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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.

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Background and Objectives: The impact of anesthetic agents on memory and cognitive function following general anesthesia is of great interest, particularly regarding their effects on the developing pediatric brain. While numerous studies have examined the relationship between anesthetic drugs and brain function, research focusing on early cognitive function following sedation remains limited. Materials and Methods: This study was a prospective, randomized controlled trial involving 148 pediatric patients scheduled for hematological procedures, specifically bone marrow aspiration (BMA) and intrathecal chemotherapy (ITC). Patients were divided into two groups based on the primary anesthetic used: the inhalational sedation group (IHG), in which sevoflurane was used, and the intravenous sedation group (IVG), which received propofol infusion. Apart from the main anesthetic agent, all sedation methods were consistent across both groups. A cognitive function test administered before sedation involved memorizing four distinct images, each associated with a different number. Then, the patients were asked to identify the omitted image upon awakening in the recovery room. Herein, this pre- vs. post-sedation test is called the early recognition assessment (ERA) tool. The primary outcome was the correct response rate after sedation for the two groups. Secondary outcomes included the sedation score, the behavior response score, and the correct response rates according to the number of sedation procedures. Results: This study included 130 patients in the final analysis, with 74 originally assigned to each group. The initial cognitive assessment revealed no significant difference in performance between the anesthetic agents. In addition, no differences were observed in the rates of correct responses or post-sedation scores after repeated procedures. However, the IVG demonstrated higher behavior response scores compared to the IHG. Conclusions: There were no significant differences in the rates of correct responses using the ERA tool between the two groups, irrespective of the number of sedation procedures performed. While some differences were noted in preoperative, intraoperative, and post-anesthesia care, these did not significantly impact the cognitive outcomes measured.

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INTRODUCTION: Critically ill patients often develop the Post-Intensive Care Syndrome (PICS). Current sedation guidelines mainly rely on intravenous agents. Inhaled sedatives are a promising alternative with favorable pharmacokinetics and potential benefits in critical care settings. However, their application in Latin America remains unexplored. METHODS: Case-series study that included adult ICU patients who underwent deep sedation with sevoflurane using the SEDANA anesthetic conserving device. Data on demographics, sedation protocols, adverse events, and outcomes were collected. Statistical analysis assessed changes over time in laboratory parameters. RESULTS: Eleven patients were included, with sevoflurane administered via artificial airways. Inhaled sedation led to the successful cease of intravenous sedatives in 10 of 11 patients, and reduction of at least 30% in opioid dose. No significant adverse effects were observed. Barriers to adherence included device-related issues and challenges in healthcare staff training. CONCLUSION: Sevoflurane effectively achieved sedation goals in ICU patients, reducing the need for additional sedatives and opioids. Our findings support the safety and efficacy of inhaled sedatives in ICU settings and highlight the importance of further research in this area. Longer-term studies are needed to fully determine the impact of inhaled sedatives in ICU patients.

Introducción: Los pacientes críticamente enfermos a menudo desarrollan el Síndrome Post-Cuidados Intensivos (PICS). Las pautas actuales de sedación se basan principalmente en agentes intravenosos. Los sedantes inhalados son una alternativa prometedora con farmacocinética favorable y beneficios potenciales en entornos de cuidados críticos. Sin embargo, su aplicación en América Latina sigue sin explorarse. Métodos: Estudio de serie de casos que incluyó a pacientes adultos de UCI que recibieron sedación profunda con sevoflurano utilizando el dispositivo conservador anestésico SEDANA. Se recopilaron datos demográficos, protocolos de sedación, eventos adversos y resultados. El análisis estadístico evaluó los cambios en el tiempo en los parámetros de laboratorio. Resultados: Se incluyeron once pacientes, a quienes se les administró sevoflurano a través de vías respiratorias artificiales. Se incluyeron once pacientes, a quienes se les administró sevoflurano a través de vías respiratorias artificiales. La sedación inhalada llevó a la cesación exitosa de sedantes intravenosos en 10 de los 11 pacientes, con una reducción de al menos 30% la dosis de opioides. No se observaron efectos adversos significativos. Las barreras para la adherencia incluyeron problemas relacionados con el dispositivo y desafíos en la capacitación del personal de salud. Conclusión: El sevoflurano logró de manera efectiva los objetivos de sedación en pacientes de UCI, reduciendo la necesidad de sedantes y opioides adicionales. Nuestros hallazgos respaldan la seguridad y eficacia de los sedantes inhalados en entornos de UCI y resaltan la importancia de una mayor investigación en esta área. Se necesitan estudios a más largo plazo para determinar completamente el impacto de los sedantes inhalados en pacientes de UCI.

