Effect of combined sedation using multiple drugs on inflammatory cytokines in patients with acute respiratory distress syndrome

Abstract he innate immune response plays an important role in the pathophysiology of acute respiratory distress syndrome (ARDS); however, no drug has been proven to be beneficial in the management of ARDS. Therefore, the aim of this study was to investigate the effects of using combined sedatives on systemic inflammatory responses in patients with ARDS. A total of 90 patients with ARDS and an intubation time of > 120 h were randomly divided into the propofol group (group P), midazolam group (group M), and combined sedation group (group U). Patients in groups P and M were sedated with propofol and midazolam, respectively, whereas patients in group U were sedated with a combination of propofol, midazolam, and dexmedetomidine. The dosage of sedatives and vasoactive drugs, duration of mechanical ventilation, and incidence of sedative adverse reactions were documented. The dosage of sedatives and vasoactive drugs, as well as the incidence of sedative adverse reactions in group U, was significantly lower than those in groups P and M. Similarly, the duration of mechanical ventilation in group U was significantly shorter than that in groups P and M. Hence, inducing sedation through a combination of multiple drugs can significantly reduce their adverse effects, improve their sedative effect, inhibit systemic inflammatory responses, and improve oxygenation in patients with ARDS

Abordaje del implante valvular aórtico transcateter durante la pandemia por COVID-19 con alta prevoz: reporte de una serie de casos / Transcatheter aortic valve implantation (TAVI) with conscious sedation and early discharge: report of seven cases

COVID-19 pandemic generated multiple challenges for the health system. Cardiovascular disease is associated with a worse prognosis of infections. Moreover, most hospital resources and operative rooms were destined to patients with COVID-19 infection, deferring the treatment of most valvular patients requiring surgery. We report seven patients with symptomatic severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) with conscious sedation and early discharge. No patient required intensive care unit admission or mechanical ventilation. After a 90-day follow-up, there were no complications or unplanned readmissions.

Factores de riesgo de reacción paradójica asociados a sedación endovenosa con midazolam / Paradoxical reactions associated with midazolam conscious sedation

Background: Benzodiazepines are used for perioperative conscious sedation. However, its use may be associated with paradoxical reactions. The known risk factors for these reactions are age, alcohol and drug abuse and psychiatric disorders. Aim: To assess the incidence and impact of risk factors of paradoxical reactions to midazolam. Material and Methods: Cross sectional study of 218 patients aged 50 ± 16 years (51% women) scheduled for elective surgical procedures under regional anesthesia and midazolam sedation. The paradoxical reactions were classified according to their severity in three categories. Results: The incidence of paradoxical reactions to midazolam was 8.3% (95% confidence interval (CI) 5.0-12.7). All were mild and only 28% of the affected patients required pharmacological treatment, none of them flumazenil. A multivariable logistic regression model showed that the variables independently associated with a paradoxical reaction to midazolam were the use of psychoactive medications (Odds Ratio (OR) = 3.4 [1.1-11], p = 0.04, and the dose of midazolam (OR 1.35 [1.03-1.78], p = 0.03. Conclusions: The incidence of paradoxical reactions to midazolam was 8,3% and all were mild. Their risk factors are the use of psychoactive medications and the use of higher doses of midazolam.

Associação entre nível de sedação e mortalidade de pacientes em ventilação mecânica em terapia intensiva / Asociación entre nivel de sedación y mortalidad de pacientes con ventilación mecánica en cuidados intensivos / Association between sedation level and mortality of intensive care patients on mechanical ventilation

RESUMO Objetivo Associar nível de sedação, critérios de desligamento diário das drogas sedoanalgésicas e mortalidade de pacientes em ventilação mecânica em Unidade de Terapia Intensiva. Método Estudo prospectivo, longitudinal e quantitativo, realizado com pacientes, por meio da Escala de Agitação e Sedação de Richmond (do inglês, RASS) e o Sepsis-related Organ Failure Assessment, através de protocolo assistencial gerenciado por enfermeiro da unidade para a interrupção diária da sedação, uma vez ao dia. O teste estatístico de Qui Quadrado foi utilizado para verificar associação entres variáveis e o teste T para análises independentes. Resultados Participaram 204 pacientes. A maioria era do sexo masculino, idade entre 40 e 60 anos, cirúrgicos, em sedoanalgesia com fentanil, midazolan e propofol, com tempo de sedação de um a cinco dias e média de permanência de 10,7 dias. Estavam com sedação moderada e apresentavam risco alto para mortalidade. Houve correlação estatística entre óbito em pacientes com sedação profunda, e sensibilidade em relação à alta da Unidade de Terapia Intensiva daqueles que sofreram a interrupção da sedação e foram reavaliados diariamente. Conclusão A interrupção diária da sedação guiada pela Escala Richmond auxilia no controle da sedação, o que favorece o tratamento e recuperação do paciente e direciona a tomada de decisão do enfermeiro. Porém, neste estudo, não se configurou como fator independente para previsão de mortalidade em terapia intensiva.

