This study aimed to investigate the risk factors and whether acute hypercapnia contributes to postoperative delirium (POD) during bronchoscopic intervention under general anesthesia or deep sedation.A prospective study was conducted with 119 consecutive patients who had undergone bronchoscopic intervention between February 2016 and December 2016 at the Emergency General Hospital.Twenty-eight patients (23.8%) were diagnosed with POD. The patients were divided into 2 groups: the POD (n = 28) and the control group (n = 91). The mean age of the POD group was higher than that of the control group (P < .01). All the blood gas values, PaCO2 (P < .01), PaO2 (P < .01), and PH (P < .01), were significantly different. Multivariate analyses revealed that age (P < .01), operation duration (P = .01), and PO2 (P = .01) were independent predictive factors of POD, while hypercapnia (P = .54) was established as not being a predictive factor of POD.Age, operation duration, and PO2 were determined as independent predictive factors of POD, whereas moderate hypercapnia is not likely to contribute to POD in patients undergoing bronchoscopic intervention. Clinical Trial Registration Identifier: ChiCTR-POC-15007483.
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Affiliation(s)
- Qinghao Cheng
- Department of Anesthesiology, Emergency General Hospital
| | - Lei Li
- Department of Anesthesiology, Emergency General Hospital
| | - Mingyuan Yang
- Department of Anesthesiology, Emergency General Hospital
| | - Lei Sun
- Department of Anesthesiology, Emergency General Hospital
| | - Renjiao Li
- Department of Anesthesiology, Emergency General Hospital
| | - Rui Huang
- Department of Obstetrics and Gynecology, Emergency General Hospital
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Alvarez Escudero J, Rabanal LLevot JM. Sedations: Safety, competency, efficiency. Rev Esp Anestesiol Reanim (Engl Ed) 2018; 65:483-485. [PMID: 30100088 DOI: 10.1016/j.redar.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 06/08/2023]
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Fuller BM, Mohr NM, Roberts BW, Carpenter CR, Kollef MH, Avidan MS. Protocol for a multicentre, prospective cohort study of practice patterns and clinical outcomes associated with emergency department sedation for mechanically ventilated patients: the ED-SED Study. BMJ Open 2018; 8:e023423. [PMID: 30344178 PMCID: PMC6196824 DOI: 10.1136/bmjopen-2018-023423] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION In mechanically ventilated patients, sedation strategies are a major determinant of outcome. The emergency department (ED) is the earliest exposure to mechanical ventilation for hundreds of thousands of patients annually in the USA. The one retrospective study that exists regarding ED sedation for mechanically ventilated patients showed a strong association between deep sedation in the ED and worse clinical outcomes. This finding suggests that the ED may be an optimal location to study the impact of early sedation on outcome, yet a lack of prospective studies represents a knowledge gap in this arena. This protocol describes a prospective observational study aimed at further characterising ED sedation practices and assessing the relationship between ED sedation and clinical outcomes. An association between ED sedation and clinical outcomes across multiple sites would suggest the need for changes in the current sedation strategies used in the ED, and provide evidence for future interventional studies in this field. METHODS AND ANALYSIS This is a multicentre, prospective cohort study testing the hypothesis that deep sedation in the ED is associated with worse clinical outcomes. A cohort of over 300 mechanically ventilated ED patients will be included. The primary outcome is ventilator-free days, and secondary outcomes include hospital mortality, incidence of acute brain dysfunction and lengths of stay. Multivariable linear regression will test the hypothesis that deep sedation in the ED is associated with a decrease in ventilator-free days. ETHICS AND DISSEMINATION Approval of the study by the Institutional Review Board (IRB) at each participating site has been obtained prior to data collection on the first patient. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Division of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Stephens RJ, Dettmer MR, Roberts BW, Ablordeppey E, Fowler SA, Kollef MH, Fuller BM. Practice Patterns and Outcomes Associated With Early Sedation Depth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2018; 46:471-479. [PMID: 29227367 PMCID: PMC5825247 DOI: 10.1097/ccm.0000000000002885] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world's literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency. DATA SOURCES The following data sources were searched: MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, Cochrane Database of Systematic Reviews databases, ClinicalTrials.gov, conference proceedings, and reference lists. STUDY SELECTION Randomized controlled trials and nonrandomized studies were included. DATA EXTRACTION Two reviewers independently screened abstracts of identified studies for eligibility. DATA SYNTHESIS Nine studies (n = 4,521 patients) published between 2012 and 2017 were included. A random effects meta-analytic model revealed that early light sedation was associated with lower mortality (9.2%) versus deep sedation (27.6%) (odds ratio, 0.34 [0.21-0.54]). Light sedation was associated with fewer mechanical ventilation (mean difference, -2.1; 95% CI, -3.6 to -0.5) and ICU days (mean difference, -3.0 (95% CI, -5.4 to -0.6). Delirium frequency was 28.7% in the light sedation group and 48.5% in the deep sedation group, odds ratio, 0.50 (0.22-1.16). CONCLUSIONS Deep sedation in mechanically ventilated patients, as evaluated in a small number of qualifying heterogeneous randomized controlled trials and observational studies, was associated with increased mortality and lengths of stay. Interventions targeting early sedation depth assessment, starting in the emergency department and subsequent ICU admission, deserve further investigation and could improve outcome.
