Anesthesia, Sedation, and Pain Management of Donkeys and Mules

The number of donkeys in the world may not be increasing but awareness of their use and concern for welfare and pain recognition and treatment are receiving increasing veterinary interest. Therefore, accurate information about anesthesia and analgesia in donkeys and mules is important to more equine practitioners. This review highlights the current knowledge on various anesthetic and analgesic approaches in donkey and mules. The authors emphasize that there is still much information that is not available about donkeys and mules; in many circumstances, the clinician must use available equine information to treat the patient, while monitoring for differences in response.

Propofol Formulation Affects Myocardial Function in Newborn Infants

This study aimed to evaluate the effects of propofol in diluted and undiluted formulations on cardiac function in infants. Infants > 30 days received propofol sedation for central line insertion. Cases were divided into two groups: those who received undiluted 1% propofol (P1%); and those who received a diluted formulation (Pd) of equal volumes propofol 1% and 0.9% NaCl. Echocardiograms were performed pre (t₀)-, immediately post (t₁)-, and 1-h post (t₂) propofol administration. Myocardial deformation was assessed with tissue Doppler imaging (TDI) analysis and peak longitudinal strain (LS). 18 cases were included: nine (50%) P1% and nine (50%) Pd. In the P1% group, TDI velocities and LS were significantly reduced at t₁ and t₂. In the Pd Group, only TDI velocities in the left ventricle were reduced at t₁, but not at t₂. Dilution of propofol may minimize myocardial dysfunction while maintaining adequate sedation in infants. Further comparative studies are needed to investigate the safety and efficacy of this approach.

Dexmedetomidine as adjunctive therapy for the treatment of alcohol withdrawal syndrome: a systematic review protocol

OBJECTIVE

The purpose of this review is to evaluate the effectiveness and safety of dexmedetomidine as adjunctive therapy to the standard of care (benzodiazepines) compared to either the standard of care or other adjunctive treatment approaches (e.g. benzodiazepines plus propofol) for the treatment of alcohol withdrawal syndrome (AWS).

INTRODUCTION

Benzodiazepines have been the cornerstone of AWS therapy, but in some patients, AWS is refractory to high doses. Moreover, benzodiazepine use is burdened by excessive sedation, confusion and respiratory depression. Options for management of refractory AWS include the addition of phenobarbital, propofol and, more recently, dexmedetomidine to benzodiazepines therapy. The possible advantage of dexmedetomidine compared to benzodiazepines is that it does not cause respiratory depression, thus reducing the risk of intubation and hospitalization in the intensive care unit.

INCLUSION CRITERIA

This review will consider studies including patients who are 18 years or older and are diagnosed with AWS. The exclusion criteria are a history of psychoactive substances or withdrawal states and/or severe neurologic disorder (e.g. traumatic brain injury, acute stroke, severe dementia, seizure disorder).

METHODS

This review will include only studies published in English, with no restrictions on the year of publication. Both randomized controlled trials and observational studies (including cohort and case-control studies) assessing the drug effectiveness and safety will be included. The databases utilized will include: PubMed, Embase and Cochrane Central Register of Controlled Trials. In addition, the trial registers to be searched will include: World Health Organization International Clinical Trials Registry Platform (ICTRP), U.S. National Library of Medicine Drug Information Portal and ClinicalTrials.gov.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084370.

History of regular nonmedical sedative and/or alcohol use differentiates substance-use patterns and consequences among chronic heroin users

BACKGROUND

Concurrent use of sedating substances (e.g. alcohol or benzodiazepines) with opioids is associated with increased negative consequences of opioid use; however, few studies have attempted to differentiate effects of using sedating substances on heroin-use outcomes. This study examines differences between heroin users who use alcohol or misuse sedatives regularly and those who do not.

METHODS

Substance-use data were collected from 367 non-treatment seeking, chronic heroin-using, 18-to-55 year-old participants. We created 4 groups based on self-reported lifetime history of regular (at least weekly) substance use: heroin only (n = 95), heroin and sedatives (n = 21), heroin and alcohol (n = 151), and heroin, sedative, and alcohol (n = 100). Chi-square analyses and ANOVAs with Bonferroni post hoc tests were used to explore differences between these groups.

RESULTS

Heroin users who denied lifetime alcohol or nonmedical sedative use regularly endorsed fewer consequences associated with any substance they had used. Total adverse consequences of heroin use (e.g. health problems) were significantly higher among those who misused sedatives regularly, irrespective of alcohol use history (F(3,361) = 10.21; p < .001). Regular alcohol use did not independently impact heroin consequences but was associated with increased use of other substances.

CONCLUSIONS

Although polysubstance use is normative among heroin users, the risks depend on the substances used. Regular sedative use is associated with increased heroin consequences whereas regular alcohol use is not. This study refines the investigation of polysubstance use and highlights subgroup differences depending on types of substances used regularly. This knowledge is critical for understanding substance-use motivations and creating avenues for harm reduction.

A Point Process Characterization Of Electrodermal Activity

Electrodermal activity (EDA) is a measure of sympathetic activity using skin conductance that has applications in research and in clinical medicine. However, current EDA analysis does not have physiologically-based statistical models that use stochastic structure to provide nuanced insight into autonomic dynamics. Therefore, in this study, we analyzed the data of two healthy volunteers under controlled propofol sedation. We identified a novel statistical model for EDA and used a point process framework to track instantaneous dynamics. Our results demonstrate for the first time that point process models rooted in physiology and built upon inherent statistical structure of EDA pulses have the potential to accurately track instantaneous dynamics in sympathetic tone.

Co-induction with a vasopressor "chaser" to mitigate propofol-induced hypotension when intubating critically ill/frail patients-A questionable practice

Prophylactic administration of a vasopressor to mitigate the hypotensive effect of propofol (and/or other co-induction agents) during sedation/anesthesia immediately prior to tracheal intubation in frail patients in the intensive care unit and emergency and operating rooms appears to be not an uncommon practice. We submit that this practice is unnecessary and potentially harmful. Despite restoring the blood pressure, phenylephrine, for instance, may have an additive or synergistic effect with propofol in reducing the cardiac output and, ultimately, organ perfusion. Airway instrumentation often leads to sympathetic activation and hypertension (thereby increasing myocardial oxygen consumption) which may be exacerbated by an arbitrary prophylactic dose of phenylephrine. Finally, in spite of the well-recognized need to reduce dosages of propofol in frail patients, excessive doses are commonly given, leading to hypotension. We herein discuss each of these points and suggest alternative techniques to promote a stable induction in frail patients.

Evidence-based clinical practice guidelines for the management of sedoanalgesia and delirium in critically ill adult patients

Given the importance of the management of sedation, analgesia and delirium in Intensive Care Units, and in order to update the previously published guidelines, a new clinical practice guide is presented, addressing the most relevant management and intervention aspects based on the recent literature. A group of 24 intensivists from 9 countries of the Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy met to develop the guidelines. Assessment of evidence quality and recommendations was made according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. A systematic search of the literature was carried out using MEDLINE, Cochrane Library databases such as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects, the National Health Service Economic Evaluation Database and the database of Latin American and Caribbean Literature in Health Sciences (LILACS). A total of 438 references were selected. After consensus, 47 strong recommendations with high and moderate quality evidence, 14 conditional recommendations with moderate quality evidence, and 65 conditional recommendations with low quality evidence were established. Finally, the importance of initial and multimodal pain management was underscored. Emphasis was placed on decreasing sedation levels and the use of deep sedation only in specific cases. The evidence and recommendations for the use of drugs such as dexmedetomidine, remifentanil, ketamine and others were incremented.

