Risk factors for chloral hydrate sedation failure in pediatric patients: a retrospective analysis.

Background: This study aimed to investigate the risk factors for chloral hydrate sedation failure and complications in a tertiary children's hospital in South Korea. Methods: A retrospective analysis of pediatric procedural sedation with chloral hydrate between January 1, 2021, and March 30, 2022, was performed. The collected data included patient characteristics, sedation history, and procedure. Multivariable regression analysis was performed to identify the risk factors for procedural sedation failure and complications. Results: A total of 6691 procedural sedation were included in the analysis; sedation failure following chloral hydrate (50 mg/kg) occurred in 1457 patients (21.8%) and was associated with a higher rate of overall complications compared to those with successful sedation (17.5% [225 / 1457] vs. 6.2% [322 / 5234]; P < 0.001; odds ratio, 3.236). In the multivariable regression analysis, the following factors were associated with increased risk of sedation failure: general ward or intensive care unit inpatient (compared with outpatient); congenital syndrome; oxygen dependency; history of sedation failure or complications with chloral hydrate; procedure more than 60 min; and magnetic resonance imaging, radiotherapy, or procedures with painful or intense stimuli (all P values < 0.05). Factors contributing to the complications included general ward inpatient, congenital syndromes, congenital heart disease, preterm birth, oxygen dependency, history of complications with chloral hydrate, and current sedation failure with chloral hydrate (all P values < 0.05). Conclusions: To achieve successful sedation with chloral hydrate, the patient's sedation history, risk factors, and the type and duration of the procedure should be considered.

Every Second Patient Does Not Fully Understand Written Preprocedure Information: An Explorative Study About Functional Health Literacy.

PURPOSE: To investigate the self-perceived functional health literacy (FHL) of patients who underwent advanced endoscopic treatment, explore whether FHL could explain aspects of patients' perioperative experiences, and determine whether patients read the provided patient information. DESIGN: A prospective cross-sectional explorative study. METHODS: One hundred patients who underwent endoscopic bile duct intervention were enrolled and asked to answer the Swedish version of the FHL Scale and their perioperative experiences of the intervention. Along with procedural data, all data were analyzed for group comparisons; high or low FHL. FINDINGS: The study included a total of 100 patients, with half of them rating their FHL as problematic or inadequate (low FHL). Among those who perceived their FHL as inadequate, a majority had not read the provided information before the procedure. Patients with problematic or inadequate FHL experienced perioperative anxiety and pain more frequently than those with sufficient FHL (high FHL). CONCLUSIONS: This study supports previous research on the association between low FHL and patients' well-being. To better meet patients' information needs, it is crucial for nurse anesthetists and other health care providers to have knowledge about FHL. Additionally, the study highlights the importance of using alternative and more effective means of delivering information to patients.

Intervention Bundle for Optimization of Procedural Sedation for Newborns Undergoing Magnetic Resonance Imaging: A Single-Center Quality Improvement Project in Qatar.

Introduction: Magnetic resonance imaging (MRI) is a common procedure in tertiary care neonatal intensive care units (NICUs). MRIs aid in detailing structural anatomy and are increasingly utilized for prognostication. Keeping babies calm and motion-free in the MRI suite is challenging, and various approaches have been adopted to obtain the best image quality. We share our experience of intervention bundle for procedural sedation with the novel use of buccal midazolam in our NICU for babies undergoing MRI. Methods: This single-center quality improvement project comprised two epochs. Epoch 1 from April 2018 to December 2020 provided baseline data regarding sedation use and helped identify causes for suboptimal images and the adverse event rate. Following the implementation of an interventional bundle comprising specific midazolam dose recommendations tailored to background risk factors and streamlining the procedural sedation process, similar comparative data were collected in epoch 2 (May 2021 to December 2022) after a washout period. Results: Of 424 patients, 238 and 108 had MRI done under either procedural sedation protocol or feed and wrap technique in epoch 1 and 2, respectively. After excluding babies whose MRIs were performed under sedative infusions, 30 (13%) babies had adverse events in epoch 1, while only 8 (7%) events occurred in epoch 2. There was also a 37% improvement in the documentation of procedural sedation between the two epochs. Conclusion: Procedural sedation with buccal midazolam under neonatologist supervision is safe, efficient, and effective in babies undergoing MRI in this single-center study. More extensive studies may be warranted to assess the suitability of this sedation modality for broader use.