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Affiliation(s)
- Robert J Stephens
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Matthew R Dettmer
- Emergency Services Institute, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Enyo Ablordeppey
- Department of Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
- Department of Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Susan A Fowler
- Bernard Becker Medical Library, Washington University in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian M Fuller
- Department of Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
- Department of Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
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Killu AM, Sugrue A, Munger TM, Hodge DO, Mulpuru SK, McLeod CJ, Packer DL, Asirvatham SJ, Friedman PA. Impact of sedation vs. general anaesthesia on percutaneous epicardial access safety and procedural outcomes. Europace 2018; 20:329-336. [PMID: 28339558 DOI: 10.1093/europace/euw313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 09/06/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Patient movement while under moderate/deep sedation may complicate percutaneous epicardial access (EpiAcc), mapping and ablation. We sought to compare procedural outcomes in patients undergoing EpiAcc under sedation vs. general anaesthesia (GA) for ablation. Methods and results Patients undergoing EpiAcc between January 2004 and July 2014 were included. Safety, procedural, and clinical outcomes were compared between patients undergoing EpiAcc under sedation or GA for ventricular tachycardia or premature ventricular complex ablation. Between January 2004 and July 2014, 170 patients underwent EpiAcc (mean age, 53.2 ± 15.8 years; average ejection fraction, 44.3 ± 15.3%). The majority (122 [72%] patients) were male. GA was used in 69 (40.6%). There was no difference in route of access (more often anterior, 53.0%) or the rate of successful access (96% overall) between groups. Similarly, the site of ablation (endocardial vs. epicardial vs. combined endocardial/epicardial) was similar between groups. Complications were equally seen between groups-the most frequent event/complication was pericardial effusion, occurring in 10.6% of patients. Finally, procedural and clinical success rates between GA and sedation groups were comparable (93 vs. 91% and 44 vs. 51%, respectively, P > 0.05). Conclusions Choice of anaesthesia for EpiAcc does not appear to significantly affect safety and procedural or clinical outcomes. For patients in whom anaesthesia may pose increased risk, it is reasonable to obtain epicardial access under sedation.
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Affiliation(s)
- Ammar M Killu
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Alan Sugrue
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas M Munger
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Siva K Mulpuru
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Christopher J McLeod
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Douglas L Packer
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Liu D, Lyu J, Zhao H, An Y. The influence of analgesic-based sedation protocols on delirium and outcomes in critically ill patients: A randomized controlled trial. PLoS One 2017; 12:e0184310. [PMID: 28910303 PMCID: PMC5598969 DOI: 10.1371/journal.pone.0184310] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 08/21/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the influence of analgesic-based midazolam sedation on delirium and outcomes in critically ill patients and to analyze the risk factors of delirium. DESIGN Single center, prospective randomized controlled trial. SETTING A surgical intensive care unit (ICU) in a tertiary care hospital in China. PATIENTS Mechanically ventilated patients requiring sedation. MEASUREMENTS AND MAIN RESULTS Patients admitted to the surgical intensive care unit who required sedation and were undergoing mechanical ventilation for longer than 24 hours were randomly divided into three groups: 1) the remifentanil group received remifentanil and midazolam, 2) the fentanyl group received fentanyl and midazolam, and 3) the control group received only midazolam. The analgesic effect, sedation depth, and presence of delirium were evaluated. To compare the effect of different therapies on the occurrence of delirium, days of mechanical ventilation, length of the ICU stay, and 28-day mortality were measured along with the risk factors for delirium. A total of 105 patients were enrolled, and 35 patients were included in each group. Compared to the control group, patients who received remifentanil and fentanyl required less midazolam each day (P = 0.038 and <0.001, respectively). Remifentanil has a significant effect on reducing the occurrence of delirium (P = 0.007). The logistic regression analysis of delirium demonstrated that remifentanil (OR 0.230, 95%Cl 0.074-0.711, P = 0.011) is independent protective factors for delirium, and high APACHE II score (OR 1.103, 95%Cl 1.007-1.208, P = 0.036) is the independent risk factor for delirium. CONCLUSION Remifentanil and fentanyl can reduce the amount of midazolam required, and remifentanil could further reduce the occurrence of delirium.
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Affiliation(s)
- Dan Liu
- Department of Critical Care, Peking University People’s Hospital, Beijing, China
| | - Jie Lyu
- Department of Critical Care, Peking University People’s Hospital, Beijing, China
| | - Huiying Zhao
- Department of Critical Care, Peking University People’s Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care, Peking University People’s Hospital, Beijing, China
- * E-mail:
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25
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Pandharipande PP, Ely EW, Arora RC, Balas MC, Boustani MA, La Calle GH, Cunningham C, Devlin JW, Elefante J, Han JH, MacLullich AM, Maldonado JR, Morandi A, Needham DM, Page VJ, Rose L, Salluh JIF, Sharshar T, Shehabi Y, Skrobik Y, Slooter AJC, Smith HAB. The intensive care delirium research agenda: a multinational, interprofessional perspective. Intensive Care Med 2017; 43:1329-1339. [PMID: 28612089 PMCID: PMC5709210 DOI: 10.1007/s00134-017-4860-7] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/01/2017] [Indexed: 12/25/2022]
Abstract
Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.
