Sedação consciente com óxido nitroso em clínica odontológica: principais indicações e segurança / Concious sedation with nitrous oxide in dental clinics: main indications and safety

A ansiedade desempenha um papel significativo na experiência de tratamentos odontológicos e pode resultar em evasão por parte dos pacientes. Isso é especialmente relevante para grupos como pacientes pediátricos e aqueles com necessidades especiais, que muitas vezes requerem técnicas de controle de comportamento ou sedação devido à ansiedade. No entanto, a ansiedade não deve ser negligenciada mesmo em pacientes sem odontofobia grave, pois está relacionada à percepção da dor durante os procedimentos odontológicos. A sedação consciente com óxido nitroso surge como uma alternativa valiosa para reduzir a ansiedade e melhorar o conforto do paciente. Ao contrário dos benzodiazepínicos e da anestesia geral, o óxido nitroso atua no sistema nervoso de uma forma que deprime levemente o córtex cerebral, sem afetar o centro respiratório. Isso permite o uso de concentrações subanestésicas do gás, administradas com oxigênio por meio de uma máscara nasal. O óxido nitroso é de rápida ação, pouco solúvel e tem um período de recuperação breve, permitindo que os pacientes retornem rapidamente às atividades normais. Este estudo, uma revisão de literatura, explora o mecanismo de ação do óxido nitroso, suas indicações na prática odontológica e examina possíveis riscos e contraindicações associados ao seu uso. Em resumo, a sedação consciente com óxido nitroso se mostra como uma opção promissora para aliviar a ansiedade e melhorar a experiência de tratamentos odontológicos, beneficiando uma ampla gama de pacientes, não apenas aqueles com fobias graves.

Anxiety, in an outpatient dental environment, plays a fundamental role in pain and discomfort expectation, resulting in increase of treatment evasion. The groups that present greater difficulty in cooperation are children and special needs patients, with behavioral control and sedation being often necessary. Nevertheless, literature emphasizes that anxiety must be evaluated as a critical stage and its management done not only in patients with elevated anxiety levels, but being crucial on pain control of every dental patient, since higher grades of restlessness equals higher pain perception. It is known that the use of nitrous oxide in conscious sedation proves to be an useful tool on reducing anxiety and enabling comfortable interventions, indicating that it is an alternative to the use of benzodiazepines and general anesthesia. The drug acts on the nervous system, promoting a slight depression of the cerebral cortex and, unlike benzodiazepines, which act at the medulla level, it does not depress the respiratory center. The technique uses sub-anesthetic concentrations of nitrous oxide delivered with oxygen through a nasal mask. Nitrous oxide is poorly soluble and has a rapid onset of action, being therefore associated with a rapid recovery period. The duration of sedation is controlled and the patient can quickly return to normal activities. This paper is a narrative review with the objective of exploring the mechanism of action of this gas, evaluating its indications for use in dental clinic and verifying possible risks and contraindications.

Comparison of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy conducted by pediatric gastroenterologists.

Objectives: The effectiveness and safety of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy were compared. Methods: We retrospectively analyzed the cases of pediatric patients (≤15 years old) who had undergone bidirectional endoscopy, esophagogastroduodenoscopy, and colonoscopy by pediatric gastroenterologists. Demographic data, indications, sedatives/dosages, clinical outcomes, endoscopic findings, adverse events, and total patient time requirements (total time in which patients stay in our hospital) were compared in the two sedation groups. Results: Ninety-one children (51 boys, 40 girls, mean age 13 years, range 9-15) treated at our hospital were enrolled. Propofol alone or in combination with midazolam and/or pentazocine was administered to 51 patients (propofol-based sedation group). Midazolam alone or in combination with pentazocine was administered to the other 40 patients (midazolam sedation group). In the propofol group, the following mean doses were used: propofol, 96 mg (range 40-145 mg); midazolam, 4.9 mg (range 3-5 mg); and pentazocine, 7.5 mg. In the midazolam group, the mean doses of midazolam and pentazocine were 6.2 mg (range 4-10 mg) and 15 mg, respectively. All procedures were successfully completed by pediatric gastroenterologists. The total procedure times and endoscopic findings were similar in the two groups, but the median patient time requirement in the propofol group was significantly shorter versus the midazolam group (7.3 h vs. 8.4 h, p < 0.001). No adverse events occurred in either group. Conclusions: Propofol-based sedation in pediatric bidirectional endoscopy was safely and effectively performed by pediatric gastroenterologists, and its patient time requirement was shorter than that for midazolam sedation.

Efficacy and safety of intravenous thiamylal in sedation for colonoscopy in children.