RESUMEN Objetivo Asociar el nivel de sedación, los criterios para la interrupción diaria de la sedación y la mortalidad de los pacientes con ventilación mecánica en una Unidad de Cuidados Intensivos. Método Estudio prospectivo, longitudinal y cuantitativo realizado con pacientes utilizando la Escala de Agitación-Sedación de Richmond (RASS) y el Sepsis-related Organ Failure Assessment (SOFA) score, a través de un protocolo de atención administrado por enfermeros en la unidad para la interrupción diaria de la sedación, una vez al día. La prueba Chi Square se utilizó para verificar la asociación entre variables y la prueba T para análisis independientes. Resultados Participación de 204 pacientes. La mayoría eran hombres, quirúrgicos, edad entre 40 y 60 años, en sedoanalgesia con fentanilo, midazolam y propofol, con un tiempo de sedación de uno a cinco días y una estancia promedio de 10,7 días. Estaban en sedación moderada y tenían un alto riesgo de mortalidad. Hubo una correlación estadística entre la muerte en pacientes en sedación profunda y la sensibilidad en relación con el alta de la Unidad de Cuidados Intensivos de aquellos que se sometieron a la interrupción diaria de la sedación y fueron reevaluados diariamente. Conclusión La interrupción diaria de la sedación guiada por la Escala de Agitación-Sedación de Richmond ayuda a controlar la sedación, lo que favorece el tratamiento y la recuperación de pacientes y guía la toma de decisiones de los enfermeros. Sin embargo, en este estudio, no fue un factor independiente para predecir la mortalidad en cuidados intensivos.

ABSTRACT Objective To associate the sedation level, criteria for daily interruption of sedation and mortality of patients on mechanical ventilation in an Intensive Care Unit. Method Prospective, longitudinal and quantitative study conducted with patients by using the Richmond Agitation-Sedation Scale (RASS) and the Sepsis-related Organ Failure Assessment (SOFA) score, through a care protocol managed by a nurse at the unit for the daily interruption of sedation once a day. The Chi Square test was used to check the association between variables and the T test for independent analyzes. Results Participation of 204 patients. Most were male, surgical, aged between 40 and 60 years, in sedoanalgesia with fentanyl, midazolam and propofol, with sedation time of one to five days and average stay of 10.7 days. They were in moderate sedation and at high risk for mortality. There was a statistical correlation between death in patients in deep sedation, and sensitivity in relation to discharge from the Intensive Care Unit of those who underwent daily interruption of sedation and were reassessed daily. Conclusion Daily interruption of sedation guided by the Richmond Agitation-Sedation Scale assists in the control of sedation, which favors the treatment and recovery of patients and guides nurses' decision making. However, in this study, it was not configured as an independent factor for predicting mortality in intensive care.

A prediction model for hypoxemia during routine sedation for gastrointestinal endoscopy

OBJECTIVES: The current study was designed to assess the clinical predictors of hypoxemia and to develop a multivariable, predictive model for hypoxemia during routine gastrointestinal endoscopy. METHODS: In total, 308 patients were enrolled in the analysis. Demographic data, concurrent chronic disease information, anesthetic dose and Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores were collected and analyzed statistically. RESULTS: Multivariate logistic regression indicated that age (OR: 1.04; 95%CI 1.01-1.08), body mass index (BMI) (OR: 1.12; 95%CI: 1.02-1.21) and habitual snoring (OR: 3.71; 95%CI: 1.62-8.48) were independently associated with hypoxemia. A logistic regression function (LR model) was developed to predict hypoxemia considering the parameters of -7.73+0.04 age (years), +0.11 BMI, and +1.31 habitual snoring (yes or no). The area under the receiver operating characteristic (ROC) curve for the LR model was 0.76. CONCLUSIONS: The LR model, consisting of age, BMI and habitual snoring, was a useful predictor of hypoxemia during routine sedation for gastrointestinal endoscopy.

Análise epidemiológica de pacientes submetidos à endoscopia digestiva alta em uma unidade de saúde de curta permanência / Epidemiological analysis of patients submitted to high digestive endoscopy in a short-stay health unit

Introdução e objetivos: a Endoscopia Digestiva Alta (EDA) representa o método de endoscopia mais usado, e geralmente é realizada sob sedação consciente. Dentre os efeitos adversos (EA) deste exame, os eventos cardiorrespiratórios são os que implicam maior importância, representando cerca de 60% do total, estando relacionados a fatores predisponentes dos pacientes, tais como obesidade, idade e doenças pulmonares prévias. Assim, considerando-se a relevância dos fatores de risco (FR) relacionados ao paciente e seus possíveis efeitos na morbimortalidade geral do procedimento, objetiva-se com o presente trabalho epidemiológico traçar o perfil do paciente que se submete à EDA no Brasil. Métodos: o estudo é transversal com amostragem aleatória de 974 pacientes submetidos à EDA eletiva. O questionário foi aplicado entre janeiro de 2013 e junho de 2013. Resultados: a média de idade foi de 40,88 anos, sendo 11,50% acima dos 60 anos. A média do IMC foi de 26,21kg/m², com 53,18% dos entrevistados apresentando sobrepeso ou obesidade. As morbidades encontradas incluíram hipertensão arterial sistêmica (N=152); outras doenças cardíacas (N=35); doenças respiratórias (N=599); diabetes mellitus (N=43); doença tireoidiana (N=68). Os principais medicamentos utilizados foram os benzodiazepínicos (4,93%) ou outros neuropsiquiátricos, somando 11,59%. O uso de álcool foi relatado por 37,39% e 5,54% eram tabagistas. Apenas 19,40% dos pacientes não apresentavam alguma enfermidade coexistente ou FR. Conclusão: considerando-se a endoscopia e a sedação envolvida, a atenção às variações demográficas e epidemiológicas populacionais assume especial importância, visto que estão diretamente relacionadas ao aumento da probabilidade de ocorrência de EA cardiorrespiratórios durante e após o procedimento. As conclusões deste trabalho devem ser entendidas à luz de seu local de realização, que é uma unidade ambulatorial.