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BACKGROUND: Dexmedetomidine and propofol are common sedatives in intensive care units and for interventional procedures. Both may compromise sinus node function and atrioventricular conduction. The objective of this prospective, randomized study is to compare the effect of dexmedetomidine with propofol on sinus node function and atrioventricular conduction. METHODS: In a tertiary care center in Switzerland we included from September 2019 to October 2020 160 patients (65 ± 11 years old; 32% female) undergoing first ablation for atrial fibrillation by cryoballoon ablation or by radiofrequency ablation. Patients were randomly assigned to deep sedation with dexmedetomidine (DEX group) versus propofol (PRO group). A standard electrophysiological study was performed after pulmonary vein isolation with the patients still deeply sedated and hemodynamically stable. RESULTS: Eighty patients each were randomized to the DEX and PRO group. DEX group patients had higher baseline sinus cycle length (1022 vs. 1138 ms; p = 0.003) and longer sinus node recovery time (SNRT400; 1597 vs. 1412 ms; p = 0.042). However, both corrected SNRT and normalized SNRT did not differ. DEX group patients had longer PR interval (207 vs. 186 ms; p = 0.002) and AH interval (111 vs. 95 ms, p = 0.008), longer Wenckebach cycle length of the atrioventricular node (512 vs. 456 ms; p = 0.005), and longer atrioventricular node effective refractory period (390 vs. 344 ms; p = 0.009). QRS width and HV interval were not different. An arrhythmia, mainly atrial fibrillation, was induced in 33 patients during the electrophysiological study, without differences among groups (20% vs. 15%, p = 0.533). CONCLUSIONS: Dexmedetomidine has a more pronounced slowing effect on sinus rate and suprahissian AV conduction than propofol, but not on infrahissian AV conduction and ventricular repolarization. These differences need to be taken into account when using these sedatives. TRIAL REGISTRATION: ClinicalTrials.gov number NCT03844841, 19/02/2019.

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The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.

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PURPOSE OF REVIEW: This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings. RECENT FINDINGS: The number of procedural interventions under deep sedation in NORA is still increasing. Administration of oxygen is recommended to prevent hypoxemia and is usually delivered with standard oxygen through nasal cannula or a face mask. HFNO is a simple alternative with a high warmed humidified flow (ranging from 30 to 70 l/min) with a precise fraction inspired of oxygen (ranging from 21 to 100%). Compared to standard oxygen, HFNO has demonstrated efficacy in reducing the incidence of hypoxemia and the need for airway maneuvers. Research on HFNO has primarily focused on its application in gastrointestinal endoscopy procedures. Yet, it has also shown promising results in various other procedural interventions including bronchoscopy, cardiology, and endovascular procedures. However, the adoption of HFNO prompted considerations regarding cost-effectiveness and environmental impact. SUMMARY: HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.

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Propofol sedation, routinely used for endoscopic procedures, is safe and acceptable for children. Adjuvants, such as esketamine or sufentanil, are commonly added to improve the efficacy and safety of propofol sedation. This study aimed to compare the clinical efficacy and safety of propofol-esketamine (PE) versus propofol-sufentanil (PS) for deep sedation and analgesia in children with autism undergoing colonoscopy procedure. One hundred and twenty-four children with autism undergoing colonoscopy procedure were included in the study. Patients were randomly assigned to receive one of the two adjuvants: esketamine (0.3 mg/kg) or sufentanil (0.2 µg/kg), subsequently administered propofol 2.0 mg/kg to induce anesthesia. Additional doses of propofol (0.5-1.0 mg/kg) were administered as needed to ensure patient tolerance for the remaining duration of the procedure. Movement during the procedure, hemodynamic variables, the total dose of propofol, recovery time, and adverse events were recorded. The PE group exhibited a significantly lower incidence of severe movement during the procedure compared with the PS group (14.52% vs. 32.26%, p = 0.020). The PE group showed significantly lower incidence of respiratory depression, hypotension, and severe injection pain of propofol than the PS group during the procedure (all p < 0.05). The mean arterial pressure (MAP) decreased significantly after anesthesia induction in the PS group and remained lower than baseline (all p < 0.05). Compared with the combination of low-dose sufentanil (0.2 µg/mg) with propofol, the low-dose esketamine (0.3 mg/kg) combined with propofol provided more stable hemodynamics, higher quality of sedation, and fewer adverse events in children with autism undergoing colonoscopy procedure.

