Procedural sedation analgesia in the elderly patient.

Elderly patients are perceived as a high-risk group for procedural sedation. Procedural sedation analgesia (PSA) is generally safe in older adults. What is not acceptable is undertreating pain or inadequately sedating a stable patient. All the usual precautions should be taken. One should consider any comorbidities that could make the patient more at risk of adverse reactions or complications. Older patients may be at higher risk for oxygen desaturation, but they usually respond quickly to supplemental oxygen. Geriatric patients usually require lower doses of medications. They tend to be more sensitive to medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution. The use of drugs for sedation in elderly patients requires careful consideration of their age-related changes in physiology and pharmacokinetics. The choice of drug should be based on the patient's medical condition, comorbidities, and potential adverse effects. Moreover, the administration should be done by trained personnel with close monitoring of vital signs and level of consciousness to prevent complications such as respiratory depression.

Buccal versus intranasal midazolam sedation for pediatric dental patients.

PURPOSE: The purpose of this randomized, controlled, crossover clinical trial was to evaluate and compare the behavioral differences resulting from the sedative effects of atomized buccal (transmucosal) and atomized intranasal (parenteral) midazolam (0.3 mg/kg) as a method for sedation of pediatric dental patients. METHODS: Twenty-five 36- to 72-month-old patients were randomly selected and divided into two groups that were sedated with either atomized buccal in the first visit or intranasal midazolam in the second visit (0.3 mg/kg). Patient be- havior was rated, and drug acceptance by method of administration was determined. RESULTS: There were no statistically significant differences between both groups in maximum working time. There were significant differences between both groups in drug acceptance (P=.008) and onset time (P=.00). The statistical differences between the two groups were not significant in all behavior rating scales, except for the crying rating scale, since the buccal group showed more crying. CONCLUSIONS: Atomized buccal and intranasal midazolam are both effective for sedation of pediatric dental patients and have the same maximum working time. However, atomized intranasal is more acceptable by children, has faster onset time, and children demonstrate less crying.

Ultrasound-guided peripheral and truncal blocks in pediatric patients.

Ultrasound has added a feather in the cap of the anesthesiologists as real-time nerve localization and drug deposition around the nerve structure under real-time guidance is now a reality, as the saying "seeing is believing" has been proven true with the advent of ultrasound in anesthesia. Pediatric patients are a unique group regarding their anatomical and physiological features in comparison with adults; regional blocks in adults with the anatomical landmark and surface marking are almost uniform across the adult population. The landmark technique in pediatric patients is not reliable in all patients due to the variability in the age and size; the advent of ultrasound in assisting nerve localization has changed the way regional blocks are achieved in children and the range of blocks performed on adults can now be performed on pediatric patients; with advances in the technology and dexterity of ultrasound equipment, the chances of success of blocks has increased with a smaller dose of the local anesthetic in comparison to the traditional methods. Anesthesiologists are now able to perform blocks with more accuracy and avoid complications like intravascular injection and injury to the pleura and peritoneum during routine practice with the assistance of high-frequency transducers and top of the range portable ultrasound machines; catheters can be inserted to provide a continuous analgesia in the postoperative period. This review article describes the common peripheral blocks in pediatric patients; the readers are encouraged to gain experience by attending workshops, hands-on practice under supervision, and conduct random controlled trials pertaining to ultrasound-guided blocks in the pediatric age group. The recent literature is encouraging and further research is promising; a wide range of blocks being described in detail by many prominent experts from all over the world.

Ultrasound-guided supraclavicular brachial plexus block in patient with halo device.

Ultrasound guided regional blocks are on the rise, many institutes are training their staff to master this technique of regional anesthesia. Regional anesthesia in case of an emergency surgery or elective surgery can be the best choice. The case described here is an example - patient with a halo fixation device after motor vehicle accident scheduled for surgery of the extremity. The main aim of management of this case is to achieve a safe anesthesia with minimal interference of the cervical fixation. Supraclavicular brachial plexus block is a good choice for surgeries of the arm and hand and use of an ultrasound to guide the block adds to the safety profile of this versatile block. It has been described as "Spinal of the upper limb". Patients with co-morbidities and injuries to the cervical spine are challenging cases to anesthetize, as regional anesthesia is a very attractive option, failure of the regional block will expose the patient to all adverse sequelae, which were being avoided by planning for a regional anesthesia. Ultrasound has revolutionized the way regional anesthesia is practiced and the proper drug can be placed at the right place in the hands of an experienced anesthesiologist and the block will help in avoiding all the complications of endotracheal anesthesia in these cases.

Childhood vitiligo: a long-term study of localized vitiligo treated by noncultured cellular grafting.

Segmental type was the second most commonly reported in childhood vitiligo. No significant difference has been reported in the prevalence of childhood and adult focal vitiligo. However, the prevalence of segmental vitiligo has been found to be higher in children compared with that in adults. All available medical and phototherapy options are limited by adverse effects or unsatisfactory efficacy. Surgical techniques may be preferred but are not recommended for children as they are time consuming and associated with technical difficulties. In a retrospective review, 25 children aged 4 to 16 years were treated by autologous, noncultured cellular grafting performed under sedation supplemented with local anaesthesia and were followed up for a period of 9 to 54 months postgrafting. Repigmentation was graded as excellent with 95% to 100% pigmentation, good with 65% to 94%, fair with 25% to 64%, and poor with 0% to 24% of the treated area. In the segmental group, eight (62%) showed excellent, two (15%) good, one (8%) fair, and two (15%) poor pigmentation, which was retained until the end of the respective follow-up period. In the focal group, nine (75%) showed excellent, and one (8%) each showed good, fair, and poor pigmentation, which was retained until the end of the respective follow-up period. Noncultured cellular grafting may be considered to treat childhood localized vitiligo.

Recovery profile for magnetic resonance imaging in pediatric daycase--sevoflurane vs. isoflurane.

BACKGROUND: Magnetic resonance imaging (MRI) is gaining ground over other investigations particular in study of brain and soft tissues. The MRI procedure is painless but requires an immobile patient for a successful study. Children are required to be sedated or anesthetized for this procedure. We compared two inhalational anesthetics, namely sevoflurane and isoflurane, for the recovery profile of each with aim to determine the ideal drug for early discharge of children. PATIENT AND METHODS: 100 patients aged 3 yrs to 10 yrs (ASA I and II) were divided into Group S (Sevoflurane), Group I (Isoflurane). The induction time, duration of the MRI study, recovery and discharge times were recorded. The data were subjected to Students t-test and Levene's test for equal variance. RESULTS: In Group S, 27 male and 23 female were enrolled in comparison to 30 male and 20 female in Group 1. The induction time in Group S resulted in a mean of 133.7 seconds +/- 19.32), Group I yielded a mean of 157.44 seconds (+/- 24.20) p > 0.05). The mean recovery time with Group S was 124.4 seconds (+/- 31.57) when compared with Group I a mean of 376.46 seconds (+/- 58.20) p < 0.05. The mean discharge time in Group S was 25.20 minutes (+/- 5.71) in comparison to a mean of 37.40 minutes (+/- 7.43) p < 0.05 in Group I. CONCLUSION: Sevoflurane can be an ideal inhalational anesthetic for Volatile Induction and Maintenance Anesthesia (VIMA) in children under going daycase MRI examinations.