Sedoanalgesia con ketodex para la intubación selectiva en la resección de un aneurisma gigante de la arteria subclavia. Reporte de caso / Sedoanalgesia with ketodex for selective intubation in the resection of a giant aneurysm of the subclavian artery associated. Case report

Resumen: El aneurisma gigante de la arteria subclavia asociado a un síndrome de vena cava superior se presenta de forma poco frecuente. La complejidad del abordaje dependerá del tamaño, forma y disposición del aneurisma, particularmente cuando el colapso de la vía aérea es potencial por un efecto compresivo de la masa mediastinal durante la aplicación del relajante neuromuscular. Presentamos el caso de un hombre de 57 años con disnea en decúbito dorsal que incrementa con el decúbito lateral izquierdo de cinco años de evolución. El estudio radiológico reporta masa mediastinal gigante compatible con aneurisma de la arteria subclavia derecha que causa compresión y desplazamiento de la vía aérea, particularmente en tráquea a nivel de la carina. El paciente es programado para resección del aneurisma y requiere de intubación selectiva para el aislamiento del pulmón derecho durante la cirugía, que fue realizada con la técnica de paciente despierto usando sedoanalgesia con ketodex. El objetivo del caso es compartir la experiencia con el uso de ketodex como una alternativa para la tolerancia de procedimientos que requieren de la cooperación del paciente, en donde el propofol y el relajante neuromuscular pueden ser un problema para la permeabilidad y el abordaje de la vía aérea.

Abstract: A giant subclavian artery aneurysm associated with superior vena cava syndrome occurs infrequently. Complexity of the approach will depend on the size, shape, and position of the aneurysm, particularly when a potential collapse of the airway is expected due to the compressive effect of the mediastinal mass after using neuromuscular relaxant for airway approach. We present a case in a 57-year-old male with shortness of breath in dorsal that increases with left lateral decubitus during five years of evolution. Radiological studies reported giant mediastinal mass compatible with an aneurysm of the right subclavian artery, which produces critical compression and airway displacement, particularly in trachea at level of the carina. The patient is scheduled for resection of the aneurysm and requires selective intubation for isolation of the right lung during surgery which was performed with the awake patient technique using sedoanalgesia with ketodex. The objective of the case is to share the experience using ketodex as an alternative for the tolerance of procedures that requires the cooperation of the patient where propofol and neuromuscular relaxant may be a problem for airway permeability and approach.

The Effects of Magnesium Sulphate on Integrated Pulmonary Index Scores and Propofol Consumption During Endobronchial Ultrasonography: A Retrospective Study.

Aim Our aim in this study was to investigate the effect of inhaled and intravenous (iv) magnesium (Mg) use on Integrated Pulmonary Index (IPI) score and propofol consumption in patients undergoing endobronchial ultrasonography (EBUS) procedure under sedoanalgesia. Materials and methods After obtaining the approval of the local ethics committee, the files of 96 patients aged 18-75 who underwent EBUS were reviewed retrospectively. Patients using Mg were classified as the M group, and patients not using Mg were classified as the control (C) group. IPI values, amount of propofol consumed, and intubation scores of group M and group C were evaluated. Results When the intubation score values ​​at the time of the bronchoscope passing through the vocal cords (assessment of vocal cord movement, cough reflex, and leg movement) during the EBUS procedure were compared, the intubation conditions were found to be significantly better in the M group than in the C group (p<0.05). Group M had less cough reflex than group C (p<0.05). IPI scores were significantly higher in the M group than in the C group at the 10th and 15th minutes (p<0.05). Total propofol consumption was found to be significantly lower in the M group (254.61±82.80 mg) than in the C group (321.25±90.04 mg) (p<0.05). Conclusion According to our results, the use of intravenous and inhaler Mg in addition to propofol sedation during the EBUS procedure may improve the respiratory parameters and can also significantly reduce the propofol dose.

Sedoanalgesia in the Debridement of Pediatric Burns in the Emergency Department: Is It Effective and Safe?