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Affiliation(s)
- Pratik P Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - E Wesley Ely
- Division of Pulmonary and Critical Care and Health Services Research, Vanderbilt University and VA-GRECC, Nashville, TN, USA
| | - Rakesh C Arora
- Department of Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - Michele C Balas
- Center of Excellence in Critical and Complex Care, College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Malaz A Boustani
- Indiana University Center for Health Innovation and Implementation Science, Indianapolis, IN, USA
| | - Gabriel Heras La Calle
- International Research Project Humanizing Intensive Care (Proyecto HU-CI), Intensive Care Unit, Hospital Universitario de Torrejón, Madrid, Spain
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience, Lloyd Institute, Trinity College Dublin, Dublin, Ireland
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Julius Elefante
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alasdair M MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland, UK
| | | | | | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Louise Rose
- Sunnybrook Health Sciences Centre, Toronto, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Jorge I F Salluh
- Department of Critical Care, rD' OR Institute for Research and Education and Post-Graduate Program Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tarek Sharshar
- Department of Intensive Care Medicine, Raymond Poincaré Hospital, Paris, France
- Laboratory of Human Histology and Animal Models, Institut Pasteur, Paris, France
| | - Yahya Shehabi
- School of Clinical Sciences, Faculty of Medicine, Monash University and Medical Center, Melbourne, Australia
- Clinical School of Medicine, University New South Wales, Sydney, NSW, 2031, Australia
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, Canada
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Heidi A B Smith
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Fernandez-Gonzalo S, Turon M, De Haro C, López-Aguilar J, Jodar M, Blanch L. Do sedation and analgesia contribute to long-term cognitive dysfunction in critical care survivors? Med Intensiva 2017; 42:114-128. [PMID: 28851588 DOI: 10.1016/j.medin.2017.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/23/2017] [Accepted: 06/29/2017] [Indexed: 01/22/2023]
Abstract
Deep sedation during stay in the Intensive Care Unit (ICU) may have deleterious effects upon the clinical and cognitive outcomes of critically ill patients undergoing mechanical ventilation. Over the last decade a vast body of literature has been generated regarding different sedation strategies, with the aim of reducing the levels of sedation in critically ill patients. There has also been a growing interest in acute brain dysfunction, or delirium, in the ICU. However, the effect of sedation during ICU stay upon long-term cognitive deficits in ICU survivors remains unclear. Strategies for reducing sedation levels in the ICU do not seem to be associated with worse cognitive and psychological status among ICU survivors. Sedation strategy and management efforts therefore should seek to secure the best possible state in the mechanically ventilated patient and lower the prevalence of delirium, in order to prevent long-term cognitive alterations.
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Affiliation(s)
- S Fernandez-Gonzalo
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
| | - M Turon
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - C De Haro
- Critical Care Department, ParcTaulí Sabadell, Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - J López-Aguilar
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - M Jodar
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, International Excellence Campus, Bellaterra, Spain; Neurology Department, ParcTaulí Sabadell, Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - L Blanch
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Critical Care Department, ParcTaulí Sabadell, Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
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Abstract
OBJECTIVE To evaluate the effect of capnography monitoring on sedation-related adverse events during procedural sedation and analgesia (PSA) administered for ambulatory surgery relative to visual assessment and pulse oximetry alone. DESIGN AND SETTING Systematic literature review and random effects meta-analysis of randomised controlled trials (RCTs) reporting sedation-related adverse event incidence when adding capnography to visual assessment and pulse oximetry in patients undergoing PSA during ambulatory surgery in the hospital setting. Searches for eligible studies published between 1 January 1995 and 31 December 2016 (inclusive) were conducted in PubMed, the Cochrane Library and EMBASE without any language constraints. Searches were conducted in January 2017, screening and data extraction were conducted by two independent reviewers, and study quality was assessed using a modified Jadad scale. INTERVENTIONS Capnography monitoring relative to visual assessment and pulse oximetry alone. PRIMARY AND SECONDARY OUTCOME MEASURES Predefined endpoints of interest were desaturation/hypoxaemia (the primary endpoint), apnoea, aspiration, bradycardia, hypotension, premature procedure termination, respiratory failure, use of assisted/bag-mask ventilation and death during PSA. RESULTS The literature search identified 1006 unique articles, of which 13 were ultimately included in the meta-analysis. Addition of capnography to visual assessment and pulse oximetry was associated with a significant reduction in mild (risk ratio (RR) 0.77, 95% CI 0.67 to 0.89) and severe (RR 0.59, 95% CI 0.43 to 0.81) desaturation, as well as in the use of assisted ventilation (OR 0.47, 95% CI 0.23 to 0.95). No significant differences in other endpoints were identified. CONCLUSIONS Meta-analysis of 13 RCTs published between 2006 and 2016 showed a reduction in respiratory compromise (from respiratory insufficiency to failure) during PSA with the inclusion of capnography monitoring. In particular, use of capnography was associated with less mild and severe oxygen desaturation, which may have helped to avoid the need for assisted ventilation.
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Affiliation(s)
- Rhodri Saunders
- Coreva Scientific GmbH & Co. KG., Freiburg, Germany
- Ossian Health Economics and Communications, Basel, Switzerland
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Anesthesia, Ghent University, Ghent, Belgium
| | | | - Michael Mestek
- Minimally Invasive Therapies Group, Medtronic, Boulder, Colorado, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology, UMass Memorial Children’s Medical Center, Westborough, Massachusetts, USA
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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28
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Canpolat DG, Dogruel F, Gönen ZB, Yılmaz C, Zararsız G, Alkan A. The role of platelet count, mean platelet volume, and the mean platelet volume/platelet count ratio in predicting postoperative vomiting in children after deep sedation. Saudi Med J 2017; 37:1082-8. [PMID: 27652358 PMCID: PMC5075371 DOI: 10.15537/smj.2016.10.14903] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objectives: To determine the role of hemogram parameters such as platelet count (PLT), mean platelet volume (MPV), and the MPV/PLT ratio in predicting the risk of postoperative vomiting (POV) in children after tooth extraction under deep sedation. Methods: A total of 100 American Society of Anesthesiology Classification I and II pediatric patients who underwent tooth extraction procedures under a standard anesthetic method were included in the study between 2012 and 2014. The study took place at the Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Erciyes University, Erciyes, Turkey Fifty patients without POV (group 1) and 50 patients with POV (group 2) were retrospectively selected randomly from the records of 885 consecutive patients. Age, gender, duration of the operation, and preoperative hemogram findings were recorded. Results: There was a statistically significant difference between the 2 groups in terms of MPV (p<0.001), PLT (p=0.006), and MPV/PLT (p<0.001) ratio. Mean platelet volume and MPV/PLT ratio were higher in group 2, whereas PLT was higher in group 1. Conclusion: The PLT count, MPV, and MPV/PLT ratio may be used to predict POV in children.
