RESUMEN
BACKGROUND: The main goal of the pediatric dentist is to address and reduce children's fear and anxiety during the dental treatment, especially when conventional behavior-guiding strategies fail. In such cases, the use of pharmacological agents becomes an essential factor to consider. OBJECTIVE: The objective of the study was to compare the efficacy, safety, and acceptability of intranasal ketamine (INK) with the combination of intranasal midazolam and dexmedetomidine (INMzD) in pediatric dental patients for the procedural sedation. PATIENTS AND METHODS: Forty-seven children aged 3-9 years who required dental procedures such as extractions, pulpectomy, and restorations were randomly distributed into two groups using the envelope drawing method. Group INK received 7 mg/kg INK, whereas Group INMzD received a combination of midazolam spray (0.3 mg/kg) and atomized dexmedetomidine (3 µg/kg). RESULTS: INK showed faster onset, faster recovery, and shorter discharge time than INMzD. Both groups had acceptable physiological parameters and no postoperative complications. INK was more accepted by the patients than INMzD. CONCLUSIONS: In terms of efficacy, safety, and acceptability, INK outperformed the combination of INMzD for the procedural sedation.
Asunto(s)
Administración Intranasal , Sedación Consciente , Estudios Cruzados , Dexmedetomidina , Hipnóticos y Sedantes , Ketamina , Midazolam , Humanos , Dexmedetomidina/administración & dosificación , Midazolam/administración & dosificación , Niño , Preescolar , Ketamina/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Masculino , Femenino , Sedación Consciente/métodos , Anestesia Dental/métodos , Atención Dental para Niños/métodos , Ansiedad al Tratamiento Odontológico/prevención & control , Extracción DentalAsunto(s)
Anestesia General , Sedación Consciente , Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Sedación Consciente/métodos , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/terapia , Anestesia General/métodos , Metaanálisis como Asunto , Accidente Cerebrovascular/cirugía , Accidente Cerebrovascular/terapiaRESUMEN
Pediatric procedural sedation (PPS), formerly known as conscious sedation, is often used outside the operating room for various procedures. Twenty years ago, nearly all cases of PPS were performed by pediatric intensivists, dentists, emergency medicine physicians, and anesthesiologists, due to the urgent nature of procedures in their settings. However, with the emergence of pediatric hospital medicine as a board-certified subspecialty, many children's hospitals have created dedicated PPS teams. These teams, composed of highly trained physicians and ancillary staff, are well-suited for procedures, quality measures, and multidisciplinary care. The wider availability of sedation outside the operating room allows other pediatric subspecialties, such as surgery and oncology, to use PPS in ensuring safe and timely interventions for their patients. This article will cover PPS as an alternative to anesthesia for otherwise healthy children and aim to answer frequent questions that arise regarding medications, risks, and candidacy for PPS. [Pediatr Ann. 2024;53(9):e324-e329.].
Asunto(s)
Sedación Consciente , Humanos , Niño , Sedación Consciente/métodos , Pediatría/métodos , Hipnóticos y Sedantes/uso terapéutico , Hipnóticos y Sedantes/administración & dosificaciónRESUMEN
BACKGROUND: Perioperative reflux aspiration presents a grave concern during sedation or general anesthesia, particularly when solid gastric contents prompt acute upper respiratory obstruction, potentially resulting in fatal consequences for patients. Currently, there are limited means for promptly assessing solid gastric contents in clinical settings. Therefore, this study examined the efficacy of ultrasound assessment for solid gastric contents, offering a rapid and non-invasive approach for early detection and decision-making regarding interventions. METHODS: The study included 400 patients scheduled for upper endoscopy procedures, which encompassed both gastroscope and gastroscope combined colonoscopy examinations with sedation. Ultrasound scanning of the antrum was performed while patients were positioned semi-sitting or in the right lateral decubitus (RLD) posture. The evaluation of solid gastric contents relied on direct visual observation during endoscopy. Gastric volume measurement occurred subsequent to endoscopic suction of gastric contents. Receiver operating characteristic curves were utilized to assess the effectiveness of ultrasonography in discerning solid contents. RESULT: Seven patients undergoing gastroscope with sedation were found to have solid gastric contents. The sensitivity, specificity, positive predictive value, and negative predictive value of the ultrasound qualitative evaluation of solid contents were 85.7%, 99%, 60%, and 99.7%, respectively. CONCLUSION: Solid stomach contents can be evaluated qualitatively with reasonable accuracy using ultrasonography. Additionally, in patients undergoing upper endoscopy and assessed to have solid gastric contents with ultrasound, administration of mild sedation is recommended. TRIAL REGISTRATION: www.chictr.org.cn (ChiCTR2100048994); registered 19/07/2021.