BACKGROUND: The routine use of sedoanalgesia has increased the number of potential minor surgical procedures that can be performed in the Emergency Department (ED) without requiring general anesthesia and, thus, hospital admission. Our aim is to analyze the effectiveness and safety of the use of sedoanalgesia in childhood burns treated in the ED. METHODS: A retrospective study was conducted in burned children in whom burn debridement was performed under sedoanalgesia in the ED between 2017 and 2021 in a tertiary referral center for burns. We collected demographic variables, burn features and the type of sedoanalgesia performed in each case, including its effectiveness and associated adverse effects. RESULTS: A total of 227 patients (118 males, 109 females) were included, with a median age of 25 months. In total, 99.2% of the burns were thermal (69.2% scald burns), with a mean total body surface area (TBSA) burned of 4%. The most commonly used drugs were intravenous ketamine (35.7%), intravenous ketamine + midazolam (15.4%), intranasal fentanyl + midazolam (14.1%) and intranasal fentanyl (10.6%). The effectiveness of sedoanalgesia was considered satisfactory in 95.2% of the cases, with an adverse effect rate of 7.5%, without severe adverse effects reported. CONCLUSIONS: The use of sedoanalgesia in the ED in the early treatment of childhood burns achieves high effectiveness and safety. It is postulated as a quality indicator; thus, it should be known by all pediatric healthcare practitioners.

Ketamine Clinical Use on the Pediatric Critically Ill Infant: A Global Bibliometric and Critical Review of Literature.

The developing central nervous system is vulnerable to several stimuli, especially psychotropic drugs. Sedation procedures during the developmental period are frequent in pediatric intensive care units (PICUs), in which the use of the sedative agent is still a challenge for the PICU team. Ketamine has been indicated for sedation in critically ill children with hemodynamic and ventilatory instabilities, but the possible neurobehavioral consequences related to this use are still uncertain. Here, we performed a bibliometric analysis with conventional metrics and a critical review of clinical findings to reveal a gap in the literature that deserves further investigation. We revealed that only 56 articles corresponded to the inclusion criteria of the study. The United States of America emerges as the main country within the scope of this review. In addition, professional clinical societies play a key role in the publications of scientific clinical findings through the specialist journals, which encourages the sharing of research work. The co-occurrence of keywords evidenced that the terms "sedation", "ketamine", and "pediatric" were the most frequent. Case series and review articles were the most prevalent study design. In the critical evaluation, the scarce studies highlight the need of use and post-use monitoring, which reinforces the importance of additional robust clinical studies to characterize the possible adverse effects resulting from ketamine anesthetic protocol in critically ill children.

Pediatric Burns Debridement Under Sedoanalgesia During the COVID-19 Pandemic: A Cost-Effective Alternative.

Early debridement of childhood burns under sedoanalgesia in the emergency department (ED) may help to reduce the need of surgery and delay in treatment. We performed a retrospective study in burned children who underwent debridement in the ED under sedoanalgesia between March 2020 and December 2020 (COVID group), and were compared with the same months in 2019 (control group). Demographics, burns features, admission rate, and estimated costs associated were collected. A total of 733 children presented at the ED with burns (302 COVID group and 431 control group) without significant differences in burn features between them. Admission rate was significantly lower in COVID group (9.4% vs 19.4%; P < .001), as was the total associated cost for each group ($101 585 vs $209 656; P < .001). The use of sedoanalgesia for the early treatment of pediatric burns in the ED during COVID-19 pandemic is a cost-effective alternative that has reduced the need for hospital admission and associated costs.

Sedoanalgesia with intravenous midazolam and fentanyl for angioplasty of dysfunctional arteriovenous access: A retrospective single-center analysis.