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Affiliation(s)
- Dilek G Canpolat
- Department of Oral Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Kayseri, Turkey. E-mail.
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Rohaut B, Porcher R, Hissem T, Heming N, Chillet P, Djedaini K, Moneger G, Kandelman S, Allary J, Cariou A, Sonneville R, Polito A, Antona M, Azabou E, Annane D, Siami S, Chrétien F, Mantz J, Sharshar T. Brainstem response patterns in deeply-sedated critically-ill patients predict 28-day mortality. PLoS One 2017; 12:e0176012. [PMID: 28441453 PMCID: PMC5404790 DOI: 10.1371/journal.pone.0176012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/03/2017] [Indexed: 12/30/2022] Open
Abstract
Background and purpose Deep sedation is associated with acute brain dysfunction and increased mortality. We had previously shown that early-assessed brainstem reflexes may predict outcome in deeply sedated patients. The primary objective was to determine whether patterns of brainstem reflexes might predict mortality in deeply sedated patients. The secondary objective was to generate a score predicting mortality in these patients. Methods Observational prospective multicenter cohort study of 148 non-brain injured deeply sedated patients, defined by a Richmond Assessment sedation Scale (RASS) <-3. Brainstem reflexes and Glasgow Coma Scale were assessed within 24 hours of sedation and categorized using latent class analysis. The Full Outline Of Unresponsiveness score (FOUR) was also assessed. Primary outcome measure was 28-day mortality. A “Brainstem Responses Assessment Sedation Score” (BRASS) was generated. Results Two distinct sub-phenotypes referred as homogeneous and heterogeneous brainstem reactivity were identified (accounting for respectively 54.6% and 45.4% of patients). Homogeneous brainstem reactivity was characterized by preserved reactivity to nociceptive stimuli and a partial and topographically homogenous depression of brainstem reflexes. Heterogeneous brainstem reactivity was characterized by a loss of reactivity to nociceptive stimuli associated with heterogeneous brainstem reflexes depression. Heterogeneous sub-phenotype was a predictor of increased risk of 28-day mortality after adjustment to Simplified Acute Physiology Score-II (SAPS-II) and RASS (Odds Ratio [95% confidence interval] = 6.44 [2.63–15.8]; p<0.0001) or Sequential Organ Failure Assessment (SOFA) and RASS (OR [95%CI] = 5.02 [2.01–12.5]; p = 0.0005). The BRASS (and marginally the FOUR) predicted 28-day mortality (c-index [95%CI] = 0.69 [0.54–0.84] and 0.65 [0.49–0.80] respectively). Conclusion In this prospective cohort study, around half of all deeply sedated critically ill patients displayed an early particular neurological sub-phenotype predicting 28-day mortality, which may reflect a dysfunction of the brainstem.
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Affiliation(s)
- Benjamin Rohaut
- Neurological Departement Intensive Care Unit, Assistance Publique - Hôpitaux de Paris (AP-HP), Pitié-Salpétrière Hospital, Paris, France
- Sorbonne University, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, Paris, France
- INSERM, U 1127, Paris, France
| | - Raphael Porcher
- Center for Clinical Epidemiology, AP-HP, Hôtel Dieu Hospital, Descartes University, Paris, France
| | - Tarik Hissem
- General Intensive Care Unit, Sud Essonne Hospital, Etampes, France
| | - Nicholas Heming
- General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Patrick Chillet
- General Intensive Care Unit, Chalons en Champagne Hospital, Chalons en Champagne, France
| | - Kamel Djedaini
- General Intensive Care Unit, Geoffroy Saint-Hilaire Hospital, Paris France
| | - Guy Moneger
- General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Stanislas Kandelman
- Department of Anesthesiology and Intensive Care Unit, AP-HP, Beaujon–Claude Bernard Hospital, Diderot University, Paris, France
| | - Jeremy Allary
- Department of Anesthesiology and Intensive Care Unit, AP-HP, Beaujon–Claude Bernard Hospital, Diderot University, Paris, France
| | - Alain Cariou
- Intensive Care Unit, AP-HP, Cochin Hospital, Descartes University, Paris, France
| | - Romain Sonneville
- Medical Intensive Care Unit, AP-HP, Bichat–Claude Bernard Hospital, Diderot University, Paris, France
| | - Andréa Polito
- General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Marion Antona
- Surgical Intensive Care Unit, AP-HP, Cochin Hospital, Descartes University, Paris, France
| | - Eric Azabou
- Department of Physiology, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Djillali Annane
- General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Shidasp Siami
- General Intensive Care Unit, Sud Essonne Hospital, Etampes, France
| | - Fabrice Chrétien
- Laboratory of Human Histopathology and Animal Models, Pasteur Institut, Paris, France
- Department of Neuropathology, Saint Anne Hospital, Descartes University, Paris, France
| | - Jean Mantz
- Laboratory of Human Histopathology and Animal Models, Pasteur Institut, Paris, France
- Department of Anesthesiology and Intensive Care Unit, AP-HP, Georges Pompidou European Hospital, Descartes University, Paris, France
| | - Tarek Sharshar
- General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
- Laboratory of Human Histopathology and Animal Models, Pasteur Institut, Paris, France
- * E-mail:
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Bennett JD, Kramer KJ, Bosack RC. How safe is deep sedation or general anesthesia while providing dental care? J Am Dent Assoc 2017; 146:705-8. [PMID: 26314981 DOI: 10.1016/j.adaj.2015.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesiologists. METHODS The goal of deep sedation or general anesthesia is to establish a safe environment in which the patient is comfortable and cooperative. This requires meticulous care in which the practitioner balances the patient's depth of sedation and level of responsiveness while maintaining airway integrity, ventilation, and cardiovascular hemodynamics. RESULTS Using the available data and informational reports, the authors estimate that the incidence of death and brain injury associated with deep sedation or general anesthesia administered by all dentists most likely exceeds 1 per month. CONCLUSIONS Airway compromise is a significant contributing factor to anesthetic complications. The American Society of Anesthesiology closed claim analysis also concluded that human error contributed highly to anesthetic mishaps. The establishment of a patient safety database for anesthetic management in dentistry would allow for a more complete assessment of morbidity and mortality that could direct efforts to further increase safe anesthetic care. PRACTICAL IMPLICATIONS Deep sedation and general anesthesia can be safely administered in the dental office. Optimization of patient care requires appropriate patient selection, selection of appropriate anesthetic agents, utilization of appropriate monitoring, and a highly trained anesthetic team. Achieving a highly trained anesthetic team requires emergency management preparation that can foster decision making, leadership, communication, and task management.