Asunto(s)
Contenido Digestivo , Ultrasonografía , Humanos , Masculino , Femenino , Persona de Mediana Edad , Contenido Digestivo/diagnóstico por imagen , Anciano , Ultrasonografía/métodos , Adulto , Sedación Consciente/métodos , Colonoscopía/métodos , Sensibilidad y Especificidad , Gastroscopios , Estudios ProspectivosRESUMEN
THE AIM OF THE PRESENT STUDY: The aim of the present study was to do a comparison of the recovery profiles and airway-related adverse events of pediatric magnetic resonance imaging (MRI) sedation patients who received propofol alone to those who received midazolam alone. METHODS: This retrospective cohort study was approved by the Mutah University Ethical Approval Committee (No. 2378). A search of the patients' medical records was performed between September 2021 and April 2022 to identify children aged 4 months-11 years who received propofol or midazolam for MRI sedation. The patients were subdivided into two groups: Those who had propofol alone (propofol group) and those who received midazolam (midazolam group) for pediatric MRI sedation. In propofol group, a 1-2 mg/kg of propofol bolus was given to have a deep sedation (Ramsay Sedation Scale score of 5). Patients in midazolam group received 0.05 mg/kg of midazolam. During the maintenance state of sedation, the patient received 150 µg/kg/min of propofol, and the infusion rate was adjusted in 25 µg/kg/min increments up or down at the discretion of the anesthesiologists to maintain a state of deep sedation. The major targets of this study were recovery profiles (time to awake and time to discharge) and airway-related intervention ratios in pediatric MRI sedation patients. Patient demographics, MRI sedation, and recovery data, including propofol induction dose, airway intervention, and sedation-related adverse events from the pediatric sedation recovery unit were also collected. RESULTS: The mean (standard deviation [SD]) propofol induction dose was higher compared to midazolam group (2.4 [0.7] mg vs. 1.3 [0.5] mg; mean difference, 1.1 mg; P < 0.001). The mean (SD) infusion rate was higher in propofol group compared to midazolam group (161.3 [37.6] µg/min/kg vs. 116.2 [25.6] µg/min/kg; mean difference 45.1 µg/min/kg; P < 0.001). The mean (SD) propofol total dose was higher in propofol group compared to midazolam group (236.3 [102.4] mg vs. 180.7 [80.9] mg; mean difference, 155.4 mg; P < 0.001). The mean (SD) time to awake was longer in midazolam group compared to propofol group (21.2 [5.6] min vs. 23.0 [7.1] min; mean difference, 1.8 min; P < 0.001). The mean (SD) time to discharge was longer in midazolam group compared to propofol group (34.5 [6.9] min vs. 38.6 [9.4] min; mean difference, 4.1 min; 95% confidence interval, 3.0-5.1; P < 0.001). CONCLUSION: The administration of midazolam during pediatric MRI sedation can decrease the frequency of airway complications without prolonging the clinically significant recovery profile.
Résumé Objectif de l'étude:L'objectif de la présente étude était de comparer les profils de récupération et les événements indésirables liés aux voies respiratoires chez les patients pédiatriques sous sédation pour une imagerie par résonance magnétique (IRM) ayant reçu du propofol seul à ceux ayant reçu du midazolam seul.Méthodes:Cette étude de cohorte rétrospective a été approuvée par le Comité d'éthique de l'Université de Mutah (No. 2378). Une recherche dans les dossiers médicaux des patients a été réalisée entre septembre 2021 et avril 2022 pour identifier les enfants âgés de 4 mois à 11 ans ayant reçu du propofol ou du midazolam pour une sédation en IRM. Les patients ont été subdivisés en deux groupes : ceux ayant reçu uniquement du propofol (groupe propofol) et ceux ayant reçu du midazolam (groupe midazolam) pour la sédation pédiatrique en IRM. Dans le groupe propofol, un bolus de 1 à 2 mg/kg de propofol a été administré pour atteindre une sédation profonde (score de 5 sur l'échelle de sédation de Ramsay). Les patients du groupe midazolam ont reçu 0,05 mg/kg de midazolam. Pendant la phase de maintien de la sédation, les patients ont reçu 150 µg/kg/min de propofol, et la vitesse de perfusion a été ajustée par paliers de 25 µg/ kg/min, à la discrétion des anesthésistes, pour maintenir un état de sédation profonde. Les principaux objectifs de cette étude étaient les profils de récupération (temps de réveil et temps de sortie) et les taux d'interventions liées aux voies respiratoires chez les patients pédiatriques sous sédation pour IRM. Les données démographiques des patients, les détails de la sédation en IRM et les données de récupération, y compris la dose d'induction de propofol, les interventions liées aux voies respiratoires, et les événements indésirables liés à la sédation dans l'unité de récupération pédiatrique ont également été collectés.Résultats:La dose moyenne (écart-type [ET]) d'induction de propofol était plus élevée par rapport au groupe midazolam (2,4 [0,7] mg contre 1,3 [0,5] mg; différence moyenne, 1,1 mg; P<0,001). Le taux de perfusion moyen (ET) était plus élevé dans le groupe propofol par rapport au groupe midazolam (161,3 [37,6] µg/min/kg contre 116,2 [25,6] µg/min/kg; différence moyenne, 45,1 µg/min/kg; P<0,001). La dose totale moyenne (ET) de propofol était plus élevée dans le groupe propofol par rapport au groupe midazolam (236,3 [102,4] mg contre 180,7 [80,9] mg; différence moyenne, 155,4 mg; P<0,001). Le temps moyen (ET) pour se réveiller était plus long dans le groupe midazolam par rapport au groupe propofol (21,2 [5,6] min contre 23,0 [7,1] min; différence moyenne, 1,8 min; P<0,001). Le temps moyen (ET) de sortie était plus long dans le groupe midazolam par rapport au groupe propofol (34,5 [6,9] min contre 38,6 [9,4] min; différence moyenne, 4,1 min; intervalle de confiance à 95 %, 3,05,1; P<0,001).Conclusion:L'administration de midazolam lors de la sédation pédiatrique pour IRM peut diminuer la fréquence des complications des voies respiratoires sans prolonger de manière significative le profil de récupération clinique.
Asunto(s)
Hipnóticos y Sedantes , Imagen por Resonancia Magnética , Midazolam , Propofol , Humanos , Propofol/administración & dosificación , Propofol/efectos adversos , Midazolam/administración & dosificación , Estudios Retrospectivos , Masculino , Femenino , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Preescolar , Imagen por Resonancia Magnética/métodos , Niño , Lactante , Sedación Profunda/métodos , Sedación Consciente/métodos , Estudios de CohortesRESUMEN
OBJECTIVE: To compare the efficacy of dexmedetomidine versus ketofol for moderate sedation in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). STUDY DESIGN: Randomised controlled trial. Place and Duration of the Study: Department of Anaesthesia, SICU and Pain Management, Sindh Institute of Urology and Transplantation, Karachi, Paksitan, from December 2021 to June 2022. METHODOLOGY: Sixty-two patients aged 20-60 years of any gender scheduled for elective ERCP were included. Patients were randomly divided into Dexmedetomidine group (2ml ampule of 100ug/ml diluted in 18ml of normal saline) and Ketofol group (2ml ketamine and 10ml of propofol 1% diluted in 8ml of normal saline) for sedation. The mean difference in time to achieve Ramsay Sedation Scale (RSS) score of 4 and Modified Aldrete's Score (MAS) of 9 were noted as outcomes in each group. In addition, complications during the procedure and recovery were also noted. RESULTS: The mean age was 39.15 ± 9.82 years. There were 33 (53.2%) males and 29 (46.8%) females. The mean time to achieve RSS 4 was significantly lower in patients who were treated with Dexmedetomidine as compared to Ketofol, i.e., 11.84 ± 1.77 minutes vs. 13.10 ± 1.64 minutes respectively (p-value 0.005, 95% CI -2.12 to -0.39). Similarly, the mean time to achieve MAS score 9 was significantly lower in patients who were treated with Dexmedetomidine as compared to Ketofol, i.e., 11.19 ± 1.72 minutes vs. 12.23 ± 1.84 minutes, respectively (p-value 0.026, 95% CI -1.94 to -0.13). CONCLUSION: Dexmedetomidine proved to be more effective than Ketofol for sedation in ERCP, achieving faster sedation and quicker recovery. KEY WORDS: Dexmedetomidine, Ketofol, Sedation, Endoscopic Retrograde Cholangiopancreatography.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica , Dexmedetomidina , Hipnóticos y Sedantes , Ketamina , Propofol , Humanos , Dexmedetomidina/administración & dosificación , Dexmedetomidina/efectos adversos , Dexmedetomidina/uso terapéutico , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Femenino , Masculino , Adulto , Ketamina/administración & dosificación , Ketamina/efectos adversos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Propofol/administración & dosificación , Propofol/efectos adversos , Persona de Mediana Edad , Sedación Consciente/métodos , Adulto JovenRESUMEN
BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in the diagnosis and staging of mediastinal lymph node lesions in lung cancer. Adequate sedation is an important part of the procedure as it provides patient comfort and potentially increases diagnostic yield. The sedation modality varies among centers and includes moderate sedation/conscious sedation, deep sedation, and general anesthesia. The object of this study will be the evaluation of patient's comfort and level of satisfaction with the involved health care providers (bronchoscopist and anesthesiologist) of remifentanil administration in target-controlled infusion (TCI) for conscious sedation in patients undergoing EBUSTBNA, with a prospective randomized study design versus the of standard sedation protocol with midazolam and/or fentanest and/or propofol. METHODS: This study was carried out at the "Campus Biomedico di Roma" University Hospital between September 2021 and November 2021, with a total number of 30 patients enrolled who met the eligibility criteria, randomly divided into 2 groups: group 1 "REMIFENTANIL TCI" (experimental group) where the patients performed the EBUS-TBNA procedure under conscious sedation with infusion of remifentanil TCI with a target between 3 ng/mL and 6 ng/mL and group 2 "STANDARD" (control group) with patients undergoing conscious sedation with the association