BACKGROUND: Endovascular therapy, such as percutaneous transluminal angioplasty (PTA), stenting, or embolization, is a well-established form of treatment to prolong the lifespan of arteriovenous access. These procedures, especially PTA, can be accompanied with severe pain. We reviewed and analyzed the efficacy, safety, and outcome of sedoanalgesia using intravenous midazolam and fentanyl, for pain relief during these procedures. METHODS: Two hundred and two consecutive patients with dysfunctional dialysis access that had undergone endovascular procedure in our institute between July and November 2017 were included in this study. The dialysis access profile, procedure complication, and 10-point Visual Analog Scale (VAS) were collected. One-year clinical follow-up record was also collected to evaluate arteriovenous access patency and long-term complications. RESULTS: Among the 202 patients, the mean age was (mean ± SD) 67.0 ± 12.08 years. Dialysis access profile of these patients were 119 (58.9%) native arteriovenous fistula and 162 (74.2%) forearm access. The number of lesions treated were 1.63 ± 0.802.Immediate complications included 11 (5.44%) nausea/vomiting, 24 (11.88%) desaturation (SpO2 < 90%, resolved after pillow removal or jaw trust), 16 (7.9%) hypotension (SBP < 90 mmHg, resolved without inotropic agents). There was a low average pain score (1.16 ± 1.594) during the procedure with 136 (67.3%) no pain (VAS 0-1) and 56 (27.7%) mild pain (VAS 2-4). Higher VAS score correlated with overweight patients, longer PTA time and pain after procedure. Six-month primary patency rate was 49.17% and primary assisted patency rate was 93.04%. CONCLUSIONS: Sedoanalgesia with intravenous midazolam and fentanyl is an easy, safe, and effective method for surgeons.

Comparación de la seguridad de sedoanalgesia entre propofol-fentanilo vs propofol-ketamina en pacientes con covid-19 sometidos a colonoscopias / Comparison of the safety of sedation analgesia between propofol-fentanyl vs propofol-ketamine in COVID-19 patients undergoing colonoscopies

Introducción: Los procedimientos anestésicos fuera de quirófano se han incrementado. Ahora se añade el reto del manejo del paciente con COVID-19, dentro de estos esta la colonoscopia que debe realizarse bajo sedoanalgesia, no se cuenta con un fármaco ideal por lo que se realizan combinaciones para la seguridad del paciente y personal de salud. Objetivo: Comparar la seguridad de sedoanalgesia con propofol-fentanilo vs propofol-ketamina en pacientes con COVID-19 sometidos a colonoscopia. Material y métodos: Se realizó un estudio experimental, transversal, comparativo con 60 pacientes sometidos a colonoscopia, estos fueron seleccionados por sucesión en 2 grupos: grupo A (propofol-fentanil) y grupo B (propofol-ketamina). Grupo A: fentanil 1 ug/kg y posteriormente propofol a 0,5 a 1,5 mg/kg, y mantenimiento con bolos de propofol a 0,5 mg/kg. Grupo B: se preparó mezcla de propofol-ketamina a proporción de 4:1, en la inducción se utilizó propofol (1mg/kg) y ketamina (0,25mg/kg), mantenimiento propofol (5 mg/kg/h) y ketamina (1,25 mg/kg/h). La información fue recolectada de fuentes primarias, se empleó el programa estadístico SPSS versión 22.0. Resultados: El grupo A tuvo tendencia a la bradicardia e hipotensión, además de mayor depresión respiratoria con una frecuencia de 4 (13,3%) en relación a 1 (3,3%) en el grupo ketofol. Conclusión: el ketofol demostró ser más seguro en comparación a propofol- fentanil para la sedoanalgesia en colonoscopia de pacientes COVID-19.

Introduction: Anesthetic procedures outside the operating room have increased. Now the challenge of managing patients with COVID-19 is included, within these is the colonoscopy that must be performed under sedo-analgesia, there is no an ideal drug so combinations are made for the safety of the patient and the health staff. Objective: To compare the safety of sedo-analgesia with propofol-fentanyl vs propofol-ketamine in patients with COVID-19 undergoing colonoscopy. Material and methods: An experimental, cross-sectional, comparative study was carried out in 60 patients submitted to colonoscopy, these were selected by succession into 2 groups: group A (propofol-fentanyl) and group B (propofol- ketamine). Group A: fentanyl 1 ug/kg and later propofol at 0.5 to 1.5 mg/kg, and maintenance with propofol boluses at 0.5 mg/kg. Group B: a mixture of propofol- ketamine was prepared at a ratio of 4:1, in induction propofol (1 mg/kg) and ketamine (0.25 mg/kg) were used, propofol maintenance (5 mg/kg/h) and ketamine (1.25 mg/ kg/h). The information was collected from primary sources, the statistical program SPSS version 22.0 was used. Results: Group A had a tendency to bradycardia and hypotension, as well as greater respiratory depression with a frequency of 4 (13.3%) in relation to 1 (3.3%) in the ketofol group. Conclusion: Ketofol has shown to be safer compared to propofol-fentanyl for colonoscopy sedo-analgesia in COVID-19 patients.