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Schumann R, Natov NS, Rocuts-Martinez KA, Finkelman MD, Phan TV, Hegde SR, Knapp RM. High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. World J Gastroenterol 2016; 22:10398-10405. [PMID: 28058020 PMCID: PMC5175252 DOI: 10.3748/wjg.v22.i47.10398] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/03/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To examine whether high-flow nasal oxygen (HFNO) availability influences the use of general anesthesia (GA) in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) and associated outcomes.
METHODS In this retrospective study, patients were stratified into 3 eras between October 1, 2013 and June 30, 2014 based on HFNO availability for deep sedation at the time of their endoscopy. During the first and last 3-mo eras (era 1 and 3), no HFNO was available, whereas it was an option during the second 3-mo era (era 2). The primary outcome was the percent utilization of GA vs deep sedation in each period. Secondary outcomes included oxygen saturation nadir during sedation between periods, as well as procedure duration, and anesthesia-only time between periods and for GA vs sedation cases respectively.
RESULTS During the study period 238 ERCP or EUS cases were identified for analysis. Statistical testing was employed and a P < 0.050 was significant unless the Bonferroni correction for multiple comparisons was used. General anesthesia use was significantly lower in era 2 compared to era 1 with the same trend between era 2 and 3 (P = 0.012 and 0.045 respectively). The oxygen saturation nadir during sedation was significantly higher in era 2 compared to era 3 (P < 0.001) but not between eras 1 and 2 (P = 0.028) or 1 and 3 (P = 0.069). The procedure time within each era was significantly longer under GA compared to deep sedation (P≤ 0.007) as was the anesthesia-only time (P≤ 0.001).
CONCLUSION High-flow nasal oxygen availability was associated with decreased GA utilization and improved oxygenation for ERCP and EUS during sedation.
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Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatr Dent 2016; 38:77-106. [PMID: 28206886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase thepotential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Dionne RA. Proposed Guideline Revisions for Dental Sedation and General Anesthesia: Why Target the Safest Level of Sedation? Compend Contin Educ Dent 2016; 37:546-552. [PMID: 27608198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Recently proposed revisions to the American Dental Association's Guidelines for the Use of Sedation and General Anesthesia by Dentists, aimed at improving safety in dental offices, differentiate between levels of sedation based on drug-induced changes in physiologic and behavioral states. However, the author of this op-ed is concerned the proposed revisions may have far-reaching and unintended consequences.
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Affiliation(s)
- Raymond A Dionne
- Faculty, Department of Pharmacology and Toxicology, Brody School of Medicine, and Department of Foundational Sciences, School of Dental Medicine, East Carolina University, Greenville, North Carolina
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Kim JE, Choi JB, Koo BN, Jeong HW, Lee BH, Kim SY. Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study. Medicine (Baltimore) 2016; 95:e3593. [PMID: 27149489 PMCID: PMC4863806 DOI: 10.1097/md.0000000000003593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is an advanced therapy for early gastric neoplasm and requires sedation with adequate analgesia. Lidocaine is a short-acting local anesthetic, and intravenous lidocaine has been shown to have analgesic efficacy in surgical settings. The aim of this study was to assess the effects of intravenous lidocaine on analgesic and sedative requirements for ESD and pain after ESD.Sixty-six patients scheduled for ESD randomly received either intravenous lidocaine as a bolus of 1.5 mg/kg before sedation, followed by continuous infusion at a rate of 2 mg/kg/h during sedation (lidocaine group; n = 33) or the same bolus and infusion volumes of normal saline (control group; n = 33). Sedation was achieved with propofol and fentanyl. The primary outcome was fentanyl requirement during ESD. We recorded hemodynamics and any events during ESD and evaluated post-ESD epigastric and throat pain.Fentanyl requirement during ESD reduced by 24% in the lidocaine group compared with the control group (105 ± 28 vs. 138 ± 37 μg, mean ± SD; P < 0.001). The lidocaine group reached sedation faster [40 (20-100) vs. 55 (30-120) s, median (range); P = 0.001], and incidence of patient movement during ESD decreased in the lidocaine group (3% vs. 26%, P = 0.026). Numerical rating scale for epigastric pain was significantly lower at 6 hours after ESD [2 (0-6) vs. 3 (0-8), median (range); P = 0.023] and incidence of throat pain was significantly lower in the lidocaine group (27% vs. 65%, P = 0.003). No adverse events associated with lidocaine were discovered.Administration of intravenous lidocaine reduced fentanyl requirement and decreased patient movement during ESD. Moreover, it alleviated epigastric and throat pain after ESD. Thus, we conclude that the use of intravenous adjuvant lidocaine is a new and safe sedative method during ESD.