Clinical experience with remimazolam in pediatric anesthesiology: An educational focused review.

Remimazolam is a novel ultrashort-acting benzodiazepine, which like midazolam, results in sedation, anxiolysis, and amnesia through its agonistic effects on the gamma-amino butyric acid A receptor. As opposed to midazolam, its unique metabolism is via tissue esterases, which results in a rapid elimination with a limited context sensitive half-life and prompt dissipation of its effect when administration is discontinued. Remimazolam received FDA approval for use in adults in 2020. In preliminary and initial clinical trials, its efficacy and safety has been suggested in the adult population, both as a primary agent for procedural sedation or as an adjunct to general anesthesia. There are limited data regarding the use of remimazolam in infants and children and its use in this population remains off label as it does not hold FDA-approval in pediatric-aged patients. This narrative outlines the pharmacologic properties of this unique medication, reviews previous published reports of its role in pediatric-aged patients, and discusses dosing parameters and clinical use in this population.

Evaluating the Quality of Systematic Reviews on Pediatric Sedation in Dentistry: An Umbrella Review.

Sedation is a depression of a patient's state of consciousness, induced by medications, that can reach different levels of intensity during a medical procedure. Conscious sedation produces a minimally depressed level of consciousness without impairment of the ability to maintain an open airway, of protective reflexes or of responses to verbal and physical stimulation. This umbrella review is aimed at critically assessing the available systematic reviews (SRs) and meta-analyses (MA) on sedation in children/adolescents. An electronic database search was conducted that included Pubmed-Medline, Web of Science, Cochrane, Scopus, Scielo, Embase, LILACS and TRIP and the scope of which extended until January 2023. The risk of bias (RoB) of SRs was analyzed using the Measurement Tool to Assess SRs criteria 2 (AMSTAR2). Of 998 entries, 37 SRs were included. In terms of methodological quality, eight studies were assessed as having critically low quality, four studies had low quality, nine studies had moderate quality, and sixteen were considered to be of high quality. Based on the current guidelines, the most employed drugs in pediatric dentistry for sedation are nitrous oxide and midazolam; however, the available evidence supporting their use is insufficient and of low/critically low quality. The combined technique is recommended (nitrous oxide (30-50%) + midazolam). The optimal dose of oral midazolam is 0.75 mg/kg. The level of methodological quality of SRs is expected to increase according to the results and future directions of this umbrella review.

Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk.

This study aimed to create a pediatric sedation scoring system independent of the American Society of Anesthesiology Physical Status (ASA-PS) classification that is predictive of adverse events, facilitates objective stratification, and resource allocation. Multivariable regression and machine learning algorithm analysis of 134,973 sedation encounters logged in to the Pediatric Sedation Research Consortium (PSRC) database between July 2007 and June 2011. Patient and procedure variables were correlated with adverse events with resultant ß -regression coefficients used to assign point values to each variable. Point values were then summed to create a risk assessment score. Validation of the model was performed with the 2011 to 2013 PSRC database followed by calculation of ROC curves and positive predictive values. Factors identified and resultant point values are as follows: 1 point: age ≤ 6 months, cardiac diagnosis, asthma, weight less than 5th percentile or greater than 95 th , and computed tomography (CT) scan; 2 points: magnetic resonance cholangiopancreatography (MRCP) and weight greater than 99th percentile; 4 points: magnetic resonance imaging (MRI); 5 points: trisomy 21 and esophagogastroduodenoscopy (EGD); 7 points: cough at the time of examination; and 18 points: bronchoscopy. Sum of patient and procedural values produced total risk assessment scores. Total risk assessment score of 5 had a sensitivity of 82.69% and a specificity of 26.22%, while risk assessment score of 11 had a sensitivity of 12.70% but a specificity of 95.29%. Inclusion of ASA-PS value did not improve model sensitivity or specificity and was thus excluded. Higher risk assessment scores predicted increased likelihood of adverse events during sedation. The score can be used to triage patients independent of ASA-PS with site-specific cut-off values used to determine appropriate sedation resource allocation.