Impact of postoperative dexmedetomidine infusion on incidence of delirium in elderly patients undergoing major elective noncardiac surgery: a randomized clinical trial

PURPOSE

Postoperative delirium is a serious and common complication, it occurs in 13-50% of elderly patients after major surgery, and presages adverse outcomes. Emerging literature suggests that dexmedetomidine sedation in critical care units (intensive care unit) is associated with reduced incidence of delirium. However, few studies have investigated whether postoperative continuous infusion of dexmedetomidine could safely decrease the incidence of delirium in elderly patients admitted to general surgical wards after noncardiac surgery.

PATIENTS AND METHODS

This double-blind, randomized, placebo-controlled trial was conducted in patients aged 65 years or older undergoing major elective noncardiac surgery without a planned ICU stay. Eligible patients were randomly assigned to receive either dexmedetomidine (0.1 μg/kg/h) or placebo (0.9% normal saline) immediately after surgery though patient-controlled intravenous analgesia device. The primary outcome was the incidence of delirium during the first 5 postoperative days. Secondary outcomes included postoperative subjective pain scores and subjective sleep quality. The study dates were from January 2018 to January 2019.

RESULTS

A total of 557 patients were randomly assigned to receive either dexmedetomidine (n=281) or placebo (n=276). The incidence of postoperative delirium had no difference between the dexmedetomidine and placebo groups (11.7% [33 of 281] vs 13.8% [38 of 276], P=0.47). Compared with placebo group, patients in dexmedetomidine group reported significant lower numerical rating score pain scores at 3, 12, 24, and 48 hrs after surgery (all P<0.05) and significant improved Richards Campbell Sleep Questionnaire results during the first 3 postoperative days (all P<0.0001). Dexmedetomidine-related adverse events were similar between the two groups.

CONCLUSION

Postoperative continuous infusion of dexmedetomidine did not decrease the incidence of postoperative delirium in elderly patients admitted to general surgical wards after elective noncardiac surgery.

Regional entropy of functional imaging signals varies differently in sensory and cognitive systems during propofol-modulated loss and return of behavioral responsiveness

The level and richness of consciousness depend on information integration in the brain. Altered interregional functional interactions may indicate disrupted information integration during anesthetic-induced unconsciousness. How anesthetics modulate the amount of information in various brain regions has received less attention. Here, we propose a novel approach to quantify regional information content in the brain by the entropy of the principal components of regional blood oxygen-dependent imaging signals during graded propofol sedation. Fifteen healthy individuals underwent resting-state scans in wakeful baseline, light sedation (conscious), deep sedation (unconscious), and recovery (conscious). Light sedation characterized by lethargic behavioral responses was associated with global reduction of entropy in the brain. Deep sedation with completely suppressed overt responsiveness was associated with further reductions of entropy in sensory (primary and higher sensory plus orbital prefrontal cortices) but not high-order cognitive (dorsal and medial prefrontal, cingulate, parietotemporal cortices and hippocampal areas) systems. Upon recovery of responsiveness, entropy was restored in the sensory but not in high-order cognitive systems. These findings provide novel evidence for a reduction of information content of the brain as a potential systems-level mechanism of reduced consciousness during propofol anesthesia. The differential changes of entropy in the sensory and high-order cognitive systems associated with losing and regaining overt responsiveness are consistent with the notion of "disconnected consciousness", in which a complete sensory-motor disconnection from the environment occurs with preserved internal mentation.

Effects of dexmedetomidine vs sufentanil during percutaneous tracheostomy for traumatic brain injury patients: A prospective randomized controlled trial

BACKGROUND

Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients.

METHODS

The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), group D2 (n = 68, DEX infusion at 1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 μg·kg for 10 minutes, then adjusted to 0.2-0.4 μg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded.

RESULTS

Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ± 3.23 vs 12.42 ± 2.12 vs 13.88 ± 3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05).

CONCLUSIONS

During percutaneous tracheostomy, compared with sufentanil, DEX (1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.

A national survey on routines regarding sedation in Swedish intensive care units

Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey. Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc. Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation. Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.

Effects of recombinant canine interferon-γ injected before general anesthesia with propofol and isoflurane on natural killer cytotoxic activity during anesthesia in dogs

We aimed to determine whether subcutaneous injection of recombinant canine interferon-γ (rCaIFN-γ) 1h before general anesthesia with a combination of propofol and isoflurane (P-I) changes the cytotoxic activity of natural killer (NK) cells during anesthesia in dogs. Nine clinically healthy beagles were assigned to one of two groups: rCaIFN-γ-treated group (n=5) and control group (no treatment, n=4). One hour before P-I anesthesia, rCaIFN-γ was subcutaneously injected at a dose of 1×104U/kg body weight for the test group and physiologic saline was subcutaneously injected for the control group. Blood samples were collected 1h before P-I anesthesia (immediately before rCaIFN-γ injection) and 1 and 3h after anesthesia induction. NK cytotoxic activity was measured using the Rose Bengal assay, using canine thyroid adenocarcinoma cells as target cells. In the control group, NK cytotoxic activity decreased significantly over time (P<0.05). On the other hand, in the rCaIFN-γ group, the activity increased for the first hour after anesthesia induction without a significant difference from the level before anesthesia; furthermore, the activity at 3h after anesthesia induction was comparable with that before anesthesia. NK cytotoxic activity at 1 and 3h after anesthesia induction was significantly higher in the rCaIFNγ group than in the control group (P<0.05). Subcutaneous injection of rCaIFN-γ 1h before P-I general anesthesia not only maintained but also enhanced NK cytotoxic activity up to 3h after anesthesia induction in dogs. In conclusion, subcutaneous injection of rCaIFN-γ before cancer resection in cancer-bearing dogs might be effective for preventing intraoperative dissemination of cancer cells and postoperative cancer recurrence and metastasis.

Effects of vatinoxan on cardiorespiratory function, fecal output and plasma drug concentrations in horses anesthetized with isoflurane and infusion of medetomidine

A constant rate infusion (CRI) of medetomidine is used to balance equine inhalation anesthesia, but its cardiovascular side effects are a concern. This experimental crossover study aimed to evaluate the effects of vatinoxan (a peripheral α2-adrenoceptor antagonist) on cardiorespiratory and gastrointestinal function in anesthetized healthy horses. Six horses received medetomidine hydrochloride 7μg/kg IV alone (MED) or with vatinoxan hydrochloride 140μg/kg IV (MED+V). Anesthesia was induced with midazolam and ketamine and maintained with isoflurane and medetomidine CRI for 60min. Heart rate, carotid and pulmonary arterial pressures, central venous pressure, cardiac output and arterial and mixed venous blood gases were measured. Selected cardiopulmonary parameters were calculated. Plasma drug concentrations were determined. Fecal output was measured over 24h. For statistical comparisons, repeated measures analysis of covariance and paired t-tests were applied. Heart rate decreased slightly from baseline in the MED group. Arterial blood pressures decreased with both treatments, but significantly more dobutamine was needed to maintain normotension with MED+V (P=0.018). Cardiac index (CI) and oxygen delivery index (DO₂I) decreased significantly more with MED, with the largest difference observed at 20min: CI was 39±2 and 73±18 (P=0.009) and DO₂I 7.4±1.2 and 15.3±4.8 (P=0.014)mL/min/kg with MED and MED+V, respectively. Fecal output or plasma concentrations of dexmedetomidine did not differ between the treatments. In conclusion, premedication with vatinoxan induced hypotension, thus its use in anesthetized horses warrants further studies. Even though heart rate and arterial blood pressures remained clinically acceptable with MED, cardiac performance and oxygen delivery were lower than with MED+V.