of midazolam and/or fentanest and/or propofol in refracted boluses based on clinical needs. Complications, safety, and level of satisfaction of the operator, the anesthesiologist, and the patient were evaluated. RESULTS: The results show that sedation with remifentanil in TCI can improve the comfort level of patients, reducing the risks associated with the procedure (lower frequency of oversedations and hypotension), allowing for greater intraprocedural safety. Furthermore, the level of satisfaction of the anesthesiologist and that of the operator appears to be significantly higher in the Remifentanil group. CONCLUSION: The execution of a mild to moderate sedation with Remifentanil in TCI in patients undergoing EBUS is safe, tolerated, and allows to obtain greater intraprocedural comfort. Further studies and larger and more representative samples are obviously needed to confirm and strengthen the validity of a remifentanil TCI-based sedation in endoscopic diagnostics.
Asunto(s)
Sedación Consciente , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico , Neoplasias Pulmonares , Midazolam , Remifentanilo , Humanos , Remifentanilo/administración & dosificación , Sedación Consciente/métodos , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/métodos , Estudios Prospectivos , Neoplasias Pulmonares/patología , Midazolam/administración & dosificación , Masculino , Satisfacción del Paciente , Femenino , Nivel de Atención , Persona de Mediana Edad , Propofol/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Fentanilo/administración & dosificación , Broncoscopía/métodos , Anciano , AdultoRESUMEN
Dental anxiety and phobia are widespread in the population, with various non-pharmacological and pharmacological techniques available to manage it, including conscious sedation. Medically complex, anxious patients may be at a higher risk of a stress-induced medical emergency during dental treatment. This article lays out the forms of sedation that may be used to help mitigate this risk, the detailed risk assessment required and how conscious sedation may be used as a prophylactic tool to prevent medical emergencies in these patients. Referring clinicians must know what options are available to enable this cohort of patients to access care.
Asunto(s)
Sedación Consciente , Ansiedad al Tratamiento Odontológico , Humanos , Sedación Consciente/métodos , Ansiedad al Tratamiento Odontológico/prevención & control , Masculino , Femenino , Adulto , Estrés Psicológico/prevención & control , Anestesia Dental/métodos , Anestesia Dental/efectos adversos , Urgencias Médicas , Conducta de Reducción del Riesgo , Medición de Riesgo , Hipnóticos y Sedantes/administración & dosificación , Persona de Mediana EdadRESUMEN
Importance: The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients. Objective: To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU). Data Sources: A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023. Study Selection: Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU. Data Extraction and Synthesis: Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis. Main Outcomes and Measures: The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality. Results: A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65). Conclusions and Relevance: This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.
Asunto(s)
Hipnóticos y Sedantes , Respiración Artificial , Humanos , Respiración Artificial/métodos , Niño , Hipnóticos y Sedantes/administración & dosificación , Unidades de Cuidado Intensivo Pediátrico , Enfermedad Crítica/terapia , Enfermedad Crítica/mortalidad , Preescolar , Lactante , Tiempo de Internación/estadística & datos numéricos , Adolescente , Sedación Consciente/métodos , MasculinoRESUMEN
Purpose: To compare the degree of acceptance of behavior guidance techniques (BGT) in pediatric dentistry between American and Colombian parents. Methods: American parents (n=150) and Colombian parents (n=150) of children between three and 12 years of age undergoing pediatric dental treatment participated in this multicenter cross-sectional study. Parents viewed a video depicting 10 BGTs approved by the American Academy of Pediatric Dentistry and rated their acceptance on a visual analog scale. Differences in the degree of acceptance were analyzed using quantile regression analysis. The level of significance was set at five percent. Results: American parents generally demonstrated higher median acceptance scores across various BGTs compared to Colombian parents (P<0.05). American parents exhibited higher acceptance levels of tell-show-do, voice control, non-verbal communication, positive reinforcement, distraction, presence/absence of parents and nitrous oxide, with statistically significant differences noted. American parents also displayed higher acceptance scores for advanced techniques such as protective stabilization, conscious sedation and general anesthesia. Conclusion: American parents consistently exhibited higher acceptance BGTs, suggesting variations in cultural attitudes toward pediatric dental care between the two groups.