MethOxyfluraNe in InTerventiOnal Radiology (MONITOR): A randomised controlled trial.

INTRODUCTION: Procedural sedation and pain management in interventional radiology (IR) are of critical importance to successful outcomes but remain under-researched. Methoxyflurane has been previously used in some minor procedures with several advantages including rapid onset and offset and a good safety profile. The purpose of this study was to evaluate methoxyflurane for procedures in IR. METHODS: A randomised, double-blind, placebo-controlled trial was performed between October 2021 and November 2022. Patients presenting for portacath insertion, portacath removal or solid organ biopsy were randomised to either methoxyflurane or placebo. Three hundred and fourteen patients were enrolled in total. Patients were supplied with one Penthrox inhaler containing either 3 mL methoxyflurane or placebo. The primary endpoints of the study were change in pain and anxiety scores compared with baseline, measured on a standardised visual analogue scale (VAS) pre-procedure, at 5-min intervals during the procedure and post-procedure. Baselines scores were controlled for in the statistical analysis. Safety analysis was also performed. RESULTS: One hundred and sixty-nine patients received methoxyflurane and 145 received placebo. Baseline characteristics were similar between the two groups. The methoxyflurane group had lower pain and anxiety scores throughout the procedure (P < 0.001) with 2.5 times less pain (VAS 1.08/10) and 1.6 times less anxiety (VAS 0.97/10) on average. Lower post-procedure pain (mean 0.72 vs 1.44; P < 0.001) and anxiety (mean 0.55 vs 1.13; P = 0.008) were also observed with methoxyflurane. There were no drug or major procedure-related adverse events. CONCLUSION: The results of this study suggest that methoxyflurane provides safe and effective analgesia and anxiolysis for some procedures in IR.

Integrated pulmonary index during procedural sedation and analgesia: A cluster-randomized trial.

AIM: To evaluate the effectiveness of utilizing the integrated pulmonary index for capnography implementation during sedation administered by nurses. DESIGN: Cluster-randomized trial. METHODS: Participants were enrolled from the interventional radiology department at an academic hospital in Canada. Nurses were randomized to either enable or disable the Integrated Pulmonary Index feature of the capnography monitor. Procedures were observed by a research assistant to collect information about alarm performance characteristics. The primary outcome was the number of seconds in an alert condition state without an intervention being applied. RESULTS: The number of seconds in an alarm state without intervention was higher in the group that enabled the integrated pulmonary index compared to the group that disabled this feature, but this difference did not reach statistical significance. Likewise, the difference between groups for the total alarm duration, total number of alarms and the total number of appropriate alarms was not statistically significant. The number of inappropriate alarms was higher in the group that enabled the Integrated Pulmonary Index, but this estimate was highly imprecise. There was no difference in the odds of an adverse event (measured by the Tracking and Reporting Outcomes of Procedural Sedation tool) occurring between groups. Desaturation events were uncommon and brief in both groups but the area under the SpO2 90% desaturation curve scores were lower for the group that enabled the integrated pulmonary index. CONCLUSION: Enabling the integrated pulmonary index during nurse-administered procedural sedation did not reduce nurses' response times to alarms. Therefore, integrating multiple physiological parameters related to respiratory assessment into a single index did not lower the threshold for intervention by nurses. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The time it takes to respond to capnography monitor alarms will not be reduced if the integrated pulmonary Iindex feature of capnography monitors is enabled during nurse-administered procedural sedation. IMPACT: Results do not support the routine enabling of the integrated pulmonary index when nurses use capnography to monitor patients during procedural sedation as a strategy to reduce the time it takes to initiate responses to alarms. REPORTING METHOD: CONSORT. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution. TRIAL REGISTRATION: This study was prospectively registered at ClinicalTrials.gov (ID: NCT05068700).