Dose rationale and pharmacokinetics of dexmedetomidine in mechanically ventilated new-borns: impact of design optimisation

PURPOSE

There is a need for alternative analgosedatives such as dexmedetomidine in neonates. Given the ethical and practical difficulties, protocol design for clinical trials in neonates should be carefully considered before implementation. Our objective was to identify a protocol design suitable for subsequent evaluation of the dosing requirements for dexmedetomidine in mechanically ventilated neonates.

METHODS

A published paediatric pharmacokinetic model was used to derive the dosing regimen for dexmedetomidine in a first-in-neonate study. Optimality criteria were applied to optimise the blood sampling schedule. The impact of sampling schedule optimisation on model parameter estimation was assessed by simulation and re-estimation procedures for different simulation scenarios. The optimised schedule was then implemented in a neonatal pilot study.

RESULTS

Parameter estimates were more precise and similarly accurate in the optimised scenarios, as compared to empirical sampling (normalised root mean square error: 1673.1% vs. 13,229.4% and relative error: 46.4% vs. 9.1%). Most importantly, protocol deviations from the optimal design still allowed reasonable parameter estimation. Data analysis from the pilot group (n = 6) confirmed the adequacy of the optimised trial protocol. Dexmedetomidine pharmacokinetics in term neonates was scaled using allometry and maturation, but results showed a 20% higher clearance in this population compared to initial estimates obtained by extrapolation from a slightly older paediatric population. Clearance for a typical neonate, with a post-menstrual age (PMA) of 40 weeks and weight 3.4 kg, was 2.92 L/h. Extension of the study with 11 additional subjects showed a further increased clearance in pre-term subjects with lower PMA.

CONCLUSIONS

The use of optimal design in conjunction with simulation scenarios improved the accuracy and precision of the estimates of the parameters of interest, taking into account protocol deviations, which are often unavoidable in this event-prone population.

Efficacy of novel sedation using the combination of dexmedetomidine and midazolam during endoscopic submucosal dissection for esophageal squamous cell carcinoma

BACKGROUND

Endoscopic submucosal dissection (ESD) is the preferred treatment for esophageal squamous cell carcinoma (ESCC). However, ESD can be difficult when patients move due to insufficient sedation. We conducted a prospective confirmatory single arm study to evaluate the efficacy of using dexmedetomidine (DEX) in combination with midazolam as a novel sedation for ESD.

METHODS

Endoscopic submucosal dissection was performed without intubation in 65 patients. The primary outcome was the proportion of patients who did not move or require restraint during ESD, compared to historical control of ESD performed under midazolam sedation. Secondary outcomes included the frequency of complications and self-report questionnaires from patients and endoscopists.

RESULTS

Restraint was not required in 97% of patients sedated using the combination of DEX and midazolam. Depressed respiration, low blood pressure, and bradycardia occurred in 23, 37, and 26% of patients, respectively. All patients recovered without severe complication. Occurrence of low blood pressure and bradycardia were higher, while respiratory depression was lower for the combination group than for the historical control group. The amount of midazolam used was significantly lower than in the control. Of note, 94% of patients had no painful sensations, with 3 reporting chest pain and 3 having a recollection of the procedure. Endoscopists were satisfied with the sedation in 94% of cases. All lesions were resected in en bloc fashion, without perforation.

CONCLUSIONS

The combination of DEX and midazolam provided effective sedation for ESD for ESCC.

Association Between Nonmedical Use of Prescription Drugs and Sleep Quality in a Large College Student Sample

Objective/Background: Poor sleep and nonmedical use (NMU) of prescription drugs (NMUPD) are both common among college students. Since lack of sleep adversely influences academic performance, this study examined the association between NMUPD and subjective sleep quality among college students. Participants: Students who completed the American College Health Association-National College Health Assessment data (Fall 2010, Spring 2011; N = 135,874). Methods: Associations were examined between NMUPD in four classes over the past 12 months (antidepressant, painkillers, sedatives, and stimulants), and five aspects of sleep quality (Enough Sleep, Early Awakening, Daytime Sleepiness, Difficulty Falling Asleep, and Problem With Daytime Sleepiness) in the past seven days. Results: Any NMUPD (at least one class), NMU of stimulants specifically, and NMU of painkillers specifically were associated with getting fewer days of Enough Sleep (OR: 0.86, 0.93, and 0.84 respectively), more days of Early Awakening (OR: 1.28, 1.10, and 1.28 respectively), Daytime Sleepiness (OR: 1.23, 1.13, and 1.16 respectively), and Difficulty Falling Asleep (OR:1.32, 1.10, and 1.27 respectively; p < .0001, each). NMU of sedatives was significantly associated with having Problem With Daytime Sleepiness (OR: 1.10), more days of Early Awakening (OR: 1.12), and Difficulty Falling Asleep (OR: 1.17; p < .0001). Conclusions: NMUPD is associated with poor sleep among college students. Therefore, behavioral medicine screening and treatment of this vulnerable population should consider sleep health, NMUPD, and the potential that these problems may be comorbid.

Sedation and the Food and Drug Administration Warning: What a Pediatric Gastroenterologist, Hepatologist, and Pancreatologist Should Know

Pediatric gastroenterologists recommend and perform a range of procedures requiring sedation and anesthesia in young children. A recent warning from the US Food and Drug Administration (FDA) states that "repeated or lengthy use of general anesthetics and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children's brains." 1 As it relates to time, the FDA warning details risks of "procedures lasting longer than 3 hours or if multiple procedures are required." Pediatric gastroenterologists and related specialists should be aware of the warning and its relevance to their patients.

Effects of dexmedetomidine, with or without vatinoxan (MK-467), on minimum alveolar concentration of isoflurane in cats

OBJECTIVE

To characterize the effects of dexmedetomidine, with or without vatinoxan, on the minimum alveolar concentration of isoflurane (MACISO) in cats.

STUDY DESIGN

Randomized crossover experimental study.

ANIMALS

A group of six adult healthy male neutered cats.

METHODS

Cats were anesthetized with isoflurane in oxygen and instrumented. Dexmedetomidine was administered using a target-controlled infusion system to achieve 10 target plasma concentrations ranging from 0 to 40 ng mL-1. Additionally, vatinoxan or an equivalent volume of saline was administered using a target-controlled infusion system to achieve a target plasma concentration of 4 μg mL-1. Pulse rate (PR), respiratory rate, systolic arterial pressure (SAP), hemoglobin oxygen saturation, body temperature, end-tidal partial pressure of carbon dioxide and drug concentrations were measured. MACISO was determined at each target plasma dexmedetomidine concentration using the bracketing method and the tail clamp technique. Pharmacodynamic models were fitted to the plasma dexmedetomidine concentration-MACISO. Pharmacodynamic parameters were tested for equivalence, and if rejected, for difference.