Asunto(s)
Padres , Odontología Pediátrica , Humanos , Colombia , Estudios Transversales , Niño , Padres/psicología , Masculino , Femenino , Estados Unidos , Preescolar , Atención Dental para Niños , Control de la Conducta/métodos , Adulto , Sedación ConscienteRESUMEN
BACKGROUND: To evaluate the efficacy and safety of rectal chloral hydrate (CH) in pediatric procedural sedation. METHODS: Seven electronic databases and 3 clinical trials registry platforms were searched, and the deadline was August 2022. Randomized controlled trials evaluating the efficacy and safety of rectal CH in pediatric procedural sedation were included by 2 reviewers. The extracted outcomes included the success rate of sedation, sedation latency, sedation duration, and adverse events. The Cochrane risk of bias tool was used to assess the risk of bias. The outcomes were analyzed using Review Manager 5.3 software. RESULTS: Forty-four randomized controlled trials with 8007 children were included in the meta-analysis. The success rate of sedation in the rectal CH group was significantly higher than that in the placebo group (risk ratio [RR], 2.60 [95% confidence interval [CI], 1.74-3.89]; Pâ <â .01; RR, 1.24 [95% CI, 1.01-1.54]; Pâ =â .04), oral CH group (RR, 1.12 [95% CI, 1.09-1.14]; I2â =â 36%; Pâ <â .001; number needed to treat [NNT]â =â 10), diazepam group (RR, 1.21 [95% CI, 1.10-1.33]; I2â =â 0%; Pâ <â .001; NNTâ =â 6), phenobarbital group (RR, 1.24 [95% CI, 1.13-1.35]; I2â =â 12%; Pâ <â .001; NNTâ =â 6), and ketamine group (RR, 1.39 [95% CI, 1.20-1.60]; I2â =â 20%; Pâ <â .001; NNTâ =â 5). There was no significant difference in the success rate of sedation between the rectal CH group and the midazolam group (RR, 0.98 [95% CI, 0.86-1.11]; I2â =â 51%; Pâ >â .05). The sedation latency was significantly shorter in rectal CH group than that in the oral CH group (mean difference [MD], -6.36 [95% CI, -7.04 to -5.68]; I2â =â 49%; Pâ <â .001) and the phenobarbital group (MD, -7.64 [95% CI, -9.12 to -6.16]; Pâ <â .00001). The sedation duration in the rectal CH group was significantly longer than in the oral CH group (MD, 6.43 [95% CI, 4.39-8.47]; I2â =â 0%; Pâ <â .001). The overall incidence of adverse events was significantly lower with rectal CH than with oral CH (RR, 0.21 [95% CI, 0.16-0.29]; I2â =â 45%; Pâ <â .001) and ketamine (RR, 0.26 [95% CI, 0.12-0.60]; I2â =â 0%; Pâ =â .001). There was no significant difference in the overall incidence of adverse events with rectal CH compared with intramuscular midazolam (RR, 0.55 [95% CI, 0.23-1.28]; Pâ =â .17) and intranasal midazolam (RR, 3.00 [95% CI, 0.66-13.69]; Pâ =â .16). CONCLUSION: The available evidence suggests that rectal CH cloud be an effective and safe sedative agent for pediatric procedural sedation.