Objectives: Since a standard sedation protocol for pediatric colonoscopy (CS) has not been established, evidence on optimal sedative agents is needed. This study aimed to evaluate the efficacy and safety of thiamylal in sedation for pediatric CS compared to midazolam. Methods: Children from 7 to 16 years of age who underwent CS under sedation with intravenous thiamylal or midazolam at our hospital between June 2010 and March 2024 were included in this retrospective observational study. The primary outcome was the efficacy (success rate of CS without mid-awakening) of the drugs. Meanwhile, the secondary outcomes were the sedation level during CS, procedure time, recovery time, and adverse events related to sedation. Results: Sixty children were included in the study. The success rate of CS without mid-awakening was significantly higher in the thiamylal group (90.6%) than in the midazolam group (64.3%; p = 0.03). The two groups had no significant differences in median sedation depth, procedure time, or recovery time. Adverse events related to sedation in thiamylal group (22%) and midazolam group (25%) were similar. No severe adverse events were reported. Conclusions: Intravenous thiamylal provides effective and safe sedation in children requiring CS, with little or no mid-awakening during the procedure.

Comparison of remimazolam and midazolam for sedation during colonoscopy in Japanese patients: A propensity score matching analysis.

Objectives: To compare the efficacy and safety of sedation with midazolam and remimazolam for colorectal endoscopy. Methods: This single-center, two-arm, post-hoc analysis of the REM-IICTJP01 study investigated the efficacy and safety of remimazolam for gastrointestinal endoscopic sedation. We enrolled 40 and 208 patients who underwent colonoscopy under remimazolam and midazolam sedation, respectively, during the same period. The primary outcome was the time from the end of the colonoscopy until discharge. The secondary outcomes included the time from the end of the colonoscopy until awakening, dosage, and adverse events. Propensity score matching was employed to eliminate the effect of confounding factors. Results: Thirty-seven patients in each group were matched. After propensity matching, the time to awakening after colonoscopy was 28.0 (13.0-37.0) min in the midazolam group and 0 (0-0) min in the remimazolam group; moreover, the time till discharge was 40.0 (35.0-46.5) min in the midazolam group and 0 (0-5.0) min in the remimazolam group, both of which were significantly shorter in the remimazolam group (p < 0.01). The number of additional doses was 0 (0-0) and 2 (1-3) in the midazolam and remimazolam groups, respectively. The total dose was 2.0 (2.0-3.5) and 6.0 (5.0-7.0) mg in the midazolam and remimazolam groups, respectively. Conclusions: Remimazolam yielded significantly faster times to awakening and discharge safely compared to midazolam.

Sedative effects of propofol and risk factors for excessive sedation in the endoscopic treatment of biliary and pancreatic diseases.

Objectives: The safety and effectiveness of propofol in more complex endoscopic procedures, such as endoscopic retrograde cholangiopancreatography, remain unknown. Thus, we aimed to evaluate propofol sedation during endoscopic cholangiopancreatography, ultrasound-guided intervention, and gastroduodenal stenting and examine risk factors for excessive sedation. Methods: We retrospectively analyzed data from 870 patients who underwent endoscopic treatment with propofol sedation for biliary and pancreatic disease between October 2020 and September 2021. Sedation included propofol and fentanyl, with continuous monitoring of vital signs and the bispectral index. The assessed risk factors included age, complications, body mass index, treatment duration, and specialty. Results: Distal bile duct treatment (n = 367), hilar bile duct treatment (n = 197), post-small-intestinal reconstruction treatment (n = 75), endoscopic ultrasound-guided intervention (n = 140), and gastrointestinal obstruction treatment (n = 91) were performed. The rates of excessive sedation, hypoxemia, and hypotension were 7.8%, 6.0%, and 1.8%, respectively. Post-small-intestinal reconstruction treatment had the highest incidence rate of excessive sedation (16%), whereas endoscopic ultrasound-guided intervention had the lowest incidence rate (4.3%). Multivariate analysis revealed significant associations between excessive sedation and comorbid sleep apnea, obesity, and prolonged procedural time. Conclusions: Obesity, sleep apnea syndrome, and prolonged procedure time are risk factors for excessive sedation related to propofol use. Thus, sedation techniques should be tailored for these patients.

Manifestaciones clínicas post supresión de sedoanalgesia en pacientes adultos de una terapia intensiva / Clinical manifestations after suppression of sedoanalgesia in adult patients in intensive care