Background: the Upper Gastrointestinal Endoscopy (UGE) represents the most common endoscopic modality and it is usually made with conscious sedation. Among the adverse events of this procedure, the cardiovascular events are the most relevant, comprising around 60% of overall events. It is known that some adverse events are related to patient's risk factors, such as obesity, age and pulmonary disease. Thus, considering the importance of risk factors and their impact in the morbimortality related to the procedure, the aim of this study is to know the epidemiological profile of the patients that need an endoscopy in Brazil. Methods: it is a sectional study with an aleatory sample of 974 patients that was submitted to an elective UGE in the period of January of 2013 and June of 2013. A questionnaire was applied to each individual. Results: the average age of the study was 40.88 years old, with 11.50% being over 60 years old. The body mass index (BMI) average was 26.21 kg/m² among which 53.18% of the interviewed could be classified as overweight or obese. The morbidities founded were high blood pressure (N=152); other cardiac diseases (N=35); respiratory diseases (N=599); diabetes mellitus (N=43); thyroid diseases (N=68). The most used drugs were benzodiazepines (4.93%) or other psychiatric drugs, comprising 11.59%. The use of alcohol was mentioned by 37.39% and 5.54% were smokers. Only 19.40% amongst the patients did not mention any comorbidity or risk factor to the procedure. Conclusion: considering the endoscopy and the sedation involved in the procedure, knowing the demographic and epidemiological differences between populations are of special importance, since they are related to the cardiorespiratory adverse events that can occur during and after an UGE. The conclusions of this study should be interpreted taking into account that it was made in an ambulatory unity.

Conhecimento de pacientes sobre o uso de benzodiazepínicos no controle da ansiedade em Odontologia / Knowledge of patients about the use of benzodiazepines for anxiety control in Dentistry

Objetivo: O objetivo desta pesquisa foi avaliar o conhecimento de pacientes sobre técnica de sedação consciente com benzodiazepínicos e sua aceitação no controle de medo e ansiedade para o tratamento odontológico. Método: Esta pesquisa baseou-se em um estudo quantitativo com abordagem descritiva através da coleta de dados realizada pelo próprio pesquisador com a finalidade de assegurar uniformidade de interpretação dos resultados através de questionários. Os pacientes antes do atendimento receberam orientação do questionário e então foram convidados a responder. Nesse momento foram prestados os devidos esclarecimentos aos responsáveis quanto à finalidade dos questionários e orientados no sentido de que os dados seriam mantidos em sigilo. Os dados foram analisados por meio de tabelas cruzando a classe socioeconômica de 150 pacientes, selecionados igualitariamente entre as classes A/B, C e D/E. A associação entre a classe social e as respostas às questões foram avaliados pelo teste exato de Fisher. Resultados: A questão 1, primeira consulta ao Cirurgião-Dentista, destaca que todos os pacientes da Classe A/B já haviam comparecido ao Cirurgião-Dentista antes, contra 86% da classe C e 94% da Classe D/E. A questão 2 aborda se o Cirurgião-Dentista afere sinais vitais na anamnese,40% dos Cirurgiões-Dentistas classe A/B afere sinais vitais e apenas 20% dos odontólogos que trabalham com uma população de classe C, D e E. As questões 3, 4 e 5 (sobre medo do cirurgião, doenças e vícios) se mostraram semelhantemente distribuída entre as classes. E as questões 6 e 7 sobre o uso de ansiolítico destaca a maior frequência na Classe A/B, o dobro da Classe C, que por sua vez também é o dobro da Classe D/E. Das sete questões avaliadas, quatro se mostraram significativamente associadas à classe social. Conclusão: Classes sociais A/B têm mais aceitação e conhecimento sobre o uso de benzodiazepínicos no controle de medo e ansiedade na Odontologia.