Asunto(s)
Administración Rectal , Hidrato de Cloral , Hipnóticos y Sedantes , Hidrato de Cloral/administración & dosificación , Hidrato de Cloral/efectos adversos , Humanos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Niño , Ensayos Clínicos Controlados Aleatorios como Asunto , Sedación Consciente/métodos , Sedación Consciente/efectos adversos , Preescolar , LactanteRESUMEN
Procedural sedation and analgesia (PSA) are a common practice in emergency departments (EDs), aiming to alleviate pain, anxiety, and discomfort during various medical procedures. We have undertaken a systematic review and meta-analysis with the aim of assessing the incidence of adverse events associated with PSA, including those related to individual drugs and various drug combinations. The study adhered to PRISMA guidelines for a systematic review and meta-analysis of adverse events in ED sedation. A comprehensive search strategy was employed across ten databases, supplemented by searches on clinicaltrials.gov and manual reviews of reference lists. Data extraction focused on medication administration and adverse events. The study considered four types of adverse events: cardiac, respiratory, gastrointestinal, and neurological. Only randomized controlled trials (RCTs) focusing on PSA administered to adult patients within the ED setting were included. The statistical analysis employed OpenMeta Analyst to conduct a one-arm meta-analysis, with findings presented alongside their corresponding 95% Confidence Intervals. Forest plots were constructed to combine and evaluate results, and sensitivity analyses were performed to identify sources of heterogeneity. From a literature search of 4246 records, 32 RCTs were deemed suitable for this meta-analysis. The analysis included 6377 procedural sedations. The most common adverse event was hypoxia, with an incidence rate of 78.5 per 1000 sedations (95% CI = 77.5-133.5). This was followed by apnea and hypotension, with incidence rates of 31 (95% CI = 19.5-41.8) and 28.1 (95% CI = 17.4-38.9) per 1,000 sedations, respectively. Agitation and vomiting each occurred in 15.6 per 1,000 sedations (95% CI = 8.7-22.6). Severe adverse events were rare, with bradycardia observed in 16.7 per 1,000 sedations, laryngospasm in 2.9 per 1,000 sedations (95% CI = - 0.1 to 6), intubation in 10.8 per 1,000 sedations (95% CI = 4-17), and aspiration in 2.7 per 1,000 sedations (95% CI = - 0.3 to 5.7). Ketamine is found to be the safest option in terms of respiratory adverse events, with the lowest rates of apnea and hypoxia, making it the least respiratory depressant among the evaluated drugs. Etomidate has the least occurrence of hypotension when used alone. Propofol has the highest incidence of hypotension when used alone and ranks second in hypoxia-related adverse events after midazolam. Using combinations of sedating agents, such as propofol and ketamine, has been found to offer several advantages over single drugs, especially in reducing adverse events like vomiting, intubation difficulty, hypotension, bradycardia, and laryngospasm. The combination significantly reduces the incidence of hypotension compared to using propofol or ketamine individually. Despite the regular use of procedural sedation, it can sometimes lead to serious adverse events. Respiratory issues like apnea and hypoxia, while not common, do occur more often than cardiovascular problems such as hypotension. However, the least frequent respiratory complications, which can also pose a threat to life, include laryngospasm, aspiration, and intubation. These incidents are extremely rare.
Asunto(s)
Servicio de Urgencia en Hospital , Adulto , Humanos , Sedación Consciente/métodos , Sedación Consciente/efectos adversos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Hipnóticos y Sedantes/efectos adversos , Hipnóticos y Sedantes/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
AIMS: Catheter ablation (CA) is a well-established treatment option for atrial fibrillation (AF), where sedation and analgesia are pivotal for patient comfort and lesion formation. The impact of anaesthesia type on AF recurrence rates remains uncertain. This study aimed to examine AF recurrence rates depending on conscious sedation (CS) vs. general anaesthesia (GA) during CA. METHODS AND RESULTS: Utilizing nationwide data from the Danish healthcare registries, we conducted this cohort study involving adults (≥18 years) undergoing first-time CA for AF between 2010 and 2018. Patients were categorized by anaesthesia type (CS or GA), with the primary endpoint being AF recurrence, defined by a composite endpoint of either antiarrhythmic drug (AAD) prescriptions, AF-related hospital admissions, electrical cardioversions, or AF re-ablation. The impact of anaesthesia type was evaluated using multivariable Cox proportional hazards analysis. The study cohort comprised 7957 (6421 CS and 1536 GA) patients. Persistent AF, hypertension, and heart failure, as well as use of AAD, were more prevalent in the GA group. Cumulative incidences of recurrent AF were higher in the CS group at 1 (46% vs. 37%) and at 5 (68% vs. 63%) years. Multivariate analysis revealed CS as significantly associated with increased risk of AF recurrence at 5-year follow-up [hazard ratio 1.26 (95% confidence interval 1.15-1.38)], consistent across paroxysmal and persistent AF subtypes. CONCLUSION: This nationwide cohort study suggests a higher risk of AF recurrence with CS during CA compared to GA. These results advocate for considering GA as the preferred anaesthesia type for improved CA outcomes.