Design Specifications for an Automated System to Deliver Instructions About Preprocedure Fasting.

PURPOSE: Many patients undergoing surgical and other medical procedures requiring sedation or anesthesia receive standardized "no eating or drinking after midnight" instructions. This "standardized" instruction does not change regardless of potential alterations in scheduling that result in significant delays in procedure start times. As a result, the duration of preprocedure fasting often far exceeds recommended requirements. A technological solution that automates the delivery of preprocedure fasting instructions to patients would likely improve the patient experience. The purpose of this study was to determine design specifications for the delivery of notifications to patients as part of an automated system. DESIGN: A qualitative study was conducted with 14 adult participants using the persona-scenario method. METHODS: Participants worked in groups to create realistic but fictitious personas and scenarios that described how individuals like themselves would interact with an automated preprocedure fasting instruction system. Data generated through the development of the scenarios were analyzed to first identify important themes, which were then interpreted into design specifications. FINDINGS: Seven women and seven men, aged 25 to 75, developed 9 persona-scenarios, which captured outpatient and inpatient preprocedure fasting experiences, as well as perspectives of individuals who were not comfortable with technology, or those for which English was not the primary spoken language. Most scenarios described preprocedure fasting instructions delivered by an automated bidirectional short message service system. Two major themes were identified as patient priorities, including: (1) enhancing communication between patients and healthcare providers; and (2) the importance of using simple technology so that a greater number of patients with varying degrees of comfort and capabilities would be able to use the system confidently. A corresponding set of proposed design specifications was devised. CONCLUSIONS: The results of this study provide actionable ways to operationalize patient-centered ideas in the design of an automated preprocedure fasting instruction system.

Procedural sedation by advanced practice providers in the emergency medical service in the Netherlands: a retrospective study.

BACKGROUND: Procedural sedation and analgesia (PSA) is a technique of administering sedatives to induce a state that allows the patient to tolerate painful procedures while maintaining cardiorespiratory function, a condition that is frequently desired prehospital. Non-physician prehospital clinicians often have a limited scope of practice when it comes to providing analgesia and sedation; sometimes resulting in a crew request for back-up from physician-staffed prehospital services.". This is also the case if sedation is desirable. Advanced practice providers (APPs), who are legally authorized and trained to carry out this procedure, may be a solution when the physician-staffed service is not available or will not be available in time. METHODS: The aim of this study is to gain insight in the circumstances in which an APP, working at the Dutch ambulance service "RAV Brabant MWN" from January 2019 to December 2022, uses propofol for PSA or to provide sedation. With this a retrospective observational document study we describe the characteristics of patients and ambulance runs and evaluates the interventions in terms of safety. RESULTS: During the study period, the APPs administered propofol 157 times for 135 PSA and in 22 cases for providing sedation. The most common indication was musculoskeletal trauma such as fracture care or the reduction of joint dislocation. In 91% of the situations where propofol was used, the predetermined goal e.g. alignment of fractured extremity, repositioning of luxated joint or providing sedation the goal was achieved. There were 12 cases in which one or more adverse events were documented and all were successfully resolved by the APP. There were no cases of laryngospam, airway obstruction, nor anaphylaxis. None of the adverse events led to unexpected hospitalization or death. CONCLUSION: During the study period, the APPs performed 135 PSAs and provided 22 sedations. The success rate of predetermined goals was higher than that stated in the literature. Although there were a number of side effects, their incidences were lower than those reported in the literature, and these were resolved by the APP during the episode of care. Applying a PSA by an APP at the EMS "RAV Brabant MWN" appears to be safe with a high success rate.