Introducción: en la unidad de cuidados intensivos (UCI), las personas asistidas con patologías relevantes se encuentran bajo sedación, una vez que estas se encuentran bajo los principios de supresión de la sedación, es importante identificar cuáles son las manifestaciones que presentan, propias de las sedaciones. Objetivo: describir las manifestaciones clínicas del síndrome de supresión de la sedoanalgesia presentes en pacientes asistidos en un Hospital Público de la Ciudad de Corrientes de enero a diciembre del 2022. Metodología: estudio cuantitativo, descriptivo, transversal y observacional. La muestra incluyó pacientes adultos de UCI. El cálculo del tamaño muestral se realizó a través del método probabilístico aleatorio simple resultando de éste una muestra de 100 historias clínicas. Para la recolección de datos se utilizó la observación y como instrumento un formulario semiestructurado, de carácter anónimo. Cada formulario contenía datos específicos donde se categorizan las variables en estudio como ser edad, sexo, comorbilidades, tiempo de sedoanalgesia, tipo de sedación, sedoanalgesia utilizada, agitación, confusión, alucinación, diaforesis, taquicardia. Resultados: en cuanto a la edad se obtuvo un promedio de 49 años, el sexo predominante fue el masculino con 52%, en cuanto a las comorbilidades más frecuentes, el 20% presentó Insuficiencia Respiratoria Aguda y el 16% Insuficiencia renal. El motivo de ingreso a UCI en mayor medida con el 33% fue por dificultad respiratoria y Post Quirúrgicos complicados 32%. Los fármacos de mayor elección fueron midazolam 94%, seguido del fentanilo 80%. En cuanto al tiempo de sedación de los pacientes, se encontró una media de 1265 horas. Las manifestaciones clínicas que se observaron en la muestra en mayor medida corresponden a taquicardia 70%, agitación 52%, un 37% confusión e hipertensión y un 24% alucinación. Conclusión: las manifestaciones que se presentaron con mayor frecuencia fueron taquicardia, agitación, confusión, hipertensión y con menor frecuencia alucinación[AU]

Introduction: in the intensive care unit (ICU), people treated with relevant pathologies are under sedation. Once they are under the principles of sedation suppression, it is important to identify the manifestations they present, typical of sedations. Objective: To describe the clinical manifestations of sedation suppression syndrome present in patients treated at a Public Hospital in the City of Corrientes from January to December 2022. Methodology: quantitative, descriptive, cross-sectional and observational study. The sample included adult ICU patients. The calculation of the sample size was carried out through the simple random probabilistic method, resulting in a sample of 100 medical records. Manifestaciones clínicas post supresión de sedoanalgesia en pacientes adultos de una terapia intensiva. Observation was used to collect data and a semi-structured, anonymous form was used as an instrument. Each form contained specific data where the variables under study were categorized, such as age, sex, comorbidities, sedation time, type of sedation, sedation used, agitation, confusion, hallucination, diaphoresis, tachycardia. Results: regarding age, an average of 49 years was obtained, the predominant sex was male with 52%, regarding the most frequent comorbidities, 20% presented Acute Respiratory Failure and 16% Renal failure. The reason for admission to the ICU to a greater extent with 33% was due to respiratory difficulty and complicated Post-Surgeries 32%. The drugs of greatest choice were midazolam 94%, followed by fentanyl 80%. Regarding the sedation time of the patients, an average of 1265 hours was found. The clinical manifestations that were observed in the sample to a greater extent correspond to tachycardia 70%, agitation 52%, confusion and hypertension 37% and hallucination 24%. Conclusion: the manifestations that occurred most frequently were tachycardia, agitation, confusion, hypertension and, less frequently, hallucination[AU]

Introdução: na unidade de terapia intensiva (UTI), as pessoas tratadas com patologias relevantes estão sob sedação. Uma vez sob os princípios da supressão da sedação, é importante identificar as manifestações que apresentam, típicas das sedações. Objetivo: Descrever as manifestações clínicas da síndrome de supressão da sedação presentes em pacientes atendidos em um Hospital Público da Cidade de Corrientes no período de janeiro a dezembro de 2022. Metodologia: estudo quantitativo, descritivo, transversal e observacional. A amostra incluiu pacientes adultos internados em UTI. O cálculo do tamanho amostral foi realizado pelo método probabilístico aleatório simples, resultando em uma amostra de 100 prontuários. A observação foi utilizada para a coleta de dados e um formulário semiestruturado e anônimo foi utilizado como instrumento. Cada formulário continha dados específicos onde foram categorizadas as variáveis em estudo, como idade, sexo, comorbidades, tempo de sedação, tipo de sedação, sedação utilizada, agitação, confusão, alucinação, sudorese, taquicardia. Resultados: em relação à idade obteve-se uma média de 49 anos, o sexo predominante foi o masculino com 52%, quanto às comorbidades mais frequentes, 20% apresentavam Insuficiência Respiratória Aguda e 16% Insuficiência Renal. O motivo de internação na UTI em maior proporção com 33% foi por dificuldade respiratória e pós-cirúrgicos complicados 32%. Os medicamentos de maior escolha foram midazolam 94%, seguido de fentanil 80%. Quanto ao tempo de sedação dos pacientes, foi encontrada uma média de 1265 horas. As manifestações clínicas mais observadas na amostra correspondem a taquicardia 70%, agitação 52%, confusão e hipertensão 37% e alucinação 24%. Conclusão: as manifestações que ocorreram com maior frequência foram taquicardia, agitação, confusão, hipertensão e, menos frequentemente, alucinação[AU]

SAFE: Safety of procedural sedation and analgesia administration in the fast-track area of the emergency department.

