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Fukano K, Homma Y, Norii T. Efficact of Supplemental Oxygen During Procedural Sedation and Analgesia in Elderly Patients in the Emergency Department. J Emerg Med 2023; 65:e310-e319. [PMID: 37704505 DOI: 10.1016/j.jemermed.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 05/07/2023] [Accepted: 05/26/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The use of supplemental oxygen (SO) for procedural sedation and analgesia (PSA) is recommended in many guidelines, but the evidence of SO for the elderly is limited. OBJECTIVES This study aimed to compare the incidence of hypoxia with or without SO in PSA for the elderly patients. METHODS We prospectively collected data on all patients undergoing PSA in the emergency department (ED) from May 2017 through December 2021. These data are from the Japanese Procedural SedaTion and Analgesia Registry. We included all elderly patients (65 years and older) who received PSA in the ED. We performed propensity score analysis for inverse probability of treatment weighting (IPTW) to balance the baseline characteristics. The primary outcome was the incidence of hypoxia (SpO2 < 90%), and the secondary outcome was the incidence of bag-valve mask ventilation. RESULTS Among 1465 patients in the registry, we included 816 (55.7%) patients in the analysis. After propensity score method for IPTW, the distributions of confounders were closely balanced between the two groups. The incidence of hypoxia was significantly lower in the SO group compared with the non-SO group (6.2% vs. 19.3%; difference -13.1%; 95% confidence interval [CI] -9.8 to -16.4; p < 0.001). SO was also associated with a lower incidence of bag-valve mask ventilation (5.2% vs. 15.4%; difference -10.2%; 95% CI -7.1 to -13.2; p < 0.001). CONCLUSIONS In a propensity-matched analysis, SO was associated with a lower incidence of hypoxia in elderly patients during ED PSA.
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Affiliation(s)
- Kentaro Fukano
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama-shi, Saitama-ken, Japan
| | - Yosuke Homma
- Department of Emergency Medicine, Chiba Kaihin Municipal Hospital, Chiba-city, Chiba, Japan
| | - Tatsuya Norii
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Fukano K, Iizuka Y, Ueda T, Fukuda Y, Otsuka Y, Sanui M. Comparison of Sedation With Ketamine-Propofol Versus Propofol-Fentanyl for Elderly Patients Undergoing Prostate Biopsy: A Retrospective Observational Study. Cureus 2023; 15:e42650. [PMID: 37644922 PMCID: PMC10461593 DOI: 10.7759/cureus.42650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Procedural sedation is increasingly used for elderly patients, but there is no established ideal method for elderly patients who are prone to respiratory and circulatory depression. This study aims to investigate the association of respiratory complications and the combination of ketamine-propofol versus fentanyl-propofol in elderly patients undergoing prostate biopsy requiring deep sedation. METHODS This was a single-center, retrospective, observational study conducted from April 2020 to March 2021. We included male patients aged 65 years and older scheduled for prostate biopsy under procedural sedation. Ketamine-propofol and fentanyl-propofol were administered at the discretion of the anesthesiologist. The primary outcome was the need for assisted ventilation. The secondary outcome was the duration of oxygen saturation (SpO2) below 90%. RESULTS We enrolled 120 patients over 65 years, and 92 patients were included in the final analysis. The anesthesiologist administered an initial dose of ketamine and propofol of 1:1 to 1:4 of 1.0 mg kg-1 (interquartile range: 0.98 to 1.17) or administered an initial dose of fentanyl of 0.05 to 0.1 mg and a target-controlled infusion of propofol of 2.8 μg ml-1 (interquartile range: 2.0 to 3.0) followed by additional doses at the discretion of the anesthesiologist. Ketamine-propofol was associated with a reduced need for assisted ventilation and a shorter duration of SpO2 below 90% than propofol-fentanyl (95.7% vs. 4.3%, P < 0.05; 0.64 minutes vs. 0.17 minutes, P = 0.26). CONCLUSIONS Ketamine-propofol is associated with a significantly reduced need for assisted ventilation compared to propofol-fentanyl during procedural sedation and analgesia for procedures requiring deep sedation for the elderly.