Objective: The aim of this search was to avaluate the knowledge of patients on technique of conscious sedation with benzodiazepines and their acceptance in the controlo the fear, pain and anxiety during dental treatment. Method: this research was based on quantitative study with descriptive approach through data gathering, conducted by the own researcher, in order to ensure uniformity in the interpretation of the results of the questionnaires. Patients were instructed about the questionnaire before treatment and then, invited to answer it. At this moment, was provided the appropriate explanations to the responsables about the purpose of the questionnaires and orientedin the sense that the data will be kept confidential. Data were analyzed by means of tables crossing the socio-economic class of 150 patients, selected equally between classes A/B, C and D/E. The association between social class and the answers to the questions were evaluated by Fisher’s exact test (Agresti, 2002; Bussab e Morettin, 2006). Results: Question 1, first visit to the dentist, highlights thatall patients Class A/B were attended by dentist before, against 86% of the class C and 94% of ClassD/E. Question 2 addresses if the dentist assesses vital signs at the anamnesis. 40% of dental surgeons class A/B assesses vital signs, against only 20% of dentists who Works with a population of class C, Dand E. Questions 3, 4 and 5 (about fear surgeon, diseases and addictions) show then selves similar lydistributed between classes. And finally, questions 6 and 7, about the use of anxiolytic highlights the most frequently in Class A/B, class C twice, which in turn is also twice the Class D/E. From 7 questions avaluated, 4 of them show thenselves significantly associated to social classes. Conclusion: Social classes A/B have more acceptence and knowledge about the use of benzodiazepines in the control of the fear and anxiety in dentistry.

Effects of bispectral index monitoring as an adjunct to nurse-administered propofol combined sedation during colonoscopy: a randomized clinical trial

BACKGROUND/AIMS: The efficacy of bispectral index (BIS) monitoring during colonoscopic sedation is debated. We aimed to determine whether BIS monitoring was useful for propofol dose titration, and to evaluate differences in sedative administration between expert and inexperienced medical personnel during colonoscopy procedures that required moderate sedation. METHODS: Between February 2012 and August 2013, 280 consecutive patients scheduled to undergo a screening colonoscopy participated in this study and were randomly allocated to the expert or inexperienced endoscopist group. Each group was further divided into either a BIS or a modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) subgroup. Trained nurses administered combined propofol sedation and monitored sedation using either the BIS or MOAA/S scale. RESULTS: The mean BIS value throughout the procedure was 74.3 +/- 6.7 for all 141 patients in the BIS group. The mean total propofol dose administered in the BIS group was higher than that in the MOAA/S group, independently of the endoscopists' experience level (36.9 +/- 29.6 and 11.3 +/- 20.7, respectively; p < 0.001). The total dose of propofol administered was not significantly different between the inexperienced endoscopist group and the expert endoscopist group, both with and without the use of BIS (p = 0.430 and p = 0.640, respectively). CONCLUSIONS: Compared with monitoring using the MOAA/S score alone, BIS monitoring was not effective for titrating the dose of propofol during colonoscopy, irrespective of colonoscopist experience.

Emergencias durante la premedicación de endoscopia / Emergencies during endoscopy premedication

Sedation for procedures performed outside the operating room (OR) doubles the mortality rate of procedures perfomed in the OR. The levels of sedation are: anxiolysis, moderate sedation, deep sedation, and general anesthesia; passing from one level to the next depending on the dose of the drug, the period of administration, the use of concomitant drugs and type of stimulus. Prevention of complications is achieved by reducing expectations, assessing and monitoring the patient, and awaiting for the effects of the drugs. Respiratory complications are the main cause of morbi-mortality associated to the use of sedation: respiratory depression induced by drugs, airway obstruction and laryngospasm. Cardiovascular complications are directly related to the level of sedation, but can also be secondary to hypoxemia, vagovagal reflexes due to distention of the gastric tract, hypotension, arrhythmia, arterial hypertension and myocardial ischemia; and anaphylaxis. Other complications can be: adverse reaction to drugs, bronchopulmonary aspiration, eye damage, mistakes in drug administration, respiratory failure, and prolonged amnesia.

La sedación para procedimientos fuera de pabellón tiene el doble de mortalidad que los pacientes de pabellón. La profundidad de sedación se divide en Ansiolisis, Sedación Moderada, Sedación Profunda y Anestesia General; pasando de un estado a otro dependiendo de dosis de droga, tiempo de administración, uso de otras drogas y estímulo. La prevención de las complicaciones se logra: bajando las expectativas, evaluando a los pacientes, monitorizando y esperando el efecto de los medicamentos. Las complicaciones respiratorias: Son la primera causa de morbimortalidad asociada al uso de sedación: depresión respiratoria inducida por drogas, obstrucción de vía aérea y espasmo laríngeo. Las complicaciones cardiovasculares: están en directa relación con la profundidad de sedación, pero pueden producirse secundariamente a hipoxemia, reflejos vagales por distensión del tubo digestivo: hipotensión, arritmias, hipertensión arterial e isquemia miocárdica; y anafilaxia. Otras Complicaciones pueden ser: reacción adversa a drogas, aspiración broncopulmonar, daño ocular, errores de administración de fármacos, tórax leñoso, amnesia prolongada.