OBJECTIVE: To determine whether undertaking procedural sedation in the low-acuity fast-track area is safe and effective in improving patient flow. METHODS: A retrospective cohort study reviewed patients who underwent procedural sedation in the Royal Brisbane and Women's Hospital Emergency and Trauma Centre between December 2020 and December 2021. RESULTS: A total of 411 cases were included. Performing sedation in the fast-track area was not associated with increased complication rates but was associated with reduced time to sedation (difference = 44.24 min, P < 0.001) and length of stay (difference = 60.64 min, P < 0.01). CONCLUSION: The sedation of patients outside a high-acuity area is safe and significantly improves patient flow.

Efficacy and safety of ciprofol versus propofol for induction of general anaesthesia or sedation: A systematic review and meta-analysis of randomised controlled trials.

Background and Aims: Propofol has been used in medical practice as an anaesthetic drug for producing and sustaining general anaesthesia due to its advantages. However, it also has drawbacks, including injection-related discomfort. Recently, ciprofol has emerged as a promising anaesthetic drug that may overcome many drawbacks associated with propofol. In this systematic review and meta-analysis, we assess the efficacy and safety of ciprofol compared to propofol in different anaesthesia procedures. Methods: The study protocol was registered in the International Prospective Register of Systematic Reviews (ID: CRD42023458170). Central, PubMed, EMBASE, Scopus and WOS were searched for English literature until 26 February 2024. Meta-analysis was performed using RevMan. The risk of bias was assessed using the RoB 2.0 tool. Results were reported as risk ratios (RRs), mean differences (MDs) and 95% confidence intervals (CIs). Results: Nineteen randomised controlled trials were included in our analysis, with 2841 participants. There was no difference between ciprofol and propofol in the success rate of endoscopy (RR: 1.01, 95% CI: 0.99, 1.02; P = 0.44), while ciprofol showed a significant increase in the success rate of general anaesthesia/sedation (RR: 1.01, 95% CI: 1.00, 1.02; P = 0.04). Ciprofol showed significantly lower pain on injection (RR: 0.14, 95% CI: 0.09, 0.22; P < 0.001), lower adverse events (RR: 0.80, 95% CI: 0.69, 0.92; P = 0.002) and higher patient satisfaction (standardised mean difference (SMD): 0.36, 95% CI: 0.24, 0.48; P < 0.001). Conclusion: Ciprofol exhibited a comparable efficacy to propofol in inducing general anaesthesia and sedation with fewer adverse events, less pain on injection and higher patient satisfaction. These collective findings may suggest that ciprofol can be used as an alternative drug to ensure effective general anaesthesia/sedation induction in the future.

Comparison of hypotension between propofol and remimazolam-propofol combinations sedation for day-surgery hysteroscopy: a prospective, randomized, controlled trial.

BACKGROUND: A combination of remimazolam and propofol could produce more stable sedation. A good medication regimen should consider not only efficacy but also safety, especially hypotension. The aim of the current study was to compare the incidence and amount of hypotension by propofol versus remimazolam-propofol combinations in day-surgery hysteroscopy. METHODS: Patients were randomly assigned to receive either propofol (Group P, n = 125) or remimazolam-propofol combinations (Group RP, n = 125) at a 1:1 ratio. Intravenous injection of sufentanil 0.1ug/kg were administered before sedative medication. In group P, a bolus of 2.5 mg/kg propofol was administered. In group RP, intravenous anesthesia was commenced with 0.125 mg/kg remimazolam and 1 mg/kg propofol. After loss of consciousness, propofol was maintained at 6 mg/kg/h. The primary outcomes were the incidence and amount of hypotension during surgery. Hypotension was defined as a MAP less than 65mmHg for at least 1 min. The amount of hypotension was assessed by time-weighted average intraoperative MAP under a threshold of 65 mmHg. The secondary outcomes were various anesthesia related parameters and some adverse events. RESULTS: In group P, 25 patients (20.0%) experienced hypotension during hysteroscopy compared with 9 patients (7.2%) in group RP, for a difference of 12.8% (RR 2.778, 95%CI [1.352-5.709]). The combination of remimazolam and propofol resulted in significantly lower TWA (Time Weighted Average) threshold 0.14 (0.10-0.56) mmHg in group RP compared to 0.31 (0.15-0.67) mmHg in group P. The total dose of propofol was nearly double in group P compared to group RP. A significantly higher frequency of injection pain and low oxygen saturation was observed in the group P than that of the group RP. Hiccup was observed only in group RP. The incidences of body movement, bradycardia and vomiting were no significant difference between groups. CONCLUSION: The incidence and amount of hypotension by remimazolam-propofol combinations was significantly less than that by propofol sedation in day-surgery hysteroscopy. The optimization of medication regimen would attenuate the harm of hypotension and contribute to patients' rapid recovery in day surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2400079888 (date: 15/01/2024).

Comparative Analysis of Intrathecal Bupivacaine With Fentanyl Versus Intrathecal Bupivacaine With Midazolam in Lower Abdominal and Lower Limb Surgeries.