Comparison of propofol-fentanyl and propofol-ketamine for sedoanalgesia in percutaneous endoscopic gastrostomy procedures.

Background: Percutaneous endoscopic gastrostomy (PEG) procedures are performed under sedation in critically ill patients who cannot be fed orally. Aim: We compared the efficacy and safety of propofol-fentanyl and propofol-ketamine for deep sedation in patients undergoing PEG. Retrospective Study. Materials and Methods: The study was conducted from 1 January 2013 to 31 December 2018 in Adiyaman University. The patients given propofol-fentanyl (0.5-1.2 mg/kg and 0.2-1 µg/kg, respectively) for sedo-analgesia were designated Group F, and those who received propofol-ketamine (0.2-0.6 mg/kg and 0.5-1 mg/kg, respectively) were placed in Group K. The demographic and hemodynamic characteristics, recovery times, perioperative complications, and need for additional doses were recorded. Results: Seventy-one patients who underwent PEG were analyzed. The age, sex, American Society of Anesthesiologists (ASA) score, comorbidities, duration of anesthesia, and duration of the PEG procedure were similar in the two groups. Recovery time was longer in Group K. The total propofol dose was 64 mg in Group F and 35 mg in Group K. Additional doses of propofol were administered to 12 patients in Group F, compared to none in Group K. The mean blood pressure values were higher in Group K at all-time points. The perioperative complication rate was higher in Group F. Desaturation was observed in 9 (22.5%) patients in Group F and in 3 (9.6%) patients in Group K. Hypotension was observed in 4 (10%) patients in Group F. Conclusion: Propofol-ketamine should be preferred for sedoanalgesia during PEG procedures because of the lower dose of propofol, more stable blood pressure, and greater peripheral oxygen saturation. In addition, we believe ketamine-propofol is safer based on its low complication rate.

Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations.

Aim: This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background: NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods: Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results: Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion: Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article: Karim HMR, Sarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938-948.

Safety, Efficacy and High-Quality Standards of Gastrointestinal Endoscopy Procedures in Personalized Sedoanalgesia Managed by the Gastroenterologist: A Retrospective Study.

Performing GI endoscopy under sedoanalgesia improves the quality-indices of the examination, in particular for cecal intubation and adenoma detection rates during colonoscopy. The implementation of procedural sedoanalgesia in GI endoscopy is also strongly recommended by the guidelines of the major international scientific societies. Nevertheless, there are regional barriers that prevent the widespread adoption of this good practice. A retrospective monocentric analytic study was performed on a cohort of 529 patients who underwent EGDS/Colonoscopy in sedoanalgesia, with personalized dosage of Fentanyl and Midazolam. ASA class, age and weight were collected for each patient. The vital parameters were recorded during, pre- and post-procedure. The rates of cecal intubation and of procedure-related complications were entered. The VAS scale was used to evaluate the efficacy of sedoanalgesia, and the Aldrete score was used for patient discharge criteria. No clinically significant differences were found between vital signs pre- and post-procedure. Both anesthesia and endoscopic-related complications occurring were few and successfully managed. At the end of examination, both the mean Aldrete score (89.56), and the VAS score (<4 in 99.1%) were suitable for discharge. For the colonoscopies, the cumulative adenoma detection rate (25%) and the cecal intubation rate in the general group (98%) and in the colorectal cancer screening group (100%) were satisfying. Pain control management is an ethical and medical issue aimed at increasing both patient compliance and the quality of the procedures. The findings of this work underscore that in selected patients personalized sedoanalgesia in GI endoscopy can be safely managed by gastroenterologists.

Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation.

OBJECTIVES: To compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. METHODOLOGY: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 h. We compared two independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. RESULTS: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean ±â€¯standard deviation of patients were 49 ±â€¯65 months, weight 17 ±â€¯16 kg. Mechanical ventilation medium time was 22 h (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8 ±â€¯10,6 min group A and 137,3 ±â€¯45 min group B (P < 0.001), extubation time after removing sedoanalgesia was of 24 ±â€¯21 min group A and 230 ±â€¯102 min group B (P < 0.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation) P = 0,572. CONCLUSIONS: Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.

Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración / Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation

Objetivos: Comparar, entre 2 regímenes de sedoanalgesia, el tiempo trascurrido desde la retirada de la medicación hasta el despertar y hasta la extubación del paciente. Metodología: Estudio observacional, en pacientes pediátricos que, tras cirugía electiva, precisaron sedoanalgesia y ventilación mecánica durante un periodo máximo de 72 h. Comparamos 2 grupos independientes de pacientes: grupo A, pacientes que recibieron sedoanalgesia con propofol-remifentanilo recogidos de forma prospectiva, y grupo B, pacientes que recibieron midazolam-fentanilo recogidos retrospectivamente mediante la revisión de las historias clínicas y base de datos de la unidad. Las variables estudiadas fueron: edad, peso, sexo, tipo de intervención, escalas de valoración de la sedoanalgesia, dosis totales empleadas, tiempo transcurrido desde la retirada de medicación hasta despertar y extubación, y efectos adversos. Resultados: Se recogió a 82 pacientes, 43 en el grupo A y 39 en el grupo B. La edad (media±desviación estándar) de los pacientes fue de 49±65 meses y 17,3±16kg de peso, con un tiempo de ventilación mecánica promedio de 22 h (3-72). Tras retirar la medicación, el tiempo de despertar fue de 11,8±10,6 min en el grupo A y de 137,3±45 min en el grupo B (p<0,001) y el tiempo de extubación de 24±21 min en el grupo A y 230±102 min en el B (p<0,001). El 10,5% de los pacientes del grupo A presentó algún efecto adverso (7,9% agitación y 2,6% bradicardia) y, del grupo B, un 13% (depresión respiratoria tras extubación), con una p=0,572. (AU)

Objectives: Compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. Methodology: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. Results: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22 hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6 minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572. (AU)

Realidad virtual: ¿puede ayudar en la realización de procedimientos invasivos a niños? / Virtual reality: can this help in the performance of invasive procedures on children?

Objetivo. Valorar si el uso de gafas de realidad virtual (RV) es un procedimiento con posible aplicación para disminuir el dolor percibido por los niños al enfrentarse a procedimientos dolorosos. Material y métodos. Se realizó un estudio prospectivo observacional en pacientes pediátricos que acuden al hospital de día de Cuidados Intensivos Pediátricos (CIP) para la realización de procedimientos invasivos que precisan canalizar una vía venosa. Resultados. Participaron en el estudio 22 pacientes (13 niños y 9 niñas) de edades comprendidas entre 5 y 16 años, con una media de edad de 9,7 ± 3,5 años. La medición del dolor se llevó a cabo mediante las escalas de Wong-Baker y la Escala Visual Analógica (EVA), según la edad de los pacientes, obteniéndose una media de dolor de 2,42 ± 2,06 sobre 10 puntos. Además, se recogió el nivel de satisfacción con la intervención, mediante una encuesta no validada valorada del 0 al 4, con una satisfacción de 3,89 puntos en los pacientes; 3,71 en sus padres; 3,94 en el personal médico y 3,50 en el de enfermería. Conclusiones. El uso de RV es fácilmente aplicable a niños sometidos a procedimientos dolorosos, con un alto nivel de satisfacción con la intervención, y podría contribuir a disminuir el dolor percibido por el paciente (AU)

Objective. Evaluate if using Virtual Reality (VR) could be useful to reduce perceived pain between children facing painful procedures. Material and methods. An observational prospective study was performed in paediatric patients who attended the Paediatric ICU’s Day hospital to get invasive procedures done, where a previous venipuncture was needed. Results. 22 patients were included (13 males and 9 females) of ages between 5 and 16 years old, with an average of 9.7 ± 3.5 years old. The most common procedure, performed in 14 patients, was digestive endoscopy. Pain measurement was analyzed with Wong-Baker and visual analog scales, depending on childrens’ ages, getting a final pain average of 2.42 ± 2.06 out of 10 points. What is more, the satisfaction level was studied with a non validate scale going from 0 to 4, getting a result of 3.89 points between patients; 3.71 between their parents; 3.94 between doctors and 3.50 between nurses. Conclusion. Using VR is suitable for children undergoing painful procedures, getting a high satisfaction level with the intervention, and it could contribute to diminish pain level perceived by the patient (AU)

The Comparison of Two Different Techniques of Remifentanil Administration During Implantable Vascular Access Device Procedures.