Safety of Gastroenterologist-Guided Sedation with Propofol for Upper Gastrointestinal Therapeutic Endoscopy in Elderly Patients Compared with Younger Patients

BACKGROUND/AIMS: Propofol sedation for elderly patients during time-consuming endoscopic procedures is controversial. Therefore, we investigated the safety of using propofol in elderly patients during upper gastrointestinal therapeutic endoscopy. METHODS: The medical records of 160 patients who underwent therapeutic endoscopic procedures under gastroenterologist-guided propofol sedation at a single institution were retrospectively reviewed. The subjects were divided into two groups: a younger group, patients or =75 years old. The two groups were compared with respect to the therapeutic regimen, circulatory dynamics, and presence/absence of discontinuation of propofol treatment. RESULTS: Although the number of patients with liver dysfunction was higher in the elderly group, there were no other significant differences in the baseline characteristics, including the American Society of Anesthesiologists classification, between the elderly and younger groups. The average maintenance rate of continuous propofol infusion was lower in the elderly patients. No statistically significant differences were found in the occurrence of adverse events between the elderly and younger groups. None of the patients returned to a resedated state after the initial recovery from sedation. CONCLUSIONS: Gastroenterologist-guided propofol sedation in elderly patients can be safely achieved in the same manner as that in younger patients, even for time-consuming upper gastrointestinal therapeutic endoscopic procedures.

Segurança da ecocardiografia transesofágica em adultos: Estudo em um hospital multidisciplinar / Safety of transesophageal echocardiography in adults: study in a multidisciplinary hospital / Seguridad de la ecocardiografía transesofágica en adultos: Estudio en un hospital multidisciplinario

FUNDAMENTO: A ecocardiografia transesofágica (ETE) é um exame semi-invasivo amplamente utilizado e seu uso associado a sedativos poderá influenciar a segurança do procedimento. OBJETIVO: analisar aspectos da segurança da ETE associada ao uso de midazolam (MZ) e flumazenil (FL) e a influência de variáveis clínicas na taxa de eventos. MÉTODO: estudo prospectivo com 137 pacientes que realizaram ETE com MZ associado à sedação moderada. Analisamos as seguintes ocorrências: complicações com anestesia tópica, ao uso do MZ e complicações relacionadas ao procedimento. Análises uni e multivariada foram usadas para testar a influência das variáveis clínicas: idade, sexo, acidente vascular cerebral (AVC), miocardiopatia (MP), duração do exame, insuficiência mitral (IM) e dose de MZ. RESULTADOS: todos pacientes (65±16 anos; 58 por cento masculino) completaram o exame. As doses médias de MZ e FL foram de 4,3±1,9 mg e 0,28±0,2 mg, respectivamente. A duração do exame e a fração de ejeção (FE) média foram de 16.4±6.1 minutos e 60±9 por cento, respectivamente. O evento mais comum foi a hipóxia leve (SO2<90 por cento), em 11 pacientes; 3 pacientes (2 por cento) apresentaram hipóxia transitória por obstrução da via aérea superior na passagem da sonda, enquanto 8 (5,8 por cento) apresentaram hipóxia devido ao uso do MZ. Hipotensão transitória (PAS<90 mmHg) ocorreu em 1 paciente (0,7 por cento). A análise multivariada mostrou que insuficiência mitral (IM) importante, MP (FE<45 por cento) e altas doses do MZ (>5mg) tiveram associação com tais eventos (p<0,001). A FE no grupo com MP foi de 40 por cento, ao passo que, no grupo com insuficiência mitral (IM), esse percentual foi de 44 por cento, podendo ser este um fator associado a eventos clínicos neste último grupo. CONCLUSÃO: ETE com sedação tem baixas taxas de eventos. Não se observou eventos graves e não houve a necessidade de interrupção dos exames.

BACKGROUND: TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE: to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD: prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS: All patients (65±16 yrs; 58 percent males) finished the examination. The mean doses of MZ and FL were 4.3±1.9 mg and 0.28±0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4±6.1 minutes and 60±9 percent, respectively. Mild hypoxia (SO2<90 percent) was the most common event (11 patients); 3 patients (2 percent) presented transient hypoxia due to upper airway obstruction by probe introduction and 8 (5.8 percent) due to hypoxia caused by MZ use. Transient hypotension (SAP<90mmHg) occurred in 1 patient (0.7 percent). The multivariate analysis showed that severe MR, MP (EF<45 percent) and high doses of MZ (>5mg) were associated with events (p<0.001). The EF was 40 percent, in the group with MP and 44 percent in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION: TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.