Asunto(s)
Anestesia General , Fibrilación Atrial , Ablación por Catéter , Sedación Consciente , Recurrencia , Sistema de Registros , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/epidemiología , Masculino , Femenino , Dinamarca/epidemiología , Anestesia General/estadística & datos numéricos , Persona de Mediana Edad , Ablación por Catéter/estadística & datos numéricos , Sedación Consciente/estadística & datos numéricos , Anciano , Resultado del Tratamiento , Factores de Riesgo , Antiarrítmicos/uso terapéuticoRESUMEN
STUDY OBJECTIVE: Hypoxemia is the most frequent adverse event observed during gastrointestinal endoscopy under procedural sedation. An optimum oxygen therapy has still not been conclusively determined. DESIGN: A systematic review and network meta-analysis of randomized clinical trials. SETTING: Digestive Endoscopy Center. PATIENTS: Adults (≥18 years old and of both sexes) during gastrointestinal endoscopy under procedural sedation. INTERVENTIONS: Pubmed, MEDLINE, Web of Science, Embase, and Clinicaltrials.gov. were searched until June 30, 2023. Randomized clinical trials (RCTs) comparing any oxygen therapy with another oxygen therapy or with placebo (nasal cannula, NC) were included. MEASUREMENT: The primary outcome was the incidence of hypoxemia, defined as the pulse oxygen saturation (SpO2). Random-effects network meta-analyses were performed. Data are reported as odds ratios (OR), prediction intervals (PrI) and 95% CI. Bias risk was evaluated following the guidelines outlined by the Cochrane Collaboration. The quality of evidence was evaluated through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS: We included 27 RCTs with a total of 7552 patients. Compared to the use of NC, non-invasive positive pressure ventilation (NIPPV) demonstrated superior efficacy in mitigating hypoxemia (NIPPV vs. NC, OR = 0.16, 95% CI: 0.08-0.31, 95% PrI: 0.06-0.41), followed by Wei nasal jet tube (WNJT) (WNJT vs. NC, OR = 0.17, 95% CI: 0.10-0.30, 95% PrI: 0.07-0.42). The efficacy for preventing hypoxemia was ranked as follows: NIPPV > WNJT > oropharynx/nasopharyngeal catheter > high-flow nasal oxygenation > nasal mask > NC. CONCLUSIONS: During gastrointestinal endoscopy under procedural sedation, all other advanced oxygen therapies were found to be more efficacious than nasal cannula. NIPPV and WNJT appear to be the most efficacious oxygen therapy for preventing hypoxemia. Additionally, clinicians should make a choice regarding the most suitable oxygen therapy based on the risk population, type of endoscopy and adverse events.
Asunto(s)
Endoscopía Gastrointestinal , Hipoxia , Metaanálisis en Red , Terapia por Inhalación de Oxígeno , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Hipoxia/prevención & control , Hipoxia/etiología , Terapia por Inhalación de Oxígeno/métodos , Endoscopía Gastrointestinal/efectos adversos , Endoscopía Gastrointestinal/métodos , Sedación Consciente/métodos , Sedación Consciente/efectos adversos , Respiración con Presión Positiva/métodos , Respiración con Presión Positiva/efectos adversosRESUMEN
BACKGROUND: Dexmedetomidine has acceptable clinical utility for inducing sedation during flexible bronchoscopy. Reducing its dose may not only ameliorate its cardiovascular side effects, but also maintain its clinical usefulness. METHODS: Patients between 18 and 65 years were randomized to either dexmedetomidine (0.75 µg/kg) or the midazolam-fentanyl group (0.035 mg/kg midazolam and 25 mcg fentanyl). The primary outcome measure was the composite score. Other parameters noted were: oxygen saturation, hemodynamic variables, Modified Ramsay Sedation Score, Numerical Rating Scale (NRS) for pain intensity and distress, Visual Analog Scale score for cough, rescue medication doses, ease of doing bronchoscopy, and patient response 24 hours after bronchoscopy. RESULTS: In each arm, 31 patients were enrolled. The composite score at the nasopharynx was in the ideal category in 26 patients in dexmedetomidine and 21 in the midazolam-fentanyl group (P=0.007). At the tracheal level, the corresponding values were 24 and 16 (P=0.056). There was no significant difference between the 2 groups regarding the secondary outcome measures except hemodynamic parameters. The mean heart rate in the dexmedetomidine and midazolam-fentanyl groups, respectively, was as follows: at 10 minutes after start of FB (90.10±14.575, 104.35±18.48; P=0.001), at the end of FB (98.39±18.70, 105.94±17.45; P=0.016), and at 10 minutes after end of FB (89.84±12.02, 93.90±13.74; P=0.022). No patient developed bradycardia. Two patients (P=0.491) in the dexmedetomidine group developed hypotension. CONCLUSION: Low-dose dexmedetomidine (0.75 µg/kg single dose) appears to lead to a better composite score compared with the midazolam-fentanyl combination.