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Affiliation(s)
- Kentaro Fukano
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
| | - Takahiro Ueda
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
| | - Yu Fukuda
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
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Cao L, Ji Z, Zhang P, Wang J. Epidemiology and mortality predictors for severe childhood community-acquired pneumonia in ICUs: A retrospective observational study. Front Pediatr 2023; 11:1031423. [PMID: 37033191 PMCID: PMC10076704 DOI: 10.3389/fped.2023.1031423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background To identify the epidemiology and mortality predictors of severe childhood community-acquired pneumonia (CAP) and evaluate the influence of medications on clinical outcomes in the real world. Methods We conducted a multicenter retrospective observational study among children aged ≤5 years with severe CAP, separately comparing the detailed information between those who experienced in-hospital death and those who survived in three different age groups. A multivariate logistic regression model was used to determine mortality predictors. Results A total of 945 children were recruited: 341 young children aged 2-59 months, 47 infants aged 29 days to 2 months, and 557 neonates aged less than 28 days. A total of 88 deaths occurred (9.3%). There was low adherence to antimicrobial guidelines in the group aged 2-59 months, and carbapenems widely served as initial empirical regimens. However, analysis of all three age groups showed that the efficacy of antibacterial drugs with initial empirical selection grades higher than those recommended by the guidelines was not better than that of antibacterial drugs with grades recommended by the guidelines. In multivariate analyses, very severe pneumonia (odds ratio (OR): 3.48; 95% confidence interval (CI): 1.36-8.93), lower birth weight (OR: 4.64; 95% CI: 1.78-12.20), severe underweight (OR: 6.06; 95% CI: 2.34-15.63), mechanical ventilation (OR: 2.58; 95% CI: 1.00-6.62; OR: 15.63; 95% CI 3.25-76.92), a higher number of comorbidities (OR: 8.40; 95% CI: 1.89-37.04), comorbidities including anemia (OR: 5.24; 95% CI: 2.33-11.76) and gastrointestinal hemorrhage (OR: 3.79; 95% CI: 1.36-10.53), and the use of sedative-hypnotics (OR: 2.60; 95% CI: 1.14-5.95) were independent risk factors for death; infants treated with probiotics had a lower mortality rate (OR: 0.14; 95% CI: 0.06-0.33). Conclusions Severe CAP remains a primary cause of death in children under 5 years of age. Clinical characteristics, comorbidities and medications are evidently associated with death. Importantly, we should pay particular attention to the identification of mortality predictors and establish prophylactic measures to reduce mortality.
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Affiliation(s)
- Lu Cao
- Department of Pharmacy, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Zhaohua Ji
- Department of Epidemiology and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, China
| | - Peng Zhang
- Department of Pharmacy, Shaanxi Provincial People's Hospital, Xi'an, China
- Correspondence: Peng Zhang Jingwen Wang
| | - Jingwen Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Correspondence: Peng Zhang Jingwen Wang
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Grégoire C, De Kock M, Henrie J, Cren R, Lavand'homme P, Penaloza A, Verschuren F. Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department. J Emerg Med 2022; 63:283-289. [PMID: 35550843 DOI: 10.1016/j.jemermed.2022.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 12/30/2021] [Accepted: 01/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic. OBJECTIVE Our aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department. METHODS This prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale. RESULTS Thirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment. CONCLUSIONS The combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine-ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.
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Affiliation(s)
- Charles Grégoire
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium.
| | - Marc De Kock
- Anesthesia Intensive Care, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Julie Henrie
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium
| | - Rosen Cren
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium
| | | | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium
| | - Franck Verschuren
- UCLouvain, Experimental and Clinical Research Institute, Acute Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Joshi R, Marvin W. Apnea with ketamine sedation in a patient with severe anorexia nervosa: A case report. Eat Weight Disord 2022; 27:387-389. [PMID: 33788180 DOI: 10.1007/s40519-021-01176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND There is a paucity of literature around sedation and anesthesia in patients with severe anorexia nervosa. Chronically malnourished patients are known to have myopathy, neuropathy, and altered neurotransmitter signaling. Ketamine is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist that is an established general anesthetic and short-acting dissociative analgesic agent. It generally has a reassuring adverse event profile and rarely has been reported to result in apnea. We aim to raise awareness of this untoward adverse event in patients with severe anorexia nervosa among sedation providers and those referring patients for hospitalization or sedation. CASE PRESENTATION We describe an episode of apnea, a rare adverse event of ketamine, which was given for procedural sedation to a severely malnourished 13-year-old female with anorexia nervosa, generalized anxiety disorder, and high-functioning autism spectrum disorder. She had no history of apnea nor of ketamine sedation. She was given a standard dose of ketamine and had no other central nervous system depressants within 24 h. Within 1 min after slow medication administration, she had a 9-min period of apnea without laryngospasm. She was supported with bag-valve-mask ventilation throughout this period and did not require intubation. She returned to baseline shortly after procedural sedation. CONCLUSIONS This case describes apnea after ketamine sedation in a patient with severe anorexia nervosa. It supports the importance of a thorough pre-procedure review of a patient's underlying medical problems and the consideration of how sedatives may interact with these conditions. We aim to alert those who care for this complex population of the possible altered neurotransmitters, myopathy, and adverse response to sedation, anesthetics, and analgesics.