RESULTS

Dexmedetomidine alone decreased MACISO in a plasma concentration-dependent manner. Maximum reduction was 77 ± 4%; the dexmedetomidine concentration producing 50% of the maximum decrease (IC50) was 0.77 ng mL-1. Vatinoxan increased MACISO in the absence of dexmedetomidine, decreased the potency of dexmedetomidine for its MACISO-reducing effect (IC50 = 12 ng mL-1) and lessened the maximum MACISO reduction (60 ± 14%). PR decreased less and SAP increased less when dexmedetomidine was administered with vatinoxan compared with saline.

CONCLUSION AND CLINICAL RELEVANCE

Vatinoxan altered the effect of dexmedetomidine on MACISO. A high plasma dexmedetomidine concentration in the presence of vatinoxan resulted in a large decrease in MACISO, with attenuation of dexmedetomidine-induced cardiovascular effects. The vatinoxan-dexmedetomidine combination may provide clinical benefits in isoflurane-anesthetized cats.

Evaluation of the sedative effects and pharmacokinetics of detomidine gel administered intravaginally to horses

OBJECTIVES

To determine the sedative effects and pharmacokinetic profile of detomidine when administered intravaginally as a gel formulation to horses.

STUDY DESIGN

Randomized, crossover, masked experimental design.

ANIMALS

A group of six healthy adult mares (494 ± 56 kg).

METHODS

Mares were studied on two occasions and were administered either detomidine hydrochloride (10 μg kg^-1) intravenously (treatment IV) or detomidine gel (40 μg kg^-1) intravaginally (treatment IVG), separated by 1 week. Sedation, ataxia, muzzle-floor distance and heart rate (HR) were evaluated every 15 minutes for 240 minutes. Venous blood samples were collected at 15, 30, 45, 60, 90, 120, 150, 180, 240, 300 and 360 minutes postadministration and were analyzed for detomidine and metabolites using liquid chromatography-tandem mass spectrometry. Measured variables were compared over time and between treatments using mixed model analysis. Correlation between drug plasma concentrations and muzzle-floor distance, and sedation and ataxia scores was determined using the Spearman correlation coefficient. Data are presented as mean ± standard error of the mean and p value was set at <0.05.

RESULTS

Sedation was shorter with IV (119 ± 16 minutes) than with IVG (188 ± 22 minutes). Ataxia scores remained greater than baseline for 90 and 135 minutes for treatments IV and IVG, respectively. HR was lower than baseline for 45 and 30 minutes for IV and IVG, respectively, but did not differ between treatments. The mean maximum plasma concentration of detomidine, time to maximum concentration and bioavailability for treatment IVG was 8.57 ng mL^-1, 0.37 hour and 25%, respectively. There was a significant correlation (r = 0.68) between plasma detomidine concentrations and sedation score.

CONCLUSIONS AND CLINICAL RELEVANCE

Detomidine gel administered intravaginally resulted in clinically important sedation and is a viable method for detomidine gel delivery in mares.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Effects of Midazolam on Postoperative Nausea and Vomiting and Discharge Times in Outpatients Undergoing Cancer-Related Surgery

Midazolam, a short-acting benzodiazepine used for preoperative anxiolysis, may also have pharmacologic properties that could further reduce the incidence of postoperative nausea and vomiting (PONV) in high-risk patients when included in a multimodal antiemetic protocol. However, concerns remain that the sedating properties of midazolam will delay discharge after short outpatient procedures. A retrospective data analysis (N = 4,057) investigated effects of midazolam on postoperative antiemetic administration and length of stay following cancer-related outpatient procedures over 15 months. Following initial univariate analysis, a multivariable model adjusting for Apfel score, surgical service, age, length of surgery, and type of anesthesia was created to test these associations. The multivariable analysis demonstrated that midazolam was associated with reduced need for postoperative antiemetic medications (3.2% lower than no-midazolam group; 95% confidence interval = 0.03%-6.0%, P = .032). Furthermore, the multivariable analysis demonstrated no clinically significant effect on postoperative length of stay (7.9 minutes shorter in midazolam group; 95% confidence interval = -20 to 4.4, P = .2). In patients for whom midazolam is not otherwise indicated, evidence is insufficient to warrant midazolam administration solely to prevent PONV. Randomized trials are needed to provide an accurate estimation of the effect size of midazolam for PONV in these patients.

Trends in Health-Risk Behaviors among Chinese Adolescents

Adolescent health-risk behaviors can have long lasting negative effects throughout an individual's life, and cause a major economic and social burden to society. This study aimed to estimate the prevalence of the health-risk behaviors among Chinese adolescents and to test the trends in health-risk behaviors without and with adjusting for sociodemographic characteristics. Data were drawn from the School-based Chinese Adolescents Health Survey, which is an ongoing school-based study about the health-risk behaviors among Chinese adolescents (7th to 12th grade). During the first wave through the third wave, the prevalence of lifetime, past 12-month, and past 30-day use of opioid decreased by 4.19%, 0.63%, and 0.56%, respectively. Moreover, the prevalence of lifetime, past 12-month, and past 30-day sedative use decreased by 3.03%, 0.65%, and 0.35%, respectively. During the three waves, most trends in the prevalence of health-risk behaviors were downward, with a few exceptions: The prevalence of lifetime smoking, drinking, methamphetamine use, and sleep disturbance increased by 7.15%, 13.08%, 0.48%, and 9.06%, respectively. The prevalence of lifetime 3,4-methylene dioxy methamphetamine use (from 0.49% to 0.48%), lifetime mephedrone use (from 0.30% to 0.24%), or suicide attempts (from 2.41% to 2.46%) remained stable.

Propofol-based palliative sedation in terminally ill children with solid tumors: A case series

RATIONALE

The palliative sedation therapy is defined as the intentional reduction of the alert state, using pharmacological tools. Propofol is a short-acting general anesthetic agent, widely used for induction and maintenance of general anesthesia and rarely employed in palliative care.

PATIENT CONCERNS AND DIAGNOSES

This case series describes 5 pediatric oncology inpatients affected by relapsed/refractory solid tumors received palliative sedation using propofol alone or in combination with opioids and benzodiazepines.

INTERVENTIONS AND OUTCOMES

Five terminally ill children affected by solid tumors received propofol-based palliative sedation. All patients were previously treated with opioids and some of them reduced the consumption of these drugs after propofol starting. In all cases the progressive increase of the level of sedation until the death has been the only effective measure of control of refractory symptoms related todisease progression and psychological suffering.

LESSONS

We evaluated the quality of propofol-based palliative sedation in a series of pediatric oncology patients with solid tumors at the end of their life. We concluded that propofol represents an effective and tolerable adjuvant drug for the management of intractable suffering and a practicable strategy for palliative sedation in pediatric oncology patients at the end of their life.