PURPOSE: The aim was to compare analgesic efficacy and adverse effects of two different techniques of intravenous remifentanil administration in patients undergoing vascular; access device procedures with monitored anesthesia care. DESIGN: A randomized, single-blinded controlled study. METHODS: The patients (N = 92) were 30-80 years old and of American Society of Anesthesiologists Physical Status I-III. The first group was the continuous infusion group (group CI). Intravenous continuous remifentanil was infused after starting at a dosage of 0.1 mcg/kg/min, and the dose was raised incrementally up to 1 mcg/kg/min if required. The second group was intravenous bolus patient-controlled sedation analgesia (PCSA) with remifentanil infusion at a dose of 0.05 mcg/kg per minute and bolus of 0.1 mcg/kg with lock-out time of 3 minutes. In both groups, a bolus dose of 0.1 mcg/kg remifentanil was administered. The data evaluated include level of pain and sedation, total amount of remifentanil consumption, bolus doses of remifentanil, patient and surgeon satisfaction, hemodynamic data, and adverse events. FINDINGS: In comparison between techniques, pain and sedation scores during procedure, duration of procedure, patient and surgeon satisfaction, additional rescue medication, and bolus doses were not statistically different (P > .05). The total amount of remifentanil administered was significantly lower in the infusion group than that in the bolus group (P = .031). CONCLUSIONS: For central venous access device procedures under monitored anesthesia care, remifentanil use in both infusion and bolus techniques could provide sufficient sedation and analgesia without serious adverse effects. Total remifentanil consumption amount in infusion group is lower than that in the bolus group.

The Effect of Preoperative Anxiety and Pain Sensitivity on Preoperative Hemodynamics, Propofol Consumption, and Postoperative Recovery and Pain in Endoscopic Ultrasonography.

INTRODUCTION: The present study investigates how preoperative anxiety and pain sensitivity affect the consumption of anesthetics, time elapsed until the desired sedation level is achieved, preoperative hemodynamics, postoperative recovery time, and postoperative pain. METHODS: The present study includes 80 ASA 1-2 patients aged between 20 and 65 who were scheduled for endoscopic ultrasonography (EUS) under sedation. Patients were instructed to fill out the Spielberger State-Trait Anxiety Inventory (STAI) and Pain Sensitivity Questionnaire (PSQ) before the procedure. For sedation, 0.03 mg  kg-1 intravenous midazolam, 1 mg  kg-1 lidocaine, 1 µ kg-1 fentanyl, and then a bolus dose of 1 mg kg-1 propofol were infused over a period of 60 s. The time elapsed until the bispectral index (BIS) value reached 75 was recorded. For anesthesia maintenance, 2 mg  kg-1 h-1 propofol infusion was administered. In the case of sedation failure, an additional dose of 0.1 mg  kg-1 propofol (IV) was administered to ensure sedation depth with a BIS level of 65-75, and the propofol infusion was halted once the BIS value dropped below 65. RESULTS: STAI-S and STAI-T scores were significantly positively correlated with PSQ minor pain and PSQ total scores. The time elapsed until reaching a BIS level of 75, propofol infusion dose used during sedation, and the need for additional doses of propofol, heart rate (HR), and duration of post-anesthesia care unit stay were significantly positively correlated with both preoperative anxiety and preoperative pain sensitivity. In terms of postoperative pain, the visual analog scale (VAS) at 1 h was more highly correlated with STAI-S and STAI-T than with PSQ. The VAS 2 h was only correlated with STAI-S and STAI-T. CONCLUSION: The significant linear correlation between preoperative anxiety and pain sensitivity and anesthesia need can facilitate better preoperative management by predicting individual anesthetic consumption. TRIAL REGISTRATION: The study was registered with the number NCT03114735 on ClinicalTrials.gov.