FUNDAMENTO: La ecocardiografía transesofágica (ETE) es un examen semiinvasivo ampliamente utilizado y su uso asociado a sedantes puede influir sobre la seguridad del procedimiento. OBJETIVO: Analizar aspectos de la seguridad de la ETE asociada al uso de midazolam (MZ) y flumazenil (FL) y la influencia de variables clínicas en la tasa de complicaciones. MÉTODO: Estudio prospectivo con 137 pacientes, a quienes se realizó ETE con MZ asociado a la sedación moderada. Analizamos los siguientes eventos: complicaciones con anestesia local, relacionadas al uso de MZ y complicaciones relacionadas con el procedimiento. Se utilizaron análisis uni y multivariados para evaluar la influencia de las variables clínicas: edad, sexo, accidente cerebrovascular (ACV), miocardiopatía (MP), duración del estudio, insuficiencia mitral (IM) y dosis de MZ. RESULTADOS: Todos los pacientes (65±16 años; 58 por ciento masculino) completaron el estudio. Las dosis promedio de MZ y FL fueron de 4,3±1,9 mg y 0,28±0,2 mg, respectivamente. La duración del estudio y la fracción de eyección (FE) promedio fueron de 16.4±6.1 minutos y 60±9 por ciento, respectivamente. El evento más común fue la hipoxia leve (SO2<90 por ciento), en 11 pacientes; 3 pacientes (2 por ciento) presentaron hipoxia transitoria por obstrucción de la vía aérea superior con el pasaje de la sonda, mientras que 8 (5,8 por ciento) presentaron hipoxia debido a la utilización del MZ. Un paciente (0.7 por ciento) padeció hipotensión transitoria (PAS<90 mmHg). El análisis multivariado mostró que IM significativa, MP (FE<45 por ciento) y altas dosis de MZ (>5mg) se asociaron a tales complicaciones (p<0,001). La FE en el grupo con MP fue de 40 por ciento, mientras que, en el grupo con insuficiencia mitral, ese porcentaje fue de 44 por ciento, pudiendo ser éste un factor asociado a complicaciones clínicas en este último grupo. CONCLUSIÓN: ETE con sedación presenta bajas tasas de ...

Cirurgia de terceiro molar sob sedação com óxido nitroso: avaliação subjetiva e cardiovascular / Nitrous oxide sedation in oral surgery: subject perception and cardiovascular monitoring

Este estudo teve por objetivo avaliar o grau de aceitação, a ansiedade e a variação de frequência cardíaca (FC), saturação de oxigênio (SpO) e pressão arterial sistólica (PAS) e diastólica (PAD) em cirurgias de terceiros molares com e sem sedação consciente com óxido nitroso e oxigênio (N2O/ 02). Vinte voluntários saudáveis com necessidade de extração dos terceiros molares bilaterais participaram do estudo, o qual foi realizado em três fases: Fase A - N2O/ 02 sem intervenção odontológica; Fases B e C - exodontia de um dos lados, de forma aleatória, com (C-N2O) ou sem (S-N2O) sedação associada. Para definir o grau de ansiedade utilizou-se a Escala de Ansiedade Dental de Corah (EADC); a sensação dolorosa foi quantificada pela Escala de 11 pontos em caixa (EC); e o grau de aceitação da sedação pelo questionário subjetivo (QS). 60% dos voluntários deram nota máxima para C-N2O e todos os voluntários afirmaram que a sessão C-N2O foi mais agradável. O relato de dor após a sessão C-N2O foi menor ou igual à da sessão S-N2O para 85% dos voluntários. A FC apresentou diferença significante entre as fases C-N2O e S-N2O, diferentemente da Sp02, PAD e PAS. Concluiu-se que os voluntários mostraram-se moderadamente ansiosos em todas as fases, sendo a sessão C-N2O mais agradável que S-N20, a C-N20 reduziu significativamente a FC, mas não influenciou na PAS, PAD e Sp02. A C-N20 não alterou a sintomatologia dolorosa durante e após a cirurgia.

The purpose of this study was to evaluate the changes of heart rate (HR), oxygen saturation (SpO) and both diastolic (DBP) and systolic (SBP) blood pressure, anxiety and acceptance of nitrous oxide conscious sedation (N2O/ 0) in three phases: A - N2O/02 without surgery; B and C - extraction of one of the sides with (C-N2O) or without (S-N2O) nitrous oxide sedation, in a random cross-over manner. Twenty healthy volunteers, average age of 20.55 years, undergoing removal of third molars were selected. Corah's Dental Anxiety Scale (CDS); Eleven points in box Scale (EC) and subject questionnaire (QS) was used to evaluation. The comparative values between phases were analyzed by Wilcoxon's and Friedman's test (= 0,05) and by explorative analysis (QS). The volunteers moderately revealed anxious in all the phases and 60% of volunteers had given maximum note for C-N2O. All volunteers had affirmed that C-N2O was more pleasant. The pain report after the C-N2O was lesser or equal for 85% of volunteers. The HR presented significant difference between phases C-N2O and S-N2O (p= 0.020). There were no significant statistical differences between phases to SpO2 (p= 0.153), DBP (p= 0.730) and SBP (p= 0.975). These results suggest that C-N2O was most pleasant and reduced the HR significantly, but it did not influence in the SBP, DBP and Sp02, nor modified the pain during or after surgery.