The Origins and Development of Pre-emptive Dermatologic Anesthesia: A Systematic Review.

This study delves into the historical trajectory of dermatological anesthesia, tracing its roots from ancient civilizations to modern times. It emphasizes the relentless pursuit of pain relief in dermatologic procedures and the transformative impact of anesthesia on surgical practices. A comprehensive analysis was conducted through an extensive literature review, employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review model on the PubMed and Embase databases. A total of 1304 articles were initially identified, with six publications from these databases and 10 additional sources from the World Wide Web included in the study. This systematic approach allowed for a thorough examination of the historical journey of dermatological anesthesia. The historical trajectory outlined in this study highlights the progress in dermatological anesthesia, showcasing its impact on contemporary procedures with a continual emphasis on patient comfort and safety. As medical knowledge expands, the ongoing quest for enhanced pain control in dermatology remains a central focus.

The clinical role of remimazolam: Protocol for a scoping review.

BACKGROUND: Remimazolam, a novel benzodiazepine, shows promise as an alternative to traditional sedatives and hypnotic agents in procedural sedation and general anaesthesia. While preliminary research indicates potential advantages over conventional agents, such as faster onset, predictable duration, and improved safety profile, the extent and quality of existing evidence remain unclear. This scoping review aims to investigate the current clinical role of remimazolam and provide a broad and comprehensive overview. METHODS: The proposed review will adhere to the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Reviews. A comprehensive search will be conducted across major peer-reviewed databases and grey literature will be sought. All studies involving individuals undergoing procedural sedation or general anaesthesia with remimazolam will be eligible. Data extraction will encompass trial and participant characteristics, intervention details, reported outcomes, comparative efficacy versus midazolam and propofol, patient and operator experience and economic costs. RESULTS: We will provide a descriptive summary supplemented by statistics, figures and tables where applicable. CONCLUSION: The outlined scoping review aims to assess the clinical use of remimazolam in procedural sedation and as the hypnotic component of general anaesthesia. The review will map the current body of evidence of remimazolam and identify knowledge gaps, contributing to understanding its clinical implications and guiding future research efforts in procedural sedation and general anaesthesia.

A Randomised Controlled Trial Comparing Ketamine versus Fentanyl for Procedural Sedation in the Emergency Department for Adults with Isolated Extremity Injury.

Introduction: Alleviating pain and anxiety of patients during procedures is an essential skill for an Emergency Physician (EP). Several sedatives and dissociative agents are used for PSA (Procedural Sedation and Analgesia). In this study, we aimed to compare two drugs that is, ketamine and fentanyl for procedural sedation in adults with isolated limb injuries in the Emergency Department (ED). Materials and methods: In this prospective, randomised controlled interventional trial, patients aged between 18 to 65 years with isolated extremity injury requiring PSA in the ED were recruited. A total of 200 subjects were included in the study and randomly allocated to either the fentanyl (n=100) or the ketamine (n=100) group. Patients were blinded to the intervention and subsequently premedicated with Midazolam. Following this, they received either ketamine or fentanyl based on the group they were allocated to. Vital signs, including but not limited to the level of sedation, were measured at predetermined time intervals. A Modified Aldrete Score of >8 was used as a criterion for disposition from the ED. Data were collected in a pre-designed proforma. We aimed to compare the effectiveness as well as ascertain the safety profile of the two drugs for PSA in the ED. Results: There was no significant difference between the two groups when age, gender, mechanism of injury and comorbidities were compared. We found that there was no statistically significant difference between the two groups when blood pressure, respiratory rate and depth of sedation were compared. In both groups, there was a significant decrease in pain on the Numerical Rating Scale (NRS) following drug administration from 8 to 3 (p<0.001). Patients in the fentanyl group had an increased incidence of transient oxygen desaturation (p<0.001). Vomiting was more common in the ketamine group (p<0.001). Conclusion: PSA is a safe and efficacious procedure for patients undergoing painful procedures in ED. Patients in both the groups maintained hemodynamic stability throughout the procedure. From our study, we were able to conclude that both ketamine and fentanyl are similar in efficacy for PSA in the ED for adults with isolated limb injuries. In addition, no significant cardiovascular adverse events were noted in either group in our study.