Asunto(s)
Broncoscopía , Dexmedetomidina , Fentanilo , Hipnóticos y Sedantes , Midazolam , Humanos , Dexmedetomidina/administración & dosificación , Dexmedetomidina/efectos adversos , Fentanilo/administración & dosificación , Fentanilo/efectos adversos , Midazolam/administración & dosificación , Midazolam/efectos adversos , Broncoscopía/métodos , Masculino , Femenino , Método Doble Ciego , Persona de Mediana Edad , Estudios Prospectivos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Adulto , Anciano , Adulto Joven , Frecuencia Cardíaca/efectos de los fármacos , Sedación Consciente/métodos , Hemodinámica/efectos de los fármacos , Adolescente , Dimensión del Dolor/métodosRESUMEN
BACKGROUND/AIM: Hysterectomy is the most frequent gynecological surgery. Vaginal hysterectomy (VH) seems to be related to favorable perioperative outcomes compared to abdominal or laparoscopic approaches. As the population ages, anesthesia that is safer for the elderly, such as local anesthesia (LA) with conscious sedation, is gaining popularity and is related to favorable outcomes in patients' recovery compared to general or regional anesthesia. We aimed to evaluate the efficacy of dexmedetomidine versus propofol for women undergoing VH for uterine prolapse under LA and conscious sedation. PATIENTS AND METHODS: A prospective study on 40 women with uterine prolapse stage ≥3 who had VH under LA with conscious sedation under either dexmedetomidine (n=20) or propofol (n=20) was performed. A standardized surgical approach with continuous hemodynamic monitoring and sedation assessment using the Ramsay Sedation Scale (RSS) was conducted. The primary endpoint of the study was to determine the percentage of patients receiving intraoperative fentanyl. RESULTS: Analysis of outcomes demonstrated a significant reduction in the proportion of patients requiring intraoperative rescue fentanyl (35% vs. 5%, respectively, p=0.04) and in postoperative pain scores, with more patients achieving an optimal RSS score of 3 in the dexmedetomidine group. CONCLUSION: Based on the findings of the present study, dexmedetomidine offered superior analgesia and patient comfort compared to propofol, suggesting a favorable anesthetic profile for VH under LA.
Asunto(s)
Anestesia Local , Sedación Consciente , Dexmedetomidina , Histerectomía Vaginal , Propofol , Humanos , Dexmedetomidina/administración & dosificación , Dexmedetomidina/uso terapéutico , Femenino , Propofol/administración & dosificación , Histerectomía Vaginal/métodos , Histerectomía Vaginal/efectos adversos , Persona de Mediana Edad , Sedación Consciente/métodos , Estudios Prospectivos , Anestesia Local/métodos , Anciano , Hipnóticos y Sedantes/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Adulto , Resultado del TratamientoRESUMEN
On July 1, 2021, cannabis became legal in Virginia for adults 21 years of age and older. Cannabis consumption may have significant implications for outcomes related to medical care, including procedural sedation. The purpose of this study was to determine whether self-reported cannabis consumption has any relationship to sedation medication requirements during endoscopic procedures. A retrospective analysis was conducted to examine two groups of surgical patients (self-reported cannabis use versus self-reported non-cannabis use) at a community hospital in the mid-Atlantic region. Results demonstrate that there were no significant differences between groups for either Time to Aldrete ≥8 (p = .486) or Time to Meet Phase II Criteria (p = .762). Equivalent recovery times for both groups may be an indicator that comparable sedation levels were maintained, despite the increased propofol requirements of the cannabis group. Open conversations to establish patient use of cannabis products prior to procedural sedation is important for determining appropriate plans of care related to risk factors and medication dosage requirements during endoscopic evaluations.
Asunto(s)
Hipnóticos y Sedantes , Humanos , Masculino , Estudios Retrospectivos , Femenino , Adulto , Persona de Mediana Edad , Virginia , Hipnóticos y Sedantes/administración & dosificación , Sedación Consciente/métodos , Anciano , Endoscopía GastrointestinalRESUMEN
Gastroenterology nurses working across a variety of clinical settings are responsible for periprocedural monitoring during moderate to deep procedural sedation and analgesia (PSA) to identify signs of respiratory compromise and intervene to prevent cardiorespiratory events. Pulse oximetry is the standard of care for respiratory monitoring, but it may delay or fail to detect abnormal ventilation during PSA. Continuous capnography, which measures end-tidal CO2 as a marker of alveolar ventilation, has been endorsed by a number of clinical guidelines. Large clinical trials have demonstrated that the addition of continuous capnography to pulse oximetry during PSA for various gastroenterological procedures reduces the incidence of hypoxemia, severe hypoxemia, and apnea. Studies have shown that the cost of adding continuous capnography is offset by the reduction in adverse events and hospital length of stay. In the postanesthesia care unit, continuous capnography is being evaluated for monitoring opioid-induced respiratory depression and to guide artificial airway removal. Studies are also examining the utility of continuous capnography to predict the risk of opioid-induced respiratory depression among patients receiving opioids for primary analgesia. Continuous capnography monitoring has become an essential tool to detect early signs of respiratory compromise in patients receiving PSA during gastroenterological procedures. When combined with pulse oximetry, it can help reduce cardiorespiratory adverse events, improve patient outcomes and safety, and reduce health care costs.