Midazolam: aspectos clínicos e farmacológicos em sedação consciente: estudo retrospectivo avaliando 258 casos clínicos / Midazolam: clinical and pharmacologic aspects in conscious sedation: retrospective study evaluating 258 clinical cases

A ansiedade associada ao tratamento odontológico normalmente está associada a diversas complicações que podem terminar em emergências médicas. O seu controle se faz cada mais necessário na atualidade nos consultórios odontológicos. Dentre as várias alternativas para este fim, a opção farmacológica pelo Midazolam, um benzodiazepínico com perfil farmacocinético, meia vida curta e potência ansiolítica apropriada, faz essa molécula agregar propriedades bastante interessantes na clínica odontológica, além da segurança necessária para utilização por profissionais treinados. Esse trabalho se propõe a apresentar 258 casos clínicos de sedação consciente com Midazolam, bem como rever a literatura sobre esse benzodiazepínico e a técnica de sedação consciente, enfocando dados mais relevantes para os cirurgiões-dentistas.

The anxiety associated to the dental treatment usually is related to various complications that can result in medical emergences. Its control is, nowadays, even more necessary in dental offices. Among the various alternatives for this purpose, the pharmacology option for the Midazolam, a benzodiazepine with a pharmacokinetic action, a short half-life and an appropriate anxiolytic potency, makes this molecule aggregating properties really interesting in dental clinic, beyond of providing the necessary security for its use by trained professionals. This research aims to describe 258 cases of conscious sedation and review the literature about Midazolam and the technique of conscious sedation, focusing in the most relevant data to the dentists.

Avaliação dos parâmetros cardiovasculares e da dosagem anestésica em cirurgias de implantes osseointegráveis sob efeito da mistura óxido nitroso/oxigênio: um estudo piloto / Evaluation of the cardiovascular parameters and anesthetical dosage in surgery of osseointegrated implant under affect of nitrous oxideloxygen mixture: a pilot study

O propósito deste trabalho foi avaliar os parâmetros cardiovasculares, a dosagem anestésica e a sintomatologia dolorosa em cirurgias para instalação de implantes osseointegráveis em pacientes sob o efeito da mistura de óxido nitroso/oxigênio (N2O/O2). A amostra foi composta por 10 indivíduos adultos, ASA I ou ASA II (American Society of Anesthesiologists, 1965), submetidos à cirurgia para instalação de implantes unitários. Os voluntários foram divididos em dois grupos cada um com cinco pacientes: Grupo “T” (teste), em que foi utilizada a inalação de óxido nitroso e oxigênio e o grupo “C” (controle), que recebeu oxigênio puro. Foram avaliados parâmetros cardiovasculares (freqüência cardíaca, pressão arterial, saturação de oxigênio), além do requerimento de droga anestésica e sintomatologia dolorosa. Os resultados demonstraram que a saturação de O2 apresentou maior estabilidade no transoperatório do grupo sedado (grupo teste). A freqüência cardíaca e a pressão arterial não se alteraram nos grupos experimentais. Também foi observada uma tendência à redução do anestésico local requerido e diminuição da sintomatologia dolorosa no grupo submetido à sedação com N2O/O2. A sedação consciente com óxido nitroso/oxigênio mostrou-se como um recurso benéfico, visto que esteve relacionada à manutenção dos parâmetros cardiovasculares em níveis normais associada à redução da percepção dolorosa e menor requerimento anestésico durante as cirurgias para a instalação de implantes osseointegráveis.

The aim of this study was to assess the cardiovascular parameters, anesthetical dosage and painful symptoms during surgery for the placement of osseointegrated implants in patients under conscious sedation with nitrous oxide/oxygen mixture (N2O/O2). The sample was composed of 10 adults ASA or ASA II (American Society of Anesthesiologists, 1965) that were submitted to surgery for the placement of unitary osseointegrated implants. The volunteers were divided at random into 2 groups with 5 patients each one: group T (test), was used an inhalation of the nitrous oxide and oxygen mixture and the group C (control) only received pure oxygen. The hemodynamic parameters were verified: cardiac frequency, blood pressure, oxygen saturation. The results showed that the O2 saturation remained more stability during the surgical act of the sedated group. The cardiac frequency and the blood pressure did not change in the groups studied. A tendency of reduction of the local anesthetic required and diminution of pain in the sedated group were also observed. The conscious sedation with nitrous oxide/oxygen mixture may be a beneficial resource, related to the maintenance of cardiovascular parameters in normal levels associated with reduction in pain perception and lower quantity of anesthetic during the surgery for the installation of osseointegrated implants.

Sedación en la endoscopia digestiva / Sedation for digestive endoscopy

Los espectaculares avances de la exploración endoscópica han requerido la necesidad de implementar distintas técnicas de sedación que se adecuen a los procedimientos diagnósticos y terapéuticos de esta área. Tanto las condiciones propias de la técnica a emplear, como las de cada paciente, juegan un rol determinante a la hora de seleccionar la aproximación ideal para cada caso, considerando además que una adecuada tolerancia tiene directa relación con la efectividad de éstos. Entre las alternativas se encuentran la exploración sin anestesia, el uso de una sedación conciente, sedación profunda y en algunos casos la anestesia general. El objetivo de este artículo es revisar y analizar las diferentes opciones disponibles para el desarrollo de exploraciones endoscópicas.