The Rise of Remimazolam: A Review of Pharmacology, Clinical Efficacy, and Safety Profiles.

Anesthesiologists often use benzodiazepines (BZDs) due to their remarkable amnestic and anxiolytic capabilities. Because of this, they are perfect for use during the perioperative phase, when patients' anxiety levels are already high. Remimazolam has replaced certain commonly used intravenous (IV) anesthetics due to its excellent safety profile, rapid onset of action, and short half-life. The four classes of BZDs, 2-keto-benzodiazepines, 3-hydroxy-benzodiazepines, triazolobenzodiazepines, and 7-nitro-benzodiazepines based on chemical structure, provide various levels of drowsiness, forgetfulness, and anxiolysis. Based on their elimination half-life, short-acting BZDs typically have a half-life ranging from one to 12 hours, e.g., oxazepam; intermediate-acting BZDs have an average elimination half-life of 12 to 40 hours, e.g., alprazolam; and long-acting BZDs have an average elimination half-life of more than 40 hours, e.g., diazepam. The chloride ion channel is conformationally shifted by the benzodiazepine molecule resulting in central nervous system (CNS) inhibition and hyperpolarization. Each type of benzodiazepine has a favored use. For example, diazepam is used to treat anxiety. Midazolam is used for its anxiolytic and anterograde amnestic effects during the perioperative phase. Anxiety and epilepsy are two conditions that lorazepam effectively treats. There are now phase II and III clinical studies investigating remimazolam. It is not sensitive to alterations in its surroundings and has a brief half-life so that it may be removed rapidly, even after extensive infusion. Being a soft drug means the body easily breaks it down via metabolism, which explains many features. Remimazolam is hydrolyzed into methanol and its carboxylic acid metabolite CNS 7054 by esterase metabolism. Therefore, remimazolam has a shorter onset time and faster recovery than other BZDs. Remimazolam is metabolized independently of any particular organ. Patients with hepatic and renal problems will not see any changes in metabolism or excretion since the drug's ester moiety makes it a substrate for general tissue esterase enzymes. Like its predecessor, midazolam, it has a high potential for addiction. Some side effects that could occur during infusion include headaches and drowsiness. In clinical trials, hypotension, respiratory depression, and bradycardia were noted in participants. BZDs are helpful when used in conjunction with anesthesia. Remimazolam stands out, thanks to its unique pharmacokinetics, pharmacodynamics, safety profile, and potential medical applications. Its desirable properties make it a potential surgical premedication and sedative in the critical care unit. Anesthesiologists and other doctors could have access to more consistent and safer medication. However, additional comprehensive clinical trials are necessary to understand remimazolam's advantages and disadvantages.

The association between different anesthetic techniques and outcomes in patients undergoing transfemoral aortic valve replacement.