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INTRODUCTION: Penile plication is commonly performed for Peyronie's disease under general or spinal anesthesia. Conscious sedation (CS) offers decreased anesthetic risks, cost-effectiveness, and the ability to perform the procedure in outpatient settings with shorter wait times. We sought to compare tolerability of penile plication under deep intravenous sedation (DIS) administered by anesthesiologists and nursing-administered CS (NACS). METHODS: Tolerability for penile plication was prospectively evaluated, excluding revision surgeries and those with hourglass or hinge deformities. DIS included midazolam and ketamine with infusion of propofol and remifentanil. NACS consisted of midazolam and fentanyl. Baseline characteristics, procedural information, and patient- and surgeon-reported pain assessments were collected. Patients were administered a standardized tolerability questionnaire on follow-up. RESULTS: Forty patients were enrolled (23 DIS; 17 NACS) with similar baseline characteristics. Median curvature of the DIS cohort was 55° (interquartile range = 43.75-76.25) and 45° (interquartile range = 45-60) in NACS. There was a 100% success rate with no procedure abortion or conversion to general anesthetic. On follow-up, all patients had functional curvature (<20°), and 100% of patients in the DIS and NACS cohorts reported that they would recommend CS to others. Over 93% of patients in both cohorts would choose CS over general anesthetic in the future, with no differences in perioperative and postoperative pain between groups. CONCLUSIONS: Penile plication with CS, whether administered by an anesthesiologist or nursing, is well tolerated with no differences in pain or complications. This indicates that outpatient penile plication with trained nursing staff administering CS can safely reduce costs, risks, and wait times.

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Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient's symptoms and suffering.

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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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AIM: Knowledge of risk factors may provide strategies to reduce the high burden of delirium in intensive care unit (ICU) patients. We aimed to compare the risk of delirium after deep sedation with propofol versus midazolam in ICU patients. METHODS: In this prospective cohort study, ICU patients who were in an unarousable state for ≥24 h due to continuous sedation with propofol and/or midazolam were included. Patients admitted ≤24 h, those with an acute neurological disorder and those receiving palliative sedation were excluded. ICU patients were assessed daily for delirium during the 7 days following an unarousable state due to continuous sedation. RESULTS: Among 950 included patients, 605 (64%) subjects were delirious during the 7 days after awaking. The proportion of subsequent delirium was higher after midazolam sedation (152/207 [73%] patients) and after both propofol and midazolam sedation (257/377 [68%] patients), compared to propofol sedation only (196/366 [54%] patients). Midazolam sedation (adjusted cause-specific hazard ratio [adj. cause-specific HR] 1.32, 95% confidence interval [CI] 1.05-1.66) and propofol and midazolam sedation (adj. cause-specific HR 1.29, 95% CI 1.06-1.56) were associated with a higher risk of subsequent delirium compared to propofol sedation only. CONCLUSION: This study among sedated ICU patients suggests that, compared to propofol sedation, midazolam sedation is associated with a higher risk of subsequent delirium. This risk seems more apparent in patients with high cumulative midazolam intravenous doses. Our findings underpin the recommendations of the Society of Critical Care Medicine Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) guidelines to use propofol over benzodiazepines for sedation in ICU patients.

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BACKGROUND: Over the past 4 years, aesthetic surgery, notably liposuction, has substantially increased. Tumescent liposuction, a popular technique, has two variants-true tumescent liposuction (TTL) and semi-tumescent liposuction. While TTL reduces risks, it has limitations. There is no literature reported on semi-tumescent liposuction under deep sedation using the propofol-ketamine protocol, which is proposed as a potentially safe alternative. METHODS: The retrospective analysis covered 8 years and included 3094 patients performed for tumescent liposuction under deep sedation, utilizing the propofol-ketamine protocol. The evaluation of patient safety involved an examination of potential adverse events with a specific focus on respiratory issues related to sedation, including instances of mask ventilation. RESULTS: Among the 3094 cases, no fatalities were recorded. Noteworthy events included 43 mask ventilation instances, primarily occurring in the initial 10 min. Twelve cases experienced surgery cancellation due to various factors, including respiratory issues. Three patients were transferred to upper-level hospitals, while another three required blood transfusions. Vigilant management prevented significant complications, and other adverse events like venous thromboembolism (VTE), fat embolism, severe lidocaine toxicity, and so on were not observed. CONCLUSIONS: The analysis of 3094 tumescent liposuction cases highlighted the overall safety profile of the propofol-ketamine protocol under deep sedation. The scarcity of severe complications underscores its viability. The study emphasizes the significance of thorough preoperative assessments, careful patient selection, and awareness of potential complications. Prompt interventions, particularly in addressing sedation-related respiratory issues, further contribute to positive outcomes for patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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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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BACKGROUND: The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability. AIM: To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers. DESIGN: Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure. SETTING: European. PARTICIPANTS: International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation. RESULTS: A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided. CONCLUSIONS: This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.