Many different adjuvants are added intrathecally along with local anaesthetics to prolong intraoperative and postoperative analgesia. Hence, this study aimed to compare intrathecal bupivacaine with fentanyl and bupivacaine with midazolam in lower abdominal and lower limb surgeries. Following permission from the Hospital Ethical Committee (Research Protocol No.: IESC/PGS/2022/143), the study was conducted on a sample of 60 patients, divided into two groups, Group F and Group M, with 30 patients each, representing the American Society of Anaesthesiologist's (ASA) grades I and II. The patients were between the ages of 18 and 60 and featured both males and females, scheduled to undergo elective surgical procedures on the lower abdomen and lower limbs via spinal anaesthesia. Group "F": 3 ml of 0.5% hyperbaric bupivacaine hydrochloride with 0.5 ml (25 mcg) of fentanyl (preservative-free) intrathecally. Group "M": 3 ml of 0.5% hyperbaric bupivacaine hydrochloride with 0.5 ml (2.5 mg) of midazolam (preservative-free) intrathecally. The primary aim was to study the onset of motor and sensory block and duration of analgesia with the addition of midazolam or fentanyl to 0.5% heavy bupivacaine in the sub-arachnoid block. A secondary aim was to evaluate the quality of anaesthesia and postoperative analgesia, determine the haemodynamic stability in the intraoperative and postoperative period in the two study groups, and observe any adverse effects of study drugs. Group F exhibited a substantially longer duration for both sensory (211.5 vs. 154.4 min) and motor blockade (269.8 vs. 214.6 min) compared to Group M, as well as a rapid onset time for both sensory (2.6 vs. 3.3 min) and motor blockade (3.1 vs. 3.9 min). Also, Group F had a significantly longer duration of effective analgesia compared to Group M (266 ± 15.9 vs. 197.6 ± 13.7 minutes). The addition of 0.5 ml (2.5 mg) Midazolam with 0.5% hyperbaric Bupivacaine intrathecally prolonged the duration of anaesthesia and postoperative analgesia; however, fentanyl 0.5 ml (25 mcg) has a more prolonged duration of intraoperative and postoperative analgesia.

Association between pre-procedural anxiety and vomiting in children who undergo procedural sedation and analgesia in the emergency department.

INTRODUCTION: Children presenting to the emergency department (ED) often require procedural sedation and analgesia (PSA) prior to procedures. Although ketamine is used widely for PSA safely, there is a risk of adverse effects. Among them, vomiting is significant as it occurs in about 10% of patients and can potentially endanger the airway. Because there is evidence that post-operative complications might be due to anxiety prior to the operation, this study aims to investigate the association between pre-procedural anxiety and vomiting in the ED. METHODS: In this cohort study, a convenient sample of children aged 2 to 14 years who were a candidate for PSA with ketamine in the ED were enrolled. Anxiety was evaluated using the short version of the modified Yale preoperative anxiety scale (mYAS). Vomiting was recorded during the period of hospitalization in the ED and 24 h after discharge by a phone call. Association between anxiety level and vomiting was analyzed using the independent samples t-test and multivariable logistic regression was used to control for covariates. RESULTS: 102 children were enrolled and 93 were included in final analysis. The mean age of participants was 3.95 ± 1.79 years and 55.9% were male. According to the mYAS, the mean score of anxiety was 48.67 ± 21.78 in the waiting room and 59.10 ± 23.86 in the operating room. The mean score of anxiety was 58.3±25.3 and 51.0±20.7 in the vomiting and non-vomiting groups, respectively. At least one episode of vomiting was reported in 23 children of which, 19 took place in the hospital and 4 after discharge. No significant association was observed between pre-procedural anxiety and the occurrence of vomiting. On univariate regression model, the odds ratio of the association between mean anxiety and vomiting was 1.02 (CI 95%: 0.99-1.04) (P-value: 0.16). On the multivariable logistic regression model, after adjusting for all the covariates, the odds ratio was 1.03 (CI 95%: 1.0-1.05) (P-value: 0.05). CONCLUSION: The present study showed that anxiety before procedural sedation and analgesia with ketamine in children was not associated with the incidence of vomiting.

Family-Led Coaching of Patients During Weaning From Sedation and Mechanical Ventilation in the ICU.