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Affiliation(s)
- Ji Eun Kim
- From the Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon (JEK, JBC, HWJ, BHL), and Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul (BNK, SYK), Republic of Korea
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Park CH, Shin S, Lee SK, Lee H, Lee YC, Park JC, Yoo YC. Assessing the stability and safety of procedure during endoscopic submucosal dissection according to sedation methods: a randomized trial. PLoS One 2015; 10:e0120529. [PMID: 25803441 PMCID: PMC4372558 DOI: 10.1371/journal.pone.0120529] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/21/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) is routinely performed under sedation, the difference in ESD performance according to sedation method is not well known. This study attempted to prospectively assess and compare the satisfaction of the endoscopists and patient stability during ESD between two sedation methods. METHODS One hundred and fifty-four adult patients scheduled for ESD were sedated by either the IMIE (intermittent midazolam/propofol injection by endoscopist) or CPIA (continuous propofol infusion by anesthesiologist) method. The primary endpoint of this study was to compare the level of satisfaction of the endoscopists between the two groups. The secondary endpoints included level of satisfaction of the patients, patient's pain scores, events interfering with the procedure, incidence of unintended deep sedation, hemodynamic and respiratory events, and ESD outcomes and complications. RESULTS Level of satisfaction of the endoscopists was significantly higher in the CPIA Group compared to the IMIE group (IMIE vs. CPIA; high satisfaction score; 63.2% vs. 87.2%, P=0.001). The incidence of unintended deep sedation was significantly higher in the IMIE Group compared to the CPIA Group (IMIE vs. CPIA; 17.1% vs. 5.1%, P=0.018) as well as the number of patients showing spontaneous movement or those requiring physical restraint (IMIE vs. CPIA; spontaneous movement; 60.5% vs. 42.3%, P=0.024, physical restraint; 27.6% vs. 10.3%, P=0.006, respectively). In contrast, level of satisfaction of the patients were found to be significantly higher in the IMIE Group (IMIE vs. CPIA; high satisfaction score; 85.5% vs. 67.9%, P=0.027). Pain scores of the patients, hemodynamic and respiratory events, and ESD outcomes and complications were not different between the two groups. CONCLUSION Continuous propofol and remifentanil infusion by an anesthesiologist during ESD can increase the satisfaction levels of the endoscopists by providing a more stable state of sedation. TRIAL REGISTRATION ClinicalTrials.gov NCT01806753.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
| | - Young Chul Yoo
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Warnke PC. Deep brain stimulation surgery under general anaesthesia with microelectrode recording: the best of both worlds or a little bit of everything? J Neurol Neurosurg Psychiatry 2014; 85:1063. [PMID: 24591455 DOI: 10.1136/jnnp-2014-307745] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Loflin R, Koyfman A. When used for sedation, does ketamine increase intracranial pressure more than fentanyl or sufentanil? Ann Emerg Med 2014; 65:55-6. [PMID: 25233812 DOI: 10.1016/j.annemergmed.2014.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 08/14/2014] [Accepted: 08/15/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Rob Loflin
- Carilion Clinic-Virginia Tech Carilion Emergency Medicine Residency Program, Carilion Roanoke Memorial Hospital, Roanoke, VA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern Medical Center/Parkland Memorial Hospital, Dallas, TX
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Prescilla R, Mason KP. Recent advances and contributions to procedural sedation with considerations for the future. Minerva Anestesiol 2014; 80:844-855. [PMID: 24226485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
As the demand for sedation services have increased, the delivery of sedation has shifted from the operating room setting to areas distant to the operating room, both within and outside the hospital setting. Sedation delivery is not monopolized by any one specialty, but rather is being delivered by anesthesiologists as well as non-anesthesiologists. As the field of sedation burgeons and multi-specialists enter the realm of meeting the demands, so also have the politics increased. Unfortunately, the choice of sedative agents has not increased in parallel with the demand for sedation. Over the past decade, there has been a paucity of new introductions for procedural sedation. Rather, new formulations of approved agents are being reexamined. The safe, efficient and predictable delivery of sedation remains at the forefront of discussion and review worldwide. This review will explore the recent, significant and noteworthy contributions to the field of sedation.