Efficacy of xylazine in neonatal calves via different routes of administration

Intramuscular (IM) injections may be more aversive than subcutaneous (SC) and intra-nasal (IN) routes. Xylazine is commonly used as a sedative for cattle, but little is known about efficacy via these routes. The first aim of this study was to compare efficacy using these different routes of administration. The second aim was to determine whether a simple behavioural assessment was associated with physiological responses. Using a within-subject design, the effects of xylazine (0.2mg/kg) were assessed in 12 Holstein calves (6.2±2.8days old) administered via IM, SC, IN drip tube (IN) and IN spray (INs). Sedation was assessed on a scale based on recumbency and eyeball rotation. Heart rate (HR), respiratory rate (RR) and rectal temperature (RT) were recorded for 2h after treatment. Intramuscular and SC routes produced an equivalent mean±standard deviation (SD) onset of sedation (IM: 4.8±2.0min vs. SC: 6.8±2.2min) and duration of sedation (IM: 60.3±25.5min vs. SC: 61.9±23.3min). IN treatments produced less consistent and longer onset times (IN: 33.0±26.9min, and INs: 31.0±15.1min) and a shorter duration of sedation (IN: 42.0±31.5min, and INs: 26.7±21.8min). Behaviour scores were moderately correlated with changes in HR (r=-0.52; CI -0.60, -0.43) and changes in RR (r=-0.42; CI -0.51, -0.32), but not with changes in RT (r=-0.09, CI -0.20, 0.02). We conclude that SC is a viable alternative to the more aversive IM route, and that a simple clinical scale can be useful for assessing xylazine sedation.

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey

OBJECTIVES

We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California.

METHODS

We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact.

RESULTS

We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control.

CONCLUSIONS

In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

The safety and efficacy of dexmedetomidine versus propofol for patients undergoing endovascular therapy for acute stroke: A prospective randomized control trial

BACKGROUND

It is uncertain if dexmedetomidine has more favorable pharmacokinetic profile than the traditional sedative drug propofol in patients who undergo endovascular therapy for acute stroke. We conducted a prospective randomized control trial to compare the safety and efficacy of dexmedetomidine with propofol for patients undergoing endovascular therapy for acute stroke.

METHODS

A total of 80 patients who met study inclusion criteria were received either propofol (n = 45) or dexmedetomidine (n = 35) between January 2016 and August 2018. We recorded the favorable neurologic outcome (modified Rankin score <3) both at discharge and 3 months after stroke, National Institute of Health Stroke scale (NIHSS) at 48 hours post intervention, modified thrombolysis in myocardial infarction score on digital subtraction angiography, intraprocedural hemodynamics, recovery time, relevant time intervals, satisfaction score of the surgeon, mortality, and complications.

RESULTS

There were no significant differences between the 2 groups (P > .05) with respect to heart rate, respiratory rate, and SPO2 during the procedure. The mean arterial pressure (MAP) was significantly low in the propofol group until 15 minutes after anesthesia was induced. No difference was recorded between the groups at the incidence of fall in MAP >20%, MAP >40% and time spent with MAP fall >20% from baseline MAP. In the propofol group, the time spent with MAP fall >40% from baseline MAP was significantly long (P < .05). Midazolam and fentanyl were similar between the 2 groups (P > .05) that used vasoactive drugs. The time interval from stroke onset to CT room, from stroke onset to groin puncture, and from stroke onset to recanalization/end of the procedure, was not significantly different between the 2 groups (P > .05). The recovery time was longer in the dexmedetomidine group (P < .05). There was no difference between the groups with respect to complications, favorable neurological outcome, and mortality both at hospital discharge and 3 months later, successful recanalization and NIHSS score after 48 hours (P > .05). However, the satisfaction score of the surgeon was higher in the dexmedetomidine group (P < .05).

CONCLUSIONS

Dexmedetomidine was undesirable than propofol as a sedative agent during endovascular therapy in patients with acute stroke for a long-term functional outcome, though the satisfaction score of the surgeon was higher in the dexmedetomidine group.

Ethics of crisis sedation: questions of performance and consent

This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term 'crisis sedation.' We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.

Successful paediatric renography does not require sedation

INTRODUCTION

Sedation is often used to optimise ren-ography in children < 3 years, but it requires continuous monitoring.

METHODS

We discontinued routine use of chloral hydrate sedation of patients undergoing renography, and introduced that children < 2 years were placed in a child immobiliser for nuclear examinations at the Department of Paediatrics before being transported for renography. In addition, children < 3 years were offered melatonin, which is not a sedative. Chloral hydrate was given only if parents wanted sedation. We analysed the results from a consecutive series of patients undergoing renography from August 2010 to December 2015 and compared data from those who had been administered choral hydrate sedation with those who had received no sedation.

RESULTS

Renography was unaccomplished in 10% (3/30) of the choral hydrated sedated children and in 11% (54/512) of the non-sedated children (p = 0.83). Uncooperative children resulted in failed renography in 0% (0/3) and 39% (21/54) of cases, respectively (p = 0.46). Patients placed in a child immobiliser at the Department of Paediatrics had the greatest probability of achieving successful renography (p = 0.0013), the shortest renography procedure duration irrespective of melatonin use (p = 0.0001) and the lowest risk of a procedure duration > 60 minutes (p = 0.0004).

CONCLUSIONS

Renography can be performed without sedation. We recommend that children < 2 years be placed in a child immobiliser at the Department of Paediatrics before being transported for renography. Additional studies are needed to investigate the effects of melatonin.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

The effects of lidocaine-prilocaine cream on responses to intravenous catheter placement in cats sedated with dexmedetomidine and either methadone or nalbuphine

OBJECTIVE

To compare the reaction to cephalic intravenous (IV) catheter placement with or without lidocaine-prilocaine cream in cats sedated with dexmedetomidine and methadone or nalbuphine.

STUDY DESIGN

Prospective, randomized, blind study.

ANIMALS

A group of 24 female mixed breed cats.

METHODS

Cats were randomly allocated to one of the two sedation protocols: dexmedetomidine (0.01 mg kg^-1) and methadone (0.3 mg kg^-1; DEXMET) or dexmedetomidine (0.01 mg kg^-1) and nalbuphine (0.3 mg kg^-1; DEXNALB). Sedation was scored 30 minutes later using a visual analog scale. Subsequently, a 2 × 3.5 cm area of the antebrachium over the cephalic vein was clipped, and half the cats within each protocol were randomly assigned for topical lidocaine-prilocaine cream (treatment), whereas no cream was applied to other cats (control). After 20 minutes, an attempt was made to place a 24 gauge catheter into the cephalic vein and the reaction of the cats to this procedure was scored using a numeric scale 0-3. Sedation and catheterization reaction scores were compared between sedation protocols and whether cats were administered lidocaine-prilocaine cream or not using the Friedman test followed by the Bonferroni procedure. A p value < 0.05 was considered significant.

RESULTS

Sedation scores were not different between sedation protocols or between treatment and control cats within each protocol. All cats administered lidocaine-prilocaine cream showed no reaction to IV catheter placement. Among the control cats, no response was observed in one cat in DEXNALB. Catheterization reaction score was lower in the treatment cats in both the sedation protocols when compared with their respective controls.

CONCLUSIONS AND CLINICAL RELEVANCE

Lidocaine-prilocaine cream applied for 20 minutes abolished the reaction to catheterization in cats sedated with dexmedetomidine and nalbuphine or methadone. Facilitation of IV catheter placement occurred within 20 minutes of lidocaine-prilocaine application.