BACKGROUND: ICU patients are weaned from sedation and mechanical ventilation through spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). Weaning can be distressing for patients and their families. Family-led coaching could reassure patients and reduce stress for families by engaging them in patient care. This study developed and piloted a family-led coaching tool to support patients undergoing SATs/SBTs. METHODS: Patient and family member dyads were recruited from 2 medical-surgical ICUs in Calgary, Canada (February 3-August 1, 2023). Surveys were administered to collect family (1) demographics, (2) anxiety and satisfaction with ICU care, (3) feedback on the tool, and (4) attitudes about family presence during SATs/SBTs (also collected from clinicians). Tool feasibility was determined by calculating the proportions of (1) eligible patients who were recommended for participation in the study by clinicians and (2) families approached who consented to participate in the study. RESULTS: One thousand one hundred fifty patients were admitted to the study ICUs during the study period of which 819 received mechanical ventilation, and 42 were recommended by bedside clinicians for participation in the study. Twenty-five dyads were approached, 21 dyads consented to participate, and one withdrew consent before data collection. Of the enrolled families, 12 (60%) reported the coaching tool to be useful, and 5 (25%) recommended minor suggestions such as "shortening" the tool. Fourteen (70%) families reported positive experiences (through open-ended feedback) with being present for the SAT/SBT. State-Trait Anxiety Inventory (Y1) scores (scale range 20-80 points) significantly decreased in families from the first (pre coaching) to the second (post coaching) measures (mean decrease 8.2 points, SD 10.3, P = .001). All clinicians indicated they were comfortable with family presence and/or coaching during SATs/SBTs. CONCLUSION: Family-led coaching of patients during SATs/SBTs appears to be feasible, favorably perceived by families and clinicians, and potentially associated with lower family anxiety.

Evaluation of Dexmedetomidine Withdrawal and Management After Prolonged Infusion.

PURPOSE: Dexmedetomidine is often used for longer than its labeled indication of 24 hours, raising concerns for potential withdrawal. Data are limited regarding this syndrome in adult patients. This study aimed to further characterize dexmedetomidine withdrawal in critically ill adult patients after prolonged use. METHODS: This was an institutional review board-approved, single-center, retrospective chart review conducted at a tertiary academic medical center. Adult intensive care unit (ICU) patients on dexmedetomidine for ≥72 hours in 2019 were screened for inclusion. Exclusion criteria were interruption of dexmedetomidine for >6 hours, indications for dexmedetomidine other than sedation, or patients with neurological or burn injury. The major end point was the incidence of dexmedetomidine withdrawal, defined as meeting ≥2 of the following criteria within 24 hours of discontinuation: newly positive Confusion Assessment Method for ICU, Richmond Agitation Sedation Scale score of ≥+2, hypertension, and tachycardia. Minor end points were incidence of individual withdrawal signs as previously described, additional sedatives or antipsychotics required, dose and duration of dexmedetomidine infusion, length of ventilation, ICU and hospital length of stay, and new onset of the following: fever, vomiting, loose stools/diarrhea, diaphoresis, or seizure. FINDINGS: Of the 152 patients included, dexmedetomidine withdrawal occurred in 54 patients (35.5%). Rebound hypertension was the most common withdrawal sign (47 patients [87.0%]). In the withdrawal group, significantly more patients required additional ß-blockers (29 [53.7%] vs 10 [10.2%]; P < 0.01), were reinitiated on dexmedetomidine (16 [29.6%] vs 10 [10.2%]; P < 0.01), and required a start or increased dose of clonidine (6 [11.1%] vs 3 [3.1%]; P = 0.04). There was no significant difference in the cumulative dose or duration of dexmedetomidine between the groups. Length of ventilation was longer in the withdrawal group (171 hours [83.7-280.8 hours] vs 159 hours [149.0-335.7 hours]; P < 0.01), but there was no difference in ICU or hospital length of stay. IMPLICATIONS: Prolonged use of dexmedetomidine was associated with withdrawal syndrome in 35.5% of patients in our study. Larger trials are needed to confirm the risk factors for dexmedetomidine withdrawal and identify measures to prevent withdrawal.

Comparative Evaluation of Oral and Intranasal Administration of Midazolam as Preanesthetic Medication in Pediatric Dental Patients Treated under General Anesthesia.

Aims and background: Midazolam is commonly used as a preanesthetic medication for behavior management of children. The current study is conducted to find out the effect of midazolam through nasal and oral routes as a premedicament in pediatric patients treated under general anesthesia. The main aims of the study were: to compare the effect of oral syrup and intranasal spray as preanesthetic medication; to record the undesirable side effects of midazolam by both routes. Materials and methods: The patients aged 2-6 years of either sex were randomly divided into two equal groups of 30 each-group I: oral; group II: intranasal. Results: The oral and intranasal routes of midazolam were found to be equally effective and provided adequate sedation for easy separation from the parents and cooperation from children during the induction of anesthesia with minimal side effects. Conclusion: Based on the study results, we can conclude that both oral and intranasal midazolam can be used as preanesthetic medication for pediatric dental patients treated under general anesthesia. Clinical significance: In pediatric patients, the oral route should be preferred for midazolam premedication in comparison to the intranasal route. How to cite this article: Swati, Shah RK, Tandon S, et al. Comparative Evaluation of Oral and Intranasal Administration of Midazolam as Preanesthetic Medication in Pediatric Dental Patients Treated under General Anesthesia. Int J Clin Pediatr Dent 2024;17(8):881-886.

Scoping review finds insufficient evidence on potential risks of procedural sedation with dexmedetomidine in children.