Adequacy of Anesthesia Guidance for Colonoscopy Procedures.

In patients undergoing colonoscopy procedures (CPs), inadequate dosing of hypnotic drugs (HD) and opioid analgesics (OA) during intravenous sedoanalgesia (ISA) may lead to intraprocedural awareness with recall (IAwR), intraprocedural (IPP) and postprocedural pain (PPP), as well as postoperative nausea and vomiting (PONV). The aim of this study was to evaluate whether the titration of HD and OA based on the observance of changing values of state entropy (SE) and surgical pleth index (SPI) (adequacy of anesthesia-AoA), state entropy alone, or standard practice may reduce the number of adverse events. One hundred and fifty-eight patients were included in the final analysis. The rate of IAwR and IPP was statistically more frequent in patients from the C group in comparison with the AoA and SE groups (p < 0.01 and p < 0.05, respectively). In turn, the rate of PPP, PONV, and patients' and operators' satisfaction with ISA between groups was not statistically significant (p > 0.05). Changes in hemodynamic parameters, demand for HD, and OA were statistically significant, but of no clinical value. In patients undergoing CPs under ISA using propofol and FNT, as compared to standard practice, intraprocedural SE monitoring reduced the rate of IAwR and IPP, with no influence on the rate of PPP, PONV, or patients' and endoscopists' satisfaction. AoA guidance on propofol and FNT titration, as compared to SE monitoring only, did not reduce the occurrence of the aforementioned studied parameters, imposing an unnecessary extra cost.

[Midazolam/fentanyl vs propofol/remifentanil in immediate postoperative with short-term mechanical ventilation]. / Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración.

OBJECTIVES: Compare between 2sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. METHODOLOGY: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. RESULTS: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572. CONCLUSIONS: Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.

Sedoanalgesia en neonato a base de remifentanyl. En relación con un caso para epiglotopexia / Sedoanalgesia in neonate based on remifentanyl. In relation to a case for epiglottopexy

Resumen: La etapa neonatal comprende del primer día hasta el día 28 de vida. Se caracteriza por ser una etapa de inmadurez anatómica, fisiológica y metabólica. Por estas características del neonato, los fármacos anestésicos impactan de manera importante en su fisiología respiratoria y cardiovascular; además la farmacocinética se ve modificada por esta inmadurez. La laringomalacia es una de las principales causas de estridor en esta etapa, misma que, dependiendo de la severidad puede requerir manejo quirúrgico, siendo una opción la epiglotopexia. Dicho procedimiento requiere analgesia potente y a su vez la posibilidad de mantener la ventilación espontánea para su adecuada evaluación, mismas que pueden ser alcanzadas con el uso de remifentanyl. Presentamos el caso clínico de un neonato de término de 22 días de vida a quien se le administró remifentanyl como base de la sedoanalgesia para realización de epiglotopexia de manera exitosa. Su potencia analgésica, capacidad de mantener el automatismo ventilatorio y la farmacocinética predecible en el neonato, convierten al remifentanyl en un agente ideal para proporcionar adecuada sedoanalgesia para diferentes procedimientos con un perfil de fácil titulación y de recuperación rápida en el neonato.

Abstract. The neonatal stage comprises from the first day of birth until day 28 of life. It is characterized by being a stage of anatomical, physiological and metabolic immaturity. Due to these characteristics of neonates, anesthetic drugs have an important impact on their respiratory and cardiovascular physiology, and their immaturity on pharmacokinetics. Laryngomalacia is one of the main causes of stridor in this stage, which depending on its severity could require surgical treatment, such as an epiglotopexy. This procedure requires potent analgesia and at the same time the possibility of maintaining spontaneous ventilation for its appropriate evaluation. This can be achieved with the use of remifentanyl. We present the clinical case of a term neonate of 22 days of age who we administered Remifentanyl as the basis of sedoanalgesia for the successful completion of an epiglotopexy. Its analgesic potency, ability to maintain ventilatory automatism and predictable pharmacokinetics in the neonate, makes it an ideal agent to provide adecuate sedoanalgesia for different procedures with an easy titration profile and rapid recovery in the neonate.