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Affiliation(s)
- R Prescilla
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA -
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Ordas-Bandera CM, Sanchez-Marcos C, Janeiro-Lumbreras D, Jimenez-Martin MJ, Muniz-Castrillo S, Cuadrado-Perez ML, Porta-Etessam J. [Neurological examination in patients undergoing sedation with propofol: a descriptive study]. Rev Neurol 2014; 58:536-540. [PMID: 24915029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The neurological examination is a resource used in evaluating patients who are in coma. Anaesthesia can be a factor that exerts an influence on the findings. We evaluated the examination of the comatose patient in the case of patients anaesthetised with propofol in order to define its clinical value. PATIENTS AND METHODS A prospective study was conducted among those who had undergone heart surgery in the intensive care unit of a tertiary hospital during the months of April and May 2011. Aspects that were analysed were the examination of the anaesthetic coma, pharmacological or medical factors that can have an influence and a full neurological examination following recovery. Patients with previous neurological symptoms were excluded. RESULTS Thirty patients were selected (16 males and 14 females); mean age: 72 ± 10 years. All the patients were sedated with propofol. During sedation, 17 (46.7%) presented unreactive pupils. No spontaneous eye movements were observed in 100% of the sample. Ocular alterations in primary position were observed in 23.3% of them. Oculocephalic reflexes were absent in 93.3% and oculovestibular reflexes, in 100%; the corneal reflex, was absent in 70% (with asymmetry), as was the ciliospinal reflex, in 83.3%. The algesic motor response was absent in 93.3%, as were the cutaneous plantar extensor reflexes, in 20%; and 66.7% were indifferent. Following anaesthesia, the neurological examination was normal in 80%, there were slight orientation impairments in 16.7% and a hemispheric syndrome was found in one patient. CONCLUSIONS Anaesthesia with propofol alters the reversible cutaneous-plantar, pupillary, trunk and motor response reflexes on withdrawing sedation. The alterations may be asymmetrical. Neurological examinations should not be used in the case of patients sedated with propofol in order to make clinical decisions.
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Shehabi Y. Early Goal Directed Sedation, a bridge to better clinical outcomes. Chin Med J (Engl) 2014; 127:1969-1972. [PMID: 24824265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Affiliation(s)
- Yahya Shehabi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne; Director Intensive Care Research, The Prince of Wales Hospital; Randwick, NSW, Australia.
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Abstract
Fat embolism to the systemic circulation in polytrauma patients is very common. The fat embolism syndrome (FES), however, is a rare condition. We describe a case of traumatic femur fracture with FES that was presented as acute tonsillar herniation (coning) and brain death postoperatively. We believe that in this case the prone position and moderate hypercapnia contributed to the acute coning.
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Affiliation(s)
- Rafael Kawati
- Central Intensive Care Unit, Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Larsson
- Central Intensive Care Unit, Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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Simpson JR, Katz SG, Laan TV. Oversedation in postoperative patients requiring ventilator support greater than 48 hours: a 4-year National Surgical Quality Improvement Program-driven project. Am Surg 2013; 79:1106-1110. [PMID: 24160809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Prolonged mechanical ventilation of postoperative patients can contribute to an increase in morbidity. Every effort should be made to wean patients from the ventilator after surgery. Oversedation may prevent successful extubation. Cases identified by the National Surgical Quality Improvement Program (NSQIP) for Huntington Hospital were reviewed. Oversedation, days on the ventilator, type and duration of sedation, and cost were studied. Data were collected from the NSQIP database and patient charts. Oversedation was determined by the Richmond Agitation Sedation Score (RASS) of each patient. The hospital pharmacy provided data on propofol. Forty-three (35%) patients were oversedated. Propofol was used in 111 (90%) cases with an average use of 4.8 days. Propofol was used greater than 48 hours in 77 (62%) cases. After identifying inconsistent nurse documentation of sedation, corrective actions helped decrease oversedation, average number of days on the ventilator, number of days on propofol, hospital expenditure on propofol, and number of patients on the ventilator greater than 48 hours. Oversedation contributed to prolonged mechanical ventilation. Standardization of RASS and physician sedation order sheets contributed to improving our NSQIP rating. Sedation use decreased and fewer patients spent less time on the ventilator. NSQIP is an effective tool to identify issues with quality in surgical patients.
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Cha JM, Jeun JW, Pack KM, Lee JI, Joo KR, Shin HP, Shin WC. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. World J Gastroenterol 2013; 19:4745-4751. [PMID: 23922472 PMCID: PMC3732847 DOI: 10.3748/wjg.v19.i29.4745] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/04/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether patients with obstructive sleep apnea (OSA) are at risk of sedation-related complications during diagnostic esophagogastroduodenoscopy (EGD).
METHODS: A prospective study was performed in consecutive patients with OSA, who were confirmed with full-night polysomnography between July 2010 and April 2011. The occurrence of cardiopulmonary complications related to sedation during diagnostic EGD was compared between OSA and control groups.
RESULTS: During the study period, 31 patients with OSA and 65 controls were enrolled. Compared with the control group, a higher dosage of midazolam was administered (P = 0.000) and a higher proportion of deep sedation was performed (P = 0.024) in the OSA group. However, all adverse events, including sedation failure, paradoxical responses, snoring or apnea, hypoxia, hypotension, oxygen or flumazenil administration, and other adverse events were not different between the two groups (all P > 0.1). Patients with OSA were not predisposed to hypoxia with multivariate logistic regression analysis (P = 0.068).
CONCLUSION: In patients with OSA, this limited sized study did not disclose an increased risk of cardiopulmonary complications during diagnostic EGD under sedation.
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Santos MELD, Maluf-Filho F, Chaves DM, Matuguma SE, Ide E, Luz GDO, Souza TFD, Pessorrusso FCS, Moura EGHD, Sakai P. Deep sedation during gastrointestinal endoscopy: propofol-fentanyl and midazolam-fentanyl regimens. World J Gastroenterol 2013; 19:3439-46. [PMID: 23801836 PMCID: PMC3683682 DOI: 10.3748/wjg.v19.i22.3439] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 12/22/2012] [Accepted: 01/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ² test, measurement of analysis of variance, and the κ statistic. RESULTS The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.