AIM: Dexmedetomidine is commonly used in hospitals for sedation during procedurals. It has been considered safe even though studies have shown that it may cause bradycardia and hypotension. The aim of this study was to map the current evidence regarding potential risks of sedation of children with dexmedetomidine. METHODS: Two database searches were conducted to gather all articles published through 30 January 2024 that matched the inclusion criteria. PubMed and Embase were chosen for the initial search. Search terms were chosen to create a broad systematic search that would include articles reporting adverse events during procedural sedation on children. From the included articles, data on type of sedation, administration, patient characteristics, endpoints and number of adverse events were collected. RESULTS: After the initial search, 357 individual papers were screened and 41 papers were included. The most common adverse event reported was bradycardia. In almost 40% of the articles that measured oxygen saturation, one or more incidents of desaturation occurred. 27% reported that interventions to prevent further harm were preformed, most of the interventions were to improve oxygenation. CONCLUSION: There is a need for further investigation regarding adverse events, especially respiratory adverse events during sedation with dexmedetomidine.

Comparison of remimazolam and midazolam for preventing intraoperative nausea and vomiting during cesarean section under spinal anesthesia: a randomized controlled trial.

Background: Preventing intraoperative nausea and vomiting (IONV) is crucial for maternal safety during cesarean section under spinal anesthesia. While midazolam is known to prevent IONV, we hypothesized that remimazolam would be superior due to its minimal hemodynamic effects. We compared the effects of the two drugs on IONV. Methods: Parturients scheduled for cesarean section were randomly assigned to receive either midazolam or remimazolam. They received midazolam 2 mg or remimazolam 5 mg, with additional doses administered upon request. The primary outcome measure was the incidence of newly developed IONV during sedation. Other outcomes included overall IONV, rescue antiemetic use, shivering, hemodynamic variables, sedation scale scores, and satisfaction scores. Results: Data from 80 participants were analyzed. Deeper sedation was induced in the remimazolam group (PGroup × Time < 0.001) despite comparable hemodynamic trends between the groups. The incidence of overall IONV was comparable between the two groups (27.5% in the midazolam group vs. 17.5% in the remimazolam group, absolute risk reduction [ARR]: 0.100, 95% confidence interval [CI] [-0.082, 0.282], P = 0.284); however, newly developed IONV during sedation was significantly reduced in the remimazolam group (20.0% vs. 5.0%, ARR: 0.150, 95% CI [0.009, 0.291], P = 0.043). The need for rescue antiemetics was also lower in the remimazolam group (15.0% vs. 2.5%, ARR: 0.125, 95% CI [0.004, 0.246], P = 0.048). Conclusion: Remimazolam significantly reduced the incidence and severity of newly developed IONV compared with midazolam, with minimal impact on hemodynamics, making it a useful sedative option for cesarean section.

Impact of the mother's voice on sedation need and stress during cardiologic examination of children (SMUSS study): a prospective, interventional, randomised, controlled, monocentric study.

INTRODUCTION: Cardiac catheterisation is crucial for diagnosing and treating paediatric heart diseases, but it is poorly tolerated by small children, infants, and newborns without sedation. This study investigated whether maternal voice during sedation could lower stress and pain in children undergoing cardiac catheterisation and also assessed mothers' stress levels before and after the procedure. METHODS: This was a prospective, monocentric, randomised, controlled interventional study at the University Hospital Bonn. Children aged 4 years or younger scheduled for elective cardiac catheterisation under procedural sedation and American Society of Anaesthesiologists class between 1 and 3 were eligible. RESULTS: At the end of cardiac catheterisation, the intervention group showed a higher Newborn Infant Parasympathetic Evaluation index with an adjusted mean difference of 9.5 (± 4.2) (p = 0.026) and a lower median Children's and Infants Postoperative Pain Scale score of 2.0 (IQR: 0.0-5.0) versus 4.5 (IQR: 3.0-6.0) than the control group (p = 0.027). No difference in the children's cortisol level was found (p = 0.424). The mothers in the intervention group had a lower cortisol level than those in the control group before cardiac catheterisation (adjusted mean difference: -4.5 nmol/l (± 1.8 nmol/l), p = 0.011). CONCLUSION: Listening to the maternal voice during cardiac catheterisation could lead to less postoperative pain and significantly lower stress and discomfort level in children. Less pain could reduce the incidence of postoperative delirium.Additionally, mothers perceived involvement as positive. A reduced stress level of mothers can positively influence children and possibly reduce pain and anxiety.

Awake microsurgical management of brain aneurysms: a comprehensive systematic review and meta-analysis on rationale, safety and clinical outcomes.