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Affiliation(s)
- Reshma Joshi
- PGY-3, Department of Pediatrics and Pediatric Neurology, Medical University of South Carolina, SJCH, 10 McClennan Banks Dr. MSC 915, Charleston, SC, 29425, USA
| | - Whitney Marvin
- Pediatric Critical Care, Medical University of South Carolina, 125 Doughty Street MSC 917, Charleston, SC, 29425, USA.
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Wells ME, Barnes RM, Caporossi J, Weant KA. The Influence of Age on Propofol Dosing Requirements During Procedural Sedation in the Emergency Department. Adv Emerg Nurs J 2021; 43:255-264. [PMID: 34699413 DOI: 10.1097/tme.0000000000000371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Propofol is a frequently used agent for procedural sedation in the emergency department (ED). Some have suggested that propofol dosing in this setting should be adjusted in elderly patients; however, limited data exist supporting this recommendation. Additional factors that may contribute to altered propofol dose requirements in this setting have not been thoroughly explored. The objective of this analysis was to ascertain the effect age may have on the propofol dose required during procedural sedation in the ED. This retrospective study was conducted at a Level 1 academic medical center ED and included patients 18 years or older who received propofol for procedural sedation from 2015 to 2017. Those patients who were 18-64 years of age were compared with those 65 years or older. Between the two groups, total and weight-based propofol requirements for sedation, opioid doses, and adverse events were compared. This analysis included 101 procedural sedations. The median induction dose and opioid requirements before or during the procedure were not significantly different between the two groups. Compared with patients 18-64 years of age, those 65 years or older had significantly less total weight-based propofol requirements (p = 0.024) and required less total propofol for sedation (p = 0.007). In addition, patients 65 years or older required fewer repeat doses of propofol during the procedure than younger patients (p = 0.043). The incidence of adverse effects, including respiratory suppression, was not significantly different between the two groups. Patients 65 years or older may have lower weight-based propofol dosing requirements than younger patients. Utilizing a reduced total dose and repeat dosing strategy for propofol in this setting may be indicated. Further investigations are recommended to clarify factors that signal the need for more tailored dosing.
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Affiliation(s)
- Maegan E Wells
- Palmetto Poison Center, University of South Carolina College of Pharmacy, Columbia, South Carolina (Dr Wells); Department of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina (Drs Barnes and Caporossi); and Department of Clinical Pharmacy and Outcome Sciences, University of South Carolina College of Pharmacy, Columbia, South Carolina (Dr Weant)
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Conway A, Jungquist CR, Chang K, Kamboj N, Sutherland J, Mafeld S, Parotto M. Predicting Prolonged Apnea During Nurse-Administered Procedural Sedation: Machine Learning Study. JMIR Perioper Med 2021; 4:e29200. [PMID: 34609322 PMCID: PMC8527383 DOI: 10.2196/29200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Capnography is commonly used for nurse-administered procedural sedation. Distinguishing between capnography waveform abnormalities that signal the need for clinical intervention for an event and those that do not indicate the need for intervention is essential for the successful implementation of this technology into practice. It is possible that capnography alarm management may be improved by using machine learning to create a "smart alarm" that can alert clinicians to apneic events that are predicted to be prolonged. OBJECTIVE To determine the accuracy of machine learning models for predicting at the 15-second time point if apnea will be prolonged (ie, apnea that persists for >30 seconds). METHODS A secondary analysis of an observational study was conducted. We selected several candidate models to evaluate, including a random forest model, generalized linear model (logistic regression), least absolute shrinkage and selection operator regression, ridge regression, and the XGBoost model. Out-of-sample accuracy of the models was calculated using 10-fold cross-validation. The net benefit decision analytic measure was used to assist with deciding whether using the models in practice would lead to better outcomes on average than using the current default capnography alarm management strategies. The default strategies are the aggressive approach, in which an alarm is triggered after brief periods of apnea (typically 15 seconds) and the conservative approach, in which an alarm is triggered for only prolonged periods of apnea (typically >30 seconds). RESULTS A total of 384 apneic events longer than 15 seconds were observed in 61 of the 102 patients (59.8%) who participated in the observational study. Nearly half of the apneic events (180/384, 46.9%) were prolonged. The random forest model performed the best in terms of discrimination (area under the receiver operating characteristic curve 0.66) and calibration. The net benefit associated with the random forest model exceeded that associated with the aggressive strategy but was lower than that associated with the conservative strategy. CONCLUSIONS Decision curve analysis indicated that using a random forest model would lead to a better outcome for capnography alarm management than using an aggressive strategy in which alarms are triggered after 15 seconds of apnea. The model would not be superior to the conservative strategy in which alarms are only triggered after 30 seconds.