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Abstract
IMPORTANCE Deep sedation for endoscopic procedures has become an increasingly used option but, because of impairment in patient response, this technique also has the potential for a greater likelihood of adverse events. The incidence of these complications has not been well studied at a population level. DESIGN Population-based study. SETTING AND PARTICIPANTS Using a 5% random sample of cancer-free Medicare beneficiaries who resided in one of the regions served by a SEER (Surveillance, Epidemiology, and End Results) registry, we identified all procedural claims for outpatient colonoscopy without polypectomy from January 1, 2000, through November 30, 2009. INTERVENTION Colonoscopy without polypectomy, with or without the use of deep sedation (identified by a concurrent claim for anesthesia services). MAIN OUTCOME MEASURES The occurrence of hospitalizations for splenic rupture or trauma, colonic perforation, and aspiration pneumonia within 30 days of the colonoscopy. RESULTS We identified a total of 165 527 procedures in 100 359 patients, including 35 128 procedures with anesthesia services (21.2%). Selected postprocedure complications were documented after 284 procedures (0.17%) and included aspiration (n = 173), perforation (n = 101), and splenic injury (n = 12). (Some patients had >1 complication.) Overall complications were more common in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others (0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10% [0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic injury were statistically similar. Other predictors of complications included age greater than 70 years, increasing comorbidity, and performance of the procedure in a hospital setting. In multivariate analysis, use of anesthesia services was associated with an increased complication risk (odds ratio, 1.46 [95% CI, 1.09-1.94]). CONCLUSIONS AND RELEVANCE Although the absolute risk of complications is low, the use of anesthesia services for colonoscopy is associated with a somewhat higher frequency of complications, specifically, aspiration pneumonia. The differences may result in part from uncontrolled confounding, but they may also reflect the impairment of normal patient responses with the use of deep sedation.
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Affiliation(s)
- Gregory S Cooper
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH 44106, USA.
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Svenningsen H. Associations between sedation, delirium and post-traumatic stress disorder and their impact on quality of life and memories following discharge from an intensive care unit. Dan Med J 2013; 60:B4630. [PMID: 23651729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
UNLABELLED In the intensive care units (ICUs) sedation strategies have changed in the past decade towards less sedation and daily wake-up calls. Recent studies indicate that no sedation (after intubation) is most beneficial for patients. A smaller number of these patients have been assessed for post-traumatic stress disorder (PTSD) after ICU discharge, but none of them were assessed for delirium while in the ICU. In other studies, delirium in the ICU is described as distressing for the patients and increasing morbidity, i.e. dementia after discharge and mortality. The associations between sedation, delirium, and PTSD have not previous been described. The aim of this PhD study was to investigate: 1) how sedation is associated with delirium in the ICU, 2) the consequences of delirium in relation to PTSD, anxiety, and depression, 3) the consequences of delirium for the patients' memories from ICU and the health-related quality of life after discharge. In a prospective observation study with patients admitted a minimum of 48 hours to the ICUs in Aarhus or Hillerød, we included all patients aged > 17 years. Non-Danish-speaking, patients transferred from other ICUs and patients with brain injury that made delirium-assessment impossible were excluded. Patients were interviewed face-to-face after 1 week, and at 2 months and 6 months by telephone using six different questionnaires. Among 3,066 patients admitted to the ICUs, 942 fulfilled the inclusion criteria. Primarily due to the inability to test for delirium, 302 patients were later excluded. Of the remaining 640 patients, 65% were delirious on 1 or more days. Fluctuations in sedation levels increased the risk of delirium statistically significantly with or without adjustments for age, gender, severity of illness, surgical/medical patient, or ICU site. After 2 months vs. 6 months, 297 patients vs. 248 patients were interviewed. PTSD was found in 7% vs. 5%, anxiety in 6% vs. 4%, and depression in 10% at both interviews. Delirium had no association with any of the psychometric results. Memories of delusion and memories of feelings were statistically significantly associated with delirium and with the psychometric outcomes, whereas memories of facts had no association with the psychometric outcomes. Health-related quality of life (SF-36) was statistically significantly decreased in most of the domains if patients had PTSD, anxiety, or depression but was not associated with delirium or the type of memories. CONCLUSION Fluctuations in the level of sedation of patients in the ICU increased the incidence of delirium, but the delirium did not affect the risk of PTSD, anxiety, or depression. These were, however, affected by the type of memories the patients had. Health-related quality of life (SF-36) was decreased if patients had PTSD, anxiety, or depression but was unaffected by memories of the ICU and the presence of delirium while in the ICU.
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Affiliation(s)
- Helle Svenningsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
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Abstract
A successful procedural sedation program requires a robust institutional policy backed by a solid educational program and an administrative structure. Given the nature of the services provided, combined with the growth in complexity of both patients and procedures, sedation presents a potential liability for both the provider and the institution. A sedation program is built with a multidisciplinary team of experts representing all stakeholders: healthcare providers, risk and quality improvement managers, and facility administration. An institutional procedural sedation policy should be based on nationally and state recognized practice requirements and guidelines. Clinical care must be supported with a robust risk and quality structure built within the program to ensure best practice at the point of care.
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Affiliation(s)
- Mary T Antonelli
- Senior Director of Health Care Quality and Patient Safety, New England Baptist Hospital, Boston, MA
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