Background: There is an increasing number of patients undergoing transfemoral aortic valve replacement (TAVR) with sedation. There is limited data assessing the efficacy and safety of the different types of sedative drugs. The objective was to compare two sedation techniques with regard to the need for vasoactive support, respiratory support, rate of conversion to general anesthesia (GA), common perioperative morbidities, intensive care unit (ICU) stay, and in-hospital mortality. Methods: A retrospective chart review study conducted among patients who underwent TAVR at a specialized cardiac center between January 2016 and December 2019. Data collection included patient diagnosis, preoperative comorbidities, intraoperative outcomes, and postoperative outcomes. Results: A total of 289 patients received local anesthesia; 210 received propofol infusion and 79 received a mixed propofol-ketamine infusion (Ketofol). The average age was 75.5 ± 8.9 years and 58.1% of the patients were females. Comparing propofol and ketofol groups, 31.2% and 34.2% of the patients required drug support, 7.6% and 6.3% required conversion to GA, 46.7% and 59.5% required respiratory support, respectively. These intraoperative outcomes were not significantly different between groups, P = 0.540, P = 0.707, and P = 0.105, respectively. In-hospital 30-day mortality in propofol and ketofol groups were 1.9% and 3.8%, respectively, P = 0.396. In both groups, the median post-procedure coronary care unit stay was 26 hours while post-procedure hospital stay was 3 days. Conclusions: There were no significant differences in perioperative or postoperative outcomes in TAVR patients receiving either propofol or ketofol. Propofol infusion, either alone or with ketamine, is reliable and safe, with minimal side effects.

Correlation of Comfort Score and Narcotrend Index during Procedural Sedation with Midazolam and Propofol in Children.

Background/Objectives: Precise assessment of hypnotic depth in children during procedural sedation with preserved spontaneous breathing is challenging. The Narcotrendindex (NI) offers uninterrupted information by continuous electrocortical monitoring without the need to apply a stimulus with the risk of assessment-induced arousal. This study aimed to explore the correlation between NI and the Comfort Scale (CS) during procedural sedation with midazolam and propofol and to identify an NI target range for deep sedation. Methods: A prospective observational study was conducted on 176 children (6 months to 17.9 years) undergoing procedural sedation with midazolam premedication and continuous propofol infusion. Statistical analyses included Pearson correlation of NI and CS values, logistic regression, and receiver operating curves. Results: Median NI values varied with CS and age. The correlation coefficient between CS and NI was 0.50 and slightly higher in procedure-specific subgroup analyses. The optimal NI cut-off for deep sedation was between 50 and 60 depending on the analyzed subgroup and displayed high positive predictive values for sufficient sedation throughout. Conclusion: Our study found a moderate correlation between NI and CS, demonstrating reliable identification of adequately sedated patients.

Dexmedetomidine as an Adjunct to Propofol in Patients Undergoing Elective Endoscopic Retrograde Cholangio-Pancreaticography - A Double-blind Randomized Controlled Study.

Background: Propofol is the drug of choice for procedural sedation. The addition of α2 agonist dexmedetomidine may improve the safety profile of the procedure by providing stable hemodynamics, better sedation quality, and decreasing the side effects of each drug during elective endoscopic retrograde cholangio-pancreaticography (ERCP). Materials and Methods: Eighty patients aged between 18 and 60 years were distributed randomly into two groups. The dexmedetomidine + propofol group (group DP) received an injection of dexmedetomidine at the dose of 1 mcg/kg in 100 mLsaline, and the propofol group (group P) received plain 100 mL normal saline over 10 min. Subsequently, both groups received a bolus dose of injection propofol 1 mg/kg as sedation, and a modified observer's assessment of alertness/sedation score (MOASS) score was assessed, followed by infusion at the rate of 50 mcg/kg/min during the procedure. A rescue bolus dose (20 mg) of propofol was administered when the patient showed signs of inadequate sedation or analgesia in both groups. Cardiovascular and respiratory parameters were recorded every 10 min throughout the procedure. Post-procedure modified Aldrete score was evaluated for 30 min, and the endoscopist's score was noted at the end of the procedure. Results: There was a significant difference (P = 0.001) in the additional number of rescue doses of propofol administered in group DP (3.47 ± 0.77) as compared to group P (8.78 ± 1.11). The total dose of propofol was lower in group DP (316.59 ± 43.29 mg) than in group P (443 ± 41.1 mg) with P value = 0.001. Statistically significant differences in the hemodynamic values were observed in group DP during infusion (P value < 0.05) of dexmedetomidine and throughout the procedure (P < 0.05) when compared with group P. Endoscopists graded the satisfaction score as very high (3.477 ± 0.77) in group DP. Conclusion: The addition of dexmedetomidine to propofol during ERCP provided better and safer sedation.