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Affiliation(s)
- Aaron Conway
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada.,School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Carla R Jungquist
- School of Nursing, The University at Buffalo, Buffalo, NY, United States
| | - Kristina Chang
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Navpreet Kamboj
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Joanna Sutherland
- Rural Clinical School, University of New South Wales, Coffs Harbour, Australia
| | - Sebastian Mafeld
- Joint Department of Medical Imaging, Toronto General Hospital, Toronto, ON, Canada
| | - Matteo Parotto
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Walravens S, Buylaert W, Steen E, De Paepe P. Implementation of a protocol using ketamine-propofol ('ketofol') in a 1 to 4 ratio for procedural sedation in adults at a university hospital emergency department - report on safety and effectiveness. Acta Clin Belg 2021; 76:359-364. [PMID: 32174247 DOI: 10.1080/17843286.2020.1741228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: To test the feasibility of an evidence-based protocol for procedural sedation in adults at our emergency department, using a mixture of ketamine and propofol ('ketofol') in a 1 to 4 ratio. We hypothesize that the protocol is safe and effective and can facilitate procedural sedation.Methods: During 14 months, adults in need of procedural sedation at our university hospital emergency department were included in a prospective convenience sample study. Patients with important comorbidity were discussed with the anaesthesiology department for feasibility of sedation in the emergency department setting. Outcome measures were procedural success, respiratory and hemodynamic events, vomiting, agitation or hallucinations, recall and physician's satisfaction.Results: Sixty-one patients between 18 and 89 years were included. All but one procedure were successful. Six respiratory events were registered in 6 patients (9.8%). These consisted of airway obstruction alleviated by airway repositioning and without influence on vital signs except for one brief episode of desaturation. Neither hemodynamic events nor vomiting were reported. Five patients (8.2%) experienced pleasant hallucinations and one patient (1.6%) became agitated upon awakening but recovered rapidly without medication. Three patients (4.9%) had recall and physician satisfaction rate was 93.4%.Conclusion: A feasibility trial of an implemented protocol for ketofol procedural sedation in adults showed only minor respiratory events, a low incidence of agitation or hallucinations, minimal recall and a high success and physician satisfaction rate. Despite a non-consecutive and limited sample used, ketofol in a 1 to 4 ratio appears safe and effective for use in the emergency department.
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Affiliation(s)
- Stig Walravens
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Walter Buylaert
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Evi Steen
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
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Nagappa M, Wong DT. Is high-flow safer than low-flow nasal oxygenation for procedural sedation? Can J Anaesth 2021; 68:439-444. [PMID: 33432498 DOI: 10.1007/s12630-020-01884-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre and St. Joseph Health Care, Western University, Schulich School of Medicine and Dentistry, London, ON, Canada.
| | - David T Wong
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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Shimizu H, Homma Y, Norii T. Incidence of adverse events among elderly vs non-elderly patients during procedural sedation and analgesia with propofol. Am J Emerg Med 2020; 44:411-414. [PMID: 32409101 DOI: 10.1016/j.ajem.2020.04.094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Hiroyasu Shimizu
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba 279-0001, Japan.
| | - Yosuke Homma
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba 279-0001, Japan
| | - Tatsuya Norii
- Department of Emergency Medicine, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131, USA
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Green SM, Roback MG, Krauss BS, Miner JR, Schneider S, Kivela PD, Nelson LS, Chumpitazi CE, Fisher JD, Gesek D, Jackson B, Kamat P, Kowalenko T, Lewis B, Papo M, Phillips D, Ruff S, Runde D, Tobin T, Vafaie N, Vargo J, Walser E, Yealy DM, O'Connor RE. Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med 2020; 73:e51-e65. [PMID: 31029297 DOI: 10.1016/j.annemergmed.2019.02.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Indexed: 11/15/2022]
Abstract
The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.