INTRODUCTION: Awake microsurgery for brain aneurysm treatment has emerged as a tool for real-time intraoperative monitoring, opportune detection of ischemic complications, and reduction of surgical morbidity. Herein, we aimed to explore the current state of the procedure's rationale, safety and clinical outcomes. METHODS: In accordance with PRISMA guidelines, five databases were queried for articles reporting awake microsurgical management of brain aneurysms. Aggregate study results were combined using random-effects meta-analyses. Publication bias was evaluated through funnel plot analysis and Egger's regression test. RESULTS: Out of 847 articles, 11 records satisfied the inclusion criteria. Seventy-five patients (68% female) with 75 brain aneurysms (68% unruptured) were analyzed. Clipping was the predominant technique (58%), followed by bypass (17%). Monitored anesthesia care was the principal anesthesia protocol (60%). The incidence of anesthesia-related complications was 1% [95%CI, 0.00-0.05, I2 = 19%], and the conversion rate from an awake-induced anesthesia protocol to general anesthesia was 1% [95%CI, 0.00-0.05, I2 = 0%]. No permanent anesthesia-related morbidity and mortality was reported. Complete aneurysm repair, occlusion and bypass patency rate was 100% [95%CI, 0.96-1.00, I2 = 0%]. The transient postoperative symptomatic event rate was 34% [95%CI, 0.06-0.81, I2 = 77%]. The overall morbidity rate was 4% [95%CI, 0.00-0.09, I2 = 0%], and the overall mortality rate was 0% [95%CI, 0.00-0.03, I2 = 0%]. CONCLUSION: Awake microsurgery of brain aneurysms is feasible, yet current evidence stems from observational studies. This procedure can reduce surgical morbidity by providing accurate and real-time neurological monitoring during aneurysm repair. While this technique appears to be tolerated, higher level evidence is needed to evaluate judiciously its safety and preference over existing practices for intraoperative neurological monitoring.

Transient bradycardia during local anaesthesia to the oral cavity under intravenous sedation and its associate factors: a prospective observational study.

BACKGROUND: Local anaesthesia in dental procedures is generally safe, although the occurrence of transient bradycardia (TB) has occasionally been reported. TB is often associated with two reflexes, the trigeminal cardiac reflex (TCR) and the vasovagal reflex (VVR) and is characterised by a rapid decrease in heart rate (HR) and blood pressure (BP). The prevalence of TCR is considered low, and its predictors have not been thoroughly investigated, although an association with the gag reflex has been suggested in recent years. METHODS: This prospective study assessed TB occurrence during local anaesthesia and its potential associated factors. A comprehensive questionnaire was used to categorise discomforts during dental treatment, and various anxiety scales were used to measure patients' anxiety levels. We investigated HR variability during local anaesthesia administration under sedation and the association between the incidence of TB and gag reflex. Subsequently, logistic regression analysis was performed to assess factors associated with TB occurrence. RESULTS: The prospective analysis included 188 patients of 234 initial patients. The analysis revealed a high TB incidence rate of 41% during local anaesthesia administration under sedation. No severe hypotensive events occurred, indicating a relatively benign nature of TB during local anaesthesia. TB occurrence was significantly higher in the group of patients with the gag reflex. Further analysis revealed that both gag reflex and trait anxiety were significantly associated with TB occurrence, whereas dental phobia did not directly correlate with TB. CONCLUSION: This study highlights the prominent occurrence of TB during local anaesthesia in dental treatment, which is primarily attributed to TCR activation. The identification of gag reflex and trait anxiety as independent factors associated with TB development may pave the way for TB prevention measures. Further research is required to clarify the mechanisms of TCR and perform safer dental procedures under sedation. Future studies should also aim to elucidate the precise mechanisms underlying TB during local anaesthesia through direct measurements of neural activity. A better understanding of TB in dentistry is crucial for improving patient safety and optimising dental practice protocols.

Efficacy of Rectal Versus Oral Chloral Hydrate in Pediatric Auditory Brainstem Response: Randomized Controlled Trial.

Objective: To compare sedation success rates between rectal (RCH) and oral chloral hydrate (OCH) administration in children undergoing auditory brainstem response (ABR) testing and assess the incidence of adverse effects. Study Design: Randomized controlled trial, performed between May 2023 and August 2023. Setting: Ear, Nose, and Throat Outpatient Department at tertiary care hospital. Methods: Pediatric patients aged 1 to 5 years, who were indicated for ABR testing were enrolled and randomly divided into 2 groups. The control group received 10% wt/vol chloral hydrate orally at a dose of 50 mg/kg, while the other group received the same dose through rectal administration. Onset of sedation, duration of sedation, recovery time, vital signs, and adverse effects were recorded and analyzed to assess sedative effectiveness and safety. Results: Eighty-eight children were randomly assigned to RCH or OCH administration groups, the sedation success rates of RCH and OCH groups were 84.09% and 90.91%, respectively (P = .33). Adverse effects were detected in 11 children (12.5%), with a vomiting rate of 20.45% in the oral group versus 0% in the rectal group (P = .002). The diarrhea rate was 4.55% in the rectal group versus 0% in the oral group (P = .16). In either group, no serious adverse effects were documented. Conclusion: RCH and OCH are both safe and effective for short-term sedation in pediatric patients during ABR testing. Interestingly, RCH administration offers a high success rate without vomiting or major adverse effects. This study established the effectiveness of RCH for sedation in children under specialized supervision.