Positive state observer for the automatic control of the depth of anesthesia-Clinical results

The depth of anesthesia (DoA) is a crucial feature in general anesthesia. Nowadays the DoA is usually evaluated by the bispectral index (BIS). According to the surgical procedure, different reference levels for the BIS may be clinically required. This can be achieved by the simultaneous administration of an analgesic (e.g. remifentanil) and an hypnotic (eg propofol). As a contribution to the effort of automating the processes of drug delivery in general anesthesia, in this paper, a positive state observer is designed for the implementation of a control scheme proposed for the automatic administration of propofol and of remifentanil, in order to track a desired level for the BIS. It is proved and illustrated by simulations that the controller-observer scheme has a very good performance. This scheme was implemented, tested and evaluated both by means of simulations and for a set of patients during surgical procedures.

Randomized clinical trial on the efficacy of intranasal or oral ketamine-midazolam combinations compared to oral midazolam for outpatient pediatric sedation

Purpose

The optimal sedative regime that provides the greatest comfort and the lowest risk for procedural sedation in young children remains to be determined. The aim of this randomized, blinded, controlled, parallel-design trial was to evaluate the efficacy of intranasal ketamine and midazolam as the main component of the behavioral guidance approach for preschoolers during dental treatment.

Materials and methods

Children under seven years of age, with caries and non-cooperative behavior, were randomized into three groups: (KMIN) intranasal ketamine and midazolam; (KMO) oral ketamine and midazolam; or (MO) oral midazolam. The dental sedation appointments were videotaped, and the videos were analyzed using the Ohio State University Behavioral Rating Scale (OSUBRS) to determine the success of the sedation in each group. Intra- and postoperative adverse events were recorded. Data analysis involved descriptive statistics and non-parametric tests (P < 0.05, IBM SPSS).

Results

Participants were 84 children (28 per group; 43 boys), with a mean age of 3.1 years (SD 1.2). Children’s baseline and the dental sedation session characteristics were balanced among groups. The success of the treatment as assessed by the dichotomous variable ‘quiet behavior for at least 60% of the session length’ was: KMIN 50.0% (n = 14; OR 2.10, 95% CI 0.71 to 6.30), KMO 46.4% (n = 13; OR 1.80, 95% CI 0.62 to 5.40), MO 32.1% (n = 9) (P = 0.360). Adverse events were minor, occurred in 37 of 84 children (44.0%), and did not differ among groups (P = 0.462).

Conclusion

All three regimens provided moderate dental sedation with minor adverse events, with marked variability in the behavior of children during dental treatment. The potential benefit of the ketamine–midazolam combination should be further investigated in studies with larger samples.

Trial registration

ClinicalTrials.gov, identifier: NCT02447289. Registered on 11 May 2015, named “Midazolam and Ketamine Effect Administered Through the Nose for Sedation of Children for Dental Treatment (NASO).”

Dramatic effect in passive ROM exercise under sedation in a patient with intractable complex regional pain syndrome (type I): A case report

RATIONALE

Complex regional pain syndrome (CRPS) usually occurs after trauma and surgery but can also occur spontaneously. There are various known pathophysiology and treatment protocols for CRPS. However, there is no established treatment guideline. Although physical therapy is known as the first line treatment for CRPS, performing physical therapy is difficult due to severe pain. This case reports the first case with positive effect of physical therapy under sedation that allowed early physical therapy.

PATIENT CONCERNS

A 19-year old female had her right elbow area slightly hit by someone else, after which it began to swell and become more painful. Active and passive range of motion (ROM) of the right upper extremity gradually decreased through 3 months, and pain and edema worsened.

DIAGNOSES

She had allodynia, nonpitting edema, temperature asymmetry, and trophic change in fingernails in the right upper extremity, which met the diagnostic criteria for CRPS. In the 3-phase bone scan, which is a specific tool to diagnose CRPS, there was trace uptake increase in the right elbow and wrist, indicating possibility of CRPS.

INTERVENTIONS

Despite conventional treatments such as pharmacologic and interventional therapies, neither pain nor edema subsided. Pain was so severe that it was impossible to apply physical therapy. Therefore, the patient underwent passive ROM exercise in the right upper extremity under sedation for 30 minutes, which was relatively easier due to decreased pain. After 2 days of passive ROM exercise under sedation, the patient was able to receive passive ROM exercise twice daily without sedation for 18 days.

OUTCOMES

After 20 days of passive ROM exercise, including 2 days of passive ROM exercise under sedation, the circumference of her right hand decreased by 5 cm, wrist 2 cm, and elbow 6 cm compared to the initial measurement. Numeric pain rating scale improved from 9 to 3, and her manual muscle test marked fair plus from trace, Jebsen-Taylor hand function test score 43 from 0.

LESSONS

This case suggests that passive ROM exercise under sedation may be a successful alternative as a treatment when exercise, currently known as a treatment to CRPS, is impossible.

Intrathecal dexmedetomidine can decrease the 95% effective dose of bupivacaine in spinal anesthesia for cesarean section: A prospective, double-blinded, randomized study

BACKGROUND

Dexmedetomidine (Dex), as an adjuvant, has been reported to prolong the duration of spinal analgesia when adding to local anesthetic. We hypothesized that Dex could enhance the efficiency of intrathecal bupivacaine for spinal anesthesia in cesarean section. The aim of his study is to test our hypothesis that 5 μg Dex could enhance the efficiency of intrathecal bupivacaine and reduce the dose requirement of spinal bupivacaine for patients undergoing cesarean section.

METHODS

Ninety patients with ASA I or II, who underwent cesarean section, were randomized into 2 groups: group D (bupivacaine + 5 μg Dex) and group C (bupivacaine + the same volume of saline). The subsequent dose of spinal bupivacaine was determined by the improved up-down allocation method. The initial dose of bupivacaine in the 2 groups was 4 mg, and the subsequent dose for the following patient was depended on the probability of the current dose. ED95 of spinal bupivacaine was calculated using logistic regression model.

RESULTS

The ED95 and 95% confidence intervals (95% CI) of spinal hyperbaric bupivacaine in group D and group C were 7.4 mg (95% CI, 5.6-12.4 mg) and 11.0 mg (95% CI, 4.4-56.8 mg), respectively. The duration of sensory block was 120.5 ± 37.0 minutes in Dex group and 70.5 ± 34.5 minutes in Control group, respectively (P < .05). The duration of analgesia was 230.5 ± 40.5 minutes in Dex group and 145.1 ± 28.5 minutes in Control group, respectively (P < .001). The consumption of postoperative rescued sufentanil was significantly lower in Dex group than in the Control group (56.3 ± 9.4 vs 65.9 ± 10.7 μg). There was not significantly different in the patient satisfaction of analgesia, incidence of side effects, neonatal outcomes and neurological deficit between the 2 groups.

CONCLUSION

Intrathecal 5 μg Dex enhances the efficacy of spinal bupivacaine by 24% in patients undergoing cesarean section with spinal anesthesia. No additional side effect was observed by adding spinal Dex.

Gender differences in prescribing of zolpidem in the Veterans Health Administration

OBJECTIVES

Use of nonbenzodiazepine sedative hypnotics, especially zolpidem, has grown substantially, raising concerns about safety. Here, we evaluated prescribing patterns of zolpidem in the Veterans Health Administration.

STUDY DESIGN

A cross-sectional study of veterans receiving zolpidem in the outpatient setting from October 1, 2011, to September 30, 2016.