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BACKGROUND: Human consciousness is generally thought to emerge from the activity of intrinsic connectivity networks (resting-state networks [RSNs]) of the brain, which have topological characteristics including, among others, graph strength and efficiency. So far, most functional brain imaging studies in anesthetized subjects have compared wakefulness and unresponsiveness, a state considered as corresponding to unconsciousness. Sedation and general anesthesia not only produce unconsciousness but also phenomenological states of preserved mental content and perception of the environment (connected consciousness), and preserved mental content but no perception of the environment (disconnected consciousness). Unresponsiveness may be seen during unconsciousness, but also during disconnectedness. Deep dexmedetomidine sedation is frequently a state of disconnected consciousness. In this study, we were interested in characterizing the RSN topology changes across 4 different and steady-state levels of dexmedetomidine-induced alteration of consciousness, namely baseline (Awake, drug-free state), Mild sedation (drowsy, still responding), Deep sedation (unresponsive), and Recovery, with a focus on changes occurring between a connected consciousness state and an unresponsiveness state. METHODS: A functional magnetic resonance imaging database acquired in 14 healthy volunteers receiving dexmedetomidine sedation was analyzed using a method combining independent component analysis and graph theory, specifically looking at changes in connectivity strength and efficiency occurring during the 4 above-mentioned dexmedetomidine-induced altered consciousness states. RESULTS: Dexmedetomidine sedation preserves RSN architecture. Unresponsiveness during dexmedetomidine sedation is mainly characterized by a between-networks graph strength alteration and within-network efficiency alteration of lower-order sensory RSNs, while graph strength and efficiency in higher-order RSNs are relatively preserved. CONCLUSIONS: The differential dexmedetomidine-induced RSN topological changes evidenced in this study may be the signature of inadequate processing of sensory information by lower-order RSNs, and of altered communication between lower-order and higher-order networks, while the latter remain functional. If replicated in an experimental paradigm distinguishing, in unresponsive subjects, disconnected consciousness from unconsciousness, such changes would sustain the hypothesis that disconnected consciousness arises from altered information handling by lower-order sensory networks and altered communication between lower-order and higher-order networks, while the preservation of higher-order networks functioning allows for an internally generated mental content (or dream).

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Background: Advancements in palliative surgery of patients with single ventricle physiology have led to an increase in the need for deep sedation protocols for painful procedures. However, positive pressure ventilation during anesthesia can result in unfavorable cardiopulmonary interactions. This patient population may benefit from sedation from these painful procedures. Methods: This study aims to demonstrate the safety and efficacy of deep sedation by pediatric intensivists outside the operating room for children with single ventricle physiology. This is a single-center, retrospective chart review on consecutive pediatric patients with single ventricle physiology who received deep sedation performed by pediatric intensivists between 2013 and 2020. Results: Thirty-three sedations were performed on 27 unique patients. The median age was 3.7 years (25th%-75th%: 2.1-15.6). The majority of the sedations, 88% (29/33), were done on children with Fontan physiology and 12% (4/33) were status-post superior cavopulmonary anastomosis. The primary cardiac defect was hypoplastic left heart in 63% (17/27) of all sedation procedures. There were 24 chest tube placements and 9 cardioversions. Ketamine alone [median dose 1.5 mg/kg (range 0.8-3.7)], ketamine [median dose 1 mg/kg (range 0.1-2.1)] with propofol [median dose 2.3 mg/kg (range 0.7-3.8)], and ketamine [median dose 1.5 mg/kg (range 0.4-3.0)] with morphine [median dose 0.06 mg/kg (range 0.03-0.20)] were the most common sedation regimens used. Adverse events (AEs) occurred in 4 patients (15%), three of which were transient AEs. All sedation encounters were successfully completed. Conclusion: Procedural deep sedation can be safely and effectively administered to single ventricle patients by intensivist-led sedation teams in selective case.

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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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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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