Accuracy of Transcutaneous Carbon Dioxide Measurement During Transcatheter Aortic Valve Replacement Under Monitored Anesthesia Care: A Prospective Observational Study.

Background Transcutaneous carbon dioxide tension (PtcCO2) measurement is a promising alternative to arterial carbon dioxide tension (PaCO2) measurement. PaCO2 measurement is invasive and intermittent, whereas PtcCO2 measurement is non-invasive and continuous. However, previous studies evaluating PtcCO2measurements did not include patients undergoing transcatheter aortic valve replacement (TAVR), who experience anticipated hemodynamic changes, particularly before and after valve placement. Therefore, we investigated whether PtcCO2 measurement could provide an alternative to PaCO2 measurement during transfemoral TAVR under monitored anesthesia care (MAC) with local anesthesia. Methodology We conducted a prospective observational study. We included all consecutive patients with severe aortic stenosis who were scheduled to undergo a transfemoral TAVR under MAC at our institution from November 1, 2020, to April 30, 2021. During the procedures, PaCO2 and PtcCO2 were concurrently monitored six times as a reference standard and index test, respectively. PtcCO2 was monitored continuously using a non-invasive earlobe sensor. The agreement between PtcCO2 and PaCO2 measurements was assessed using the Bland-Altman method, and the 95% limits of agreement were calculated. Based on previous studies, we determined that 95% limits of agreement of ±6.0 mmHg would be clinically acceptable to define PtcCO2 as an alternative to PaCO2. Results We obtained 88 measurement pairs from 15 patients. The lower and upper 95% limits of agreement between the PtcCO2 and PaCO2 measurements were -4.22 mmHg and 6.56 mmHg, respectively. Conclusions During TAVR under MAC with local anesthesia, PtcCO2 measurement could not provide a viable alternative to PaCO2 measurement to reduce high PaCO2 events. This study focused on comparing intraoperative periods before and after valve implantation. Therefore, further investigation is warranted to assess the impact of various factors, including the prosthetic valve type and the hemodynamic effects of balloon aortic valvuloplasty, on PtcCO2 measurement in TAVR.

Mastering Sedation and Associated Respiratory Events through Simulation-Based Training: A Randomised Controlled Trial Involving Non-Anaesthesiology Residents.

Non-anaesthetists commonly administer procedural sedation worldwide, posing the risk of respiratory events that can lead to severe complications. This study aimed to evaluate whether simulation-based learning could lead to enhancements in the clinical proficiency of non-anaesthesiology residents in managing sedation and related respiratory complications. Following the evaluation of baseline clinical performance through a pre-test simulation, 34 residents were randomly allocated to either participate in an innovative simulation-based learning module (intervention group) or view a brief self-learning video (control group). After a one-month period, their clinical performance was assessed again in a post-test simulation involving respiratory arrest during procedural sedation. Two independent assessors rated each resident's performance using video recordings and a scoring tool with scores ranging from 0 to 19/19. The two assessments were averaged for each performance, and the pre- to post-test change was calculated for each resident. While baseline clinical performance was similar, mean (SD) increase in clinical performance was significantly greater in the intervention group than in the control group (+2.4 (1.6) points versus +0.8 (1.3) points, respectively; p = 0.002). Our simulation-based learning sedation module resulted in the enhanced management of sedation-related complications compared to baseline and minimal self-learning. Simulation-based medical education may offer an effective approach for equipping non-anaesthesiology residents with essential skills to mitigate risks associated with sedation. (ClinicalTrials.gov identifier: NCT02722226).