Comparison of dexmedetomidine and midazolam sedation for children undergoing magnetic resonance imaging

Dexmedetomidine is a sedative with limited experience in the pediatric population. This prospective, randomized, double-blind study was designed to compare the safety and efficacy of dexmedetomidine and midazolam to sedate children undergoing magnetic resonance imaging [MRI] 40 children aged 4-10 years with American Society of Anaesthesiologist physical status I and II scheduled for elective MRI were selected for this study. Patients were randomly allocated to one of the two groups. Group D [Dexmedetomidine]: Received IV dexmedetomidine 1 micro g/kg over 10 min followed by continuous infusion of dexmedetomidine 0.5 micro g /kg/hr. Group M [Midazolam]: Received IV midazolam 0.1 mg/kg followed by continuous infusion of midazolam 0.1mg/kg/hr. Presedation behavior was assessed on a 4-point scale, by a person who did not know which drug would be administered. Baseline HR, MAP and oxygen saturation [Spo[2]] were measured before any drug administration then every 10 min. The MRI study is initiated as soon as the desired level of sedation has been achieved. Presedation behavior score, and the duration, type, and quality of MRI procedure were not statistically different between the groups. The duration of drug infusion was not different between groups [P=0.236]. There was highly significant increase in sedation onset in group D [P<0.001]. The recovery time was significantly shorter in group D [25.60 +/- 3.71] in comparison to group M [31.20 +/- 2.28] [p=0.0210]. The discharge time was insignificantly shorter in the group D [43.60 +/- 5.41] in comparison to group M [49.10 +/- 3.47] [p=0.236]. MBP and HR were only statistically significantly decreased after sedation in both groups with out clinically significant effect on patient's haemodynamics. Dexmedetomidine provided adequate sedation in most of the children aged 3-10 yr without clinically significant haemodynamic or respiratory effects during MRI procedures

Agitación y sedación conciente en cuidados intensivos / Agitation and conscious sedation in intensive care

La sedación y la analgesia son parte integral en el manejo de los pacientes críticos en las unidades intensivas, estos pacientes tienen mayor riesgo de presentar ansiedad, agitación, combatividad, delirio y síndromes de abstinencia. Con el fin de proporcionar una guía simple y práctica para la toma de decisiones en sedación y analgesia en el año 2005 la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva (FEPIMCTI) propuso la realización de un consenso con un enfoque regional, basado en la mejor evidencia disponible en la literatura médica. En este contexto nosotros realizamos la presente guía de sedación vigil y agitación. Se tratan temas importantes relacionados con el uso cauto de la sedación y optimización de la sincronía ventilador paciente, como también el control de la agitación y de los procedimientos invasivos mínimos en UCI. Cada recomendación está hecha en base a dos criterios: su aceptabilidad como recomendación fuerte o débil (considerada de acuerdo al consenso de los asistentes expertos) y su sostén en la literatura médica obtenida mediante revisión sistemática y calificada por, al menos, dos grupos de expertos en epidemiología clínica.

Sedation and analgesia play a major role in critical patients management in ICUs. These patients face a higher risk of developing anxiety, agitation, combativity, delirium, and deprivation syndromes. In order to offer a simple and practical guideline for decision making in sedation and analgesia, the Pan-American and Iberian Federation of Critical Medicine and Intensive Therapy Societies (FEPIMCTI) proposed a regional-focused consensus based on best available evidence in medical literature. It is in this context that the current Guideline on Conscious Sedation and Agitation has been developed. Important issues related to the appropriate use of sedation and improvement of ventilator-patient synchrony, as well as control of agitation and minimally invasive procedures in ICU are dealt with. Each proposed recommendation is based on two main criteria: its acceptability as a strong or weak recommendation (according to consensus of participating experts) and its support in medical literature, which has been systematically reviewed and assessed by, al least, two groups of clinical epidemiology experts.

Cardiorespiratory compromise under conscious sedation sedation during upper gastrointestinal endoscopy

To compare the cardiorespiratory effects of benzodiazepine and midazolam used for sedation in patients undergoing upper gastrointestinal endoscopy with cardiorespiratory changes in the non-sedated patients. Comparative, randomized, single blind study. Department of Medicine at Government Medical College and Hospital, Chandigarh, India, from January to July 2000.A total of 252 adult patients without previous cardiorespiratory co-morbidity, undergoing upper gastrointestinal endoscopy were recruited. They were randomly allocated in to group I [placebo with saline administration], group II [diazepam administered] and group III [midazolam administered]. The pulse rate, blood pressure, ECG and peripheral oxygen saturation [SpO2] was noted at baseline, after pre-medication, during endoscopy and postendoscopy. Statistical analysis was done by paired t-test, Chi-square test and ANOVA as applicable. There was no difference in baseline record of the three groups. Significant fall in SpO2 was noted in all the groups, more marked in the sedated one during endoscopy. Tachycardia developed in all the three groups and settled within 5 minutes of endoscopy. Blood pressure remained more stable in the sedated group. ECG changes included atrial and ventricular premature contraction in all the three groups. Endoscopy is a safe procedure where cardiorespiratory complication are minimized in non-sedated patients when appropriately selected