METHODS

The study population consisted of 500,332 zolpidem users (58,598 women and 441,734 men) and a random 10% sample (n = 631,449) of nonusers. We examined 2 outcomes related to inappropriate prescribing: high-dose zolpidem prescribing and overlap with benzodiazepines. We generated interrupted time series and logistic regression models to analyze these outcomes in men and women separately.

RESULTS

In 2016, 29.7% of female veterans received an inappropriately high guideline-discordant dosage compared with 0.1% of male veterans (P <.001 for all reported comparisons). Furthermore, more women than men had overlapping benzodiazepine and zolpidem prescriptions (18.8% vs 14.3%). In fully adjusted models, inappropriately high doses were more commonly received by younger women (adjusted odds ratios [AORs]: 2.75 for 21-39 years and 2.97 for 40-49 years compared with ≥80 years) and women with substance use disorder (AOR, 1.48). In the second inappropriateness outcome models, women with anxiety (AOR, 2.28) or schizophrenia (AOR, 2.05) and men with cancer (AOR, 1.42), anxiety (AOR, 2.66), or schizophrenia (AOR, 2.46) were more likely to receive an overlapping prescription of zolpidem and benzodiazepines.

CONCLUSIONS

We found evidence of inappropriate zolpidem prescribing among veterans, particularly women. Greater understanding of the drivers of this inappropriate prescribing is necessary to develop interventions to promote safer, more guideline-concordant prescribing.

Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial

Importance

Postoperative delirium is common following cardiac surgery and may be affected by choice of analgesic and sedative.

Objective

To evaluate the effect of postoperative intravenous (IV) acetaminophen (paracetamol) vs placebo combined with IV propofol vs dexmedetomidine on postoperative delirium among older patients undergoing cardiac surgery.

Design, Setting, and Participants

Randomized, placebo-controlled, factorial clinical trial among 120 patients aged 60 years or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries at a US center. Enrollment was September 2015 to April 2018, with follow-up ending in April 2019.

Interventions

Patients were randomized to 1 of 4 groups receiving postoperative analgesia with IV acetaminophen or placebo every 6 hours for 48 hours and postoperative sedation with dexmedetomidine or propofol starting at chest closure and continued for up to 6 hours (acetaminophen and dexmedetomidine: n = 29; placebo and dexmedetomidine: n = 30; acetaminophen and propofol: n = 31; placebo and propofol: n = 30).

Main Outcomes and Measures

The primary outcome was incidence of postoperative in-hospital delirium by the Confusion Assessment Method. Secondary outcomes included delirium duration, cognitive decline, breakthrough analgesia within the first 48 hours, and ICU and hospital length of stay.

Results

Among 121 patients randomized (median age, 69 years; 19 women [15.8%]), 120 completed the trial. Patients treated with IV acetaminophen had a significant reduction in delirium (10% vs 28% placebo; difference, -18% [95% CI, -32% to -5%]; P = .01; HR, 2.8 [95% CI, 1.1-7.8]). Patients receiving dexmedetomidine vs propofol had no significant difference in delirium (17% vs 21%; difference, -4% [95% CI, -18% to 10%]; P = .54; HR, 0.8 [95% CI, 0.4-1.9]). There were significant differences favoring acetaminophen vs placebo for 3 prespecified secondary outcomes: delirium duration (median, 1 vs 2 days; difference, -1 [95% CI, -2 to 0]), ICU length of stay (median, 29.5 vs 46.7 hours; difference, -16.7 [95% CI, -20.3 to -0.8]), and breakthrough analgesia (median, 322.5 vs 405.3 µg morphine equivalents; difference, -83 [95% CI, -154 to -14]). For dexmedetomidine vs propofol, only breakthrough analgesia was significantly different (median, 328.8 vs 397.5 µg; difference, -69 [95% CI, -155 to -4]; P = .04). Fourteen patients in both the placebo-dexmedetomidine and acetaminophen-propofol groups (46% and 45%) and 7 in the acetaminophen-dexmedetomidine and placebo-propofol groups (24% and 23%) had hypotension.

Conclusions and Relevance

Among older patients undergoing cardiac surgery, postoperative scheduled IV acetaminophen, combined with IV propofol or dexmedetomidine, reduced in-hospital delirium vs placebo. Additional research, including comparison of IV vs oral acetaminophen and other potentially opioid-sparing analgesics, on the incidence of postoperative delirium is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT02546765.

Medicalisation, pharmaceuticalisation, or both? Exploring the medical management of sleeplessness as insomnia

In this paper we examine the medical management of sleeplessness as 'insomnia', through the eyes of general practitioners (GPs) and sleep experts in Britain. Three key themes were evident in the data. These related to (i) institutional issues around advocacy and training in sleep medicine (ii) conceptual issues in the diagnosis of insomnia (iii) and how these played out in terms of treatment issues. As a result, the bulk of medical management occurred at the primary rather than secondary care level. These issues are then reflected on in terms of the light they shed on relations between the medicalisation and the pharmaceuticalisation of sleeplessness as insomnia. Sleeplessness, we suggest, is only partially and problematically medicalised as insomnia to date at the conceptual, institutional and interactional levels owing to the foregoing factors. Much of this moreover, on closer inspection, is arguably better captured through recourse to pharmaceuticalisation, including countervailing moves and downward regulatory pressures which suggest a possible degree of depharmaceuticalisation in future, at least as far prescription hypnotics are concerned. Pharmaceuticalisation therefore, we conclude, has distinct analytical value in directing our attention, in this particular case, to important dynamics occurring within if not beyond the medicalisation of sleeplessness as insomnia.

Sedation for terminally ill cancer patients: A multicenter retrospective cohort study in South Korea

Sedation therapy is a potential solution to providing relief from refractory symptoms at end of life. The aim of this study was to investigate actual sedation practice and physician characteristics associated with the use of sedation for terminally ill cancer patients in South Korea.A retrospective review was conducted on consecutive patients who had died from cancer at seven tertiary medical centers between January 2010 and October 2015. The use of sedation was defined as the administration of sedative agents to relieve intolerable symptoms within the last 2 weeks preceding death. Patients and physician characteristics and information on the use of sedation were collected.A total of 8309 patients were included in the study. Sedatives were administered in 1334 patients (16.1%) for the following indications: delirium in 39.3%, intractable pain in 23.1%, and dyspnea in 21.9%. Median duration of sedation from initiation to death was 3 days. The use of sedation depended on physician specialty and experience. Family physicians used sedation most often (57.6%), followed by medical oncologists (13.9%), other internists (10.7%), and surgical oncologists (9.4%). The use of sedation was highest for physicians with >5 to 10 years practice experience (22.1%) and lowest for those in practice for 5 years or less (10.2%). The proportion of patients receiving sedation also varied markedly across participating institutions (range, 7.0%-49.7%).This large cohort study provides insight into sedation practice for terminally ill cancer patients in South Korea. Our study shows that the use of sedation depends on physician background and institution. A nation-wide guidelines and continued education on end-of-life sedation are required in South Korea.

DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities

Background Prolonged use of anticholinergic and sedative medicines is correlated with worsening cognition and physical function decline. Deprescribing is a proposed intervention that can help to minimise polypharmacy whilst potentially improving several health outcomes in older people. Objective This study aimed to examine the feasibility of implementing a deprescribing intervention that utilises a patient-centred pharmacist-led intervention model; in order to address major deprescribing challenges such as general practitioner time constraints and lack of accessible deprescribing guidelines and processes. Setting Three residential care facilities. Methods The intervention involved a New Zealand registered pharmacist utilising peer-reviewed deprescribing guidelines to recommend targeted deprescribing of anticholinergic and sedative medicines to GPs. Main outcome measure The change in the participants' Drug Burden Index (DBI) total and DBI 'as required' (PRN) was assessed 3 and 6 months after implementing the deprescribing intervention. Results Seventy percent of potential participants were recruited for the study (n = 46), and 72% of deprescribing recommendations suggested by the pharmacist were implemented by General Pratitioners (p = 0.01; Fisher's exact test). Ninety-six percent of the residents agreed to the deprescribing recommendations, emphasising the importance of patient centred approach. Deprescribing resulted in a significant reduction in participants' DBI scores by 0.34, number of falls and adverse drug reactions, 6 months post deprescribing. Moreover, participants reported lower depression scores and scored lower frailty scores 6 months after deprescribing. However, cognition did not improve; nor did participants' reported quality of life. Conclusion This patient-centred deprescribing approach, demonstrated a high uptake of deprescribing recommendations and success rate. After 6 months, significant benefits were noted across a range of important health measures including mood, frailty, falls and reduced adverse reactions. This further supports deprescribing as a possible imperative to improve health outcomes in older adults.

Difficult Extubation: Calming the Sympathetic Storm

Tracheal extubation can evoke an equally strong haemodyamic stress response as tracheal intubation. We present a patient with myocardial infarction who repeatedly failed tracheal extubation. He developed acute pulmonary oedema following each attempt at tracheal extubation due to sympathetic overactivity. A change of approach with extubation under propofol sedation followed by continued sympatholysis with dexmedetomidine infusion allowed successful extubation.

Determination of blood dexmedetomidine in dried blood spots by LC-MS/MS to screen therapeutic levels in paediatric patients

Dexmedetomidine is an imidazole derivative, with high affinity for α2 adrenergic receptors, used for sedation, analgesia and adjuvant anaesthesia. In this study, an analytical method for the quantification of dexmedetomidine in dried blood spots was developed, validated and applied. The drug was extracted from dried blood spot by liquid extraction; the separation was carried out by ultra high-resolution liquid chromatography in reverse phase coupled to tandem mass spectrometry method. An X Select cyano 5 μm HSS column (2.1 X 150 mm, Waters) and a mobile phase composed of 0.1% formic acid: acetonitrile [50:50 v/v], were used. The test was linear over the concentration range of 50 to 2000 pg/mL. The coefficients of variation for the intra and interday trials were less than 15%. The drug was stable under the conditions tested. The method was successfully applied for the quantification of 6 patients, aged 0 to 2 years, with classification ASA I, who underwent ambulatory surgeries, receiving a dose of 1 μg/Kg dexmedetomidine IV. The drug concentrations in the different sampling times were in the range of 76 to 868 pg/mL.

Dexmedetomidine Infusion without Loading Dose in Surgical Patients Requiring Mechanical Ventilation: Haemodynamic Effects and Efficacy

We investigated the haemodynamic effects and the efficacy of a continuous infusion of dexmedetomidine without a loading dose in 50 patients having had cardiac surgery (n=33), complex major surgery (n=9) and multiple trauma (n=8). The mean age was 60 (±16) years, and the mean APACHE II score was 13 (±5). Dexmedetomidine was commenced at an initial rate of 0.2 to 0.4 μg/kg/h (depending on whether anaesthetic or sedative agents had already been used) and rescue analgesia and sedation was administered with morphine and midazolam respectively. Propofol was used if additional sedation was needed. Sedation was targeted to a modified Motor Activity Assessment Score. Eighty percent of patients required no or “minimal” rescue therapy (<10 mg midazolam /day and/or <10 mg morphine/day and/or <100 mg propofol/day). The cardiac surgery group needed the least rescue therapy. A statistically significant but clinically unimportant reduction in mean heart rate and mean systolic blood pressure was observed over the first six hours (P<0.0001, and P=0.009 respectively). The baseline heart rate of 85 (±17) beats per minute (bpm), fell to a low of 78 (±13) bpm at four hours and then remained stable throughout the infusion period. The systolic blood pressure fell from 125 (±22) mmHg to a low of 112 (±20) mmHg at 1.5 hours with minimal change afterwards.

Dexmedetomidine was an effective sedative and analgesic in this group of complex surgical and trauma patients with pronounced benefit in the cardiac surgery group. Omitting the loading dose avoided undesirable haemodynamic effects without compromising sedation and analgesia.

[Swedish emergency physicians can safely sedate patients with propofol prior to cardioversion]

Emergency Medicine became a full-fledged speciality in Sweden in 2015. This prospective study analyzed the safety and implementation of Emergency Physician-administered propofol to sedate patients with hemodynamically stable atrial fibrillation prior to cardioversion. During the first 1.5 years, 321 sedations were carried out at Lund's Emergency Department by Emergency Physicians or senior residents. In two cases, the oxygen saturation dipped below 90% before responding to simple measures. In 12 cases, the systolic blood pressure dipped below 90 mmHg, and in two cases patients were administered a push-dose pressor. No patient required hospitalization due to sedation-induced complications. The majority of eligible specialists and senior residents voluntarily participated in an Emergency Physician-driven certification process. This study demonstrates the safety and feasibility of a locally implemented process for Emergency Physician-driven procedural sedation.

[The Role of the Medical Profession in Euthanasia, Particularly in the Prescription of Sodium Pentobarbital]

The Role of the Medical Profession in Euthanasia, Particularly in the Prescription of Sodium Pentobarbital Abstract. The delivery of sodium pentobarbital as part of assisted suicide requires a doctor's prescription. This prescription must meet the legal and professional requirements as well as the corresponding ethical guidelines. Current legal practice restrictively permits suicide assistance in this form, especially in the case of patients who are willing to die and whose death is foreseeable. The new guidelines of the SAMS (2018) extend the possibility to patients who suffer intolerably due to disease symptoms and/or functional restrictions. The prescription of NaP in other cases or in violation of the duty of care provided for in the guidelines may result in supervisory, professional and criminal consequences. Suicide assistance itself is a decision of conscience, not a medical task, which is why there is no entitlement to it.

The effect of intramuscular dexmedetomidine-butorphanol combination on tear production in dogs

This study assessed the effects of a combination of dexmedetomidine and butorphanol on the Schirmer tear test I (STT I) values in dogs. Ninety-eight dogs were sedated with an intramuscular injection of a combination of dexmedetomidine, 5 μg/kg body weight (BW), and butorphanol, 0.2 mg/kg BW. The effects of dexmedetomidine were reversed by administering atipamezole at the end of the procedure. The combination of dexmedetomidine and butorphanol significantly decreased tear production 15 minutes after sedation. The STT I values 15 minutes after reversal of dexmedetomidine with atipamezole were significantly higher than the STT I values 15 minutes after sedation but were significantly lower than the STT I values before sedation. Gender, weight, duration of sedation, right or left eye did not affect STT I values after sedation. It is recommended that dogs sedated with a combination of dexmedetomidine and butorphanol be treated with a tear substitute to combat decreased tear production.