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Conway A, Collins P, Chang K, Mafeld S, Sutherland J, Fingleton J, Parotto M. Pre-apneic capnography waveform abnormalities during procedural sedation and analgesia. J Clin Monit Comput 2019; 34:1061-1068. [DOI: 10.1007/s10877-019-00391-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 09/22/2019] [Indexed: 01/30/2023]
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Conway A, Collins P, Chang K, Mafeld S, Sutherland J, Fingleton J. Sequence analysis of capnography waveform abnormalities during nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory. Sci Rep 2019; 9:10214. [PMID: 31308455 PMCID: PMC6629622 DOI: 10.1038/s41598-019-46751-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/04/2019] [Indexed: 11/17/2022] Open
Abstract
Identifying common patterns in capnography waveform abnormalities and the factors that influence these patterns could yield insights to optimize responses to sedation-induced respiratory depression. Respiratory state sequences for 102 patients who had a procedure in a cardiac catheterisation laboratory with procedural sedation and analgesia were developed by classifying each second of procedures into a state of normal breathing or other capnography waveform abnormalities based on pre-specified cut-offs for respiratory rate and end-tidal CO2 concentration. Hierarchical clustering identified four common patterns in respiratory state sequences, which were characterized by a predominance of the state assigned normal breathing (n = 42; 41%), hypopneic hypoventilation (n = 38; 38%), apnea (n = 15; 15%) and bradypneic hypoventilation (n = 7; 7%). A multivariable distance matrix regression model including demographic and clinical variables explained 28% of the variation in inter-individual differences in respiratory state sequences. Obstructive sleep apnea (R2 = 2.4%; p = 0.02), smoking status (R2 = 2.8%; p = 0.01), Charlson comorbidity index score (R2 = 2.5%; p = 0.021), peak transcutaneous carbon dioxide concentration (R2 = 4.1%; p = 0.002) and receiving an intervention to support respiration (R2 = 5.6%; p = 0.001) were significant covariates but each explained only small amounts of the variation in respiratory state sequences. Oxygen desaturation (SpO2 < 90%) was rare (n = 3; 3%) and not associated with respiratory state sequence trajectories.
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Affiliation(s)
- Aaron Conway
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada.
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Brisbane, Australia.
| | - Peter Collins
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Kristina Chang
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sebastian Mafeld
- Interventional Radiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Joanna Sutherland
- Department of Anaesthesia, Coffs Harbour Health Campus, Coffs Harbour, Australia
| | - James Fingleton
- Medical Research Institute of New Zealand, Wellington, New Zealand
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Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med 2019; 73:470-480. [DOI: 10.1016/j.annemergmed.2018.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
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King BJ, Megison A, Scogin Z, Christensen BJ. Capnography Detection Using Nasal Cannula Is Superior to Modified Nasal Hood in an Open Airway System: A Randomized Controlled Trial. J Oral Maxillofac Surg 2019; 77:1576-1581. [PMID: 30851253 DOI: 10.1016/j.joms.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/16/2019] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The nasal cannula and modified nasal hood are methods used by oral and maxillofacial surgeons to detect expired carbon dioxide during procedural sedation in an open airway system. The purpose of this study was to compare the accuracy of the detection of expired carbon dioxide between the nasal cannula and modified nasal hood. MATERIALS AND METHODS The authors designed a parallel-group randomized controlled trial to compare the nasal cannula and modified nasal hood. Patients presenting to the authors' institution for outpatient oral and maxillofacial surgery (OMS) using intravenous deep sedation or general anesthesia were randomized to have capnography detection by the modified nasal hood or the nasal cannula. The primary outcome variable was the percentage of accurately captured breaths, as determined by the average number of capnography waveforms per auscultated breath using a precordial stethoscope. The 2 groups were compared using t test. RESULTS Fifty patients were screened for enrollment in the study. Twenty-five patients were randomized to the nasal cannula group and 25 patients were randomized to the modified nasal hood group. The proportion of accurate waveforms, recorded as a percentage of total breaths, was 95.7 ± 4.7% for the nasal cannula and 75.8 ± 14.1% for the modified nasal hood (P < .0001). CONCLUSIONS When used for capnography for procedural sedation in an open airway system for routine OMS, the nasal cannula accurately recorded more breaths than the modified nasal hood.
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Affiliation(s)
- Brett J King
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, LA.
| | - Andrew Megison
- Resident, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Zach Scogin
- Resident, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Brian J Christensen
- Chief Resident, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
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Norii T, Homma Y, Shimizu H, Takase H, Kim SH, Nagata S, Shimosato A, Crandall C. Procedural sedation and analgesia in the emergency department in Japan: interim analysis of multicenter prospective observational study. J Anesth 2019; 33:238-249. [PMID: 30617546 DOI: 10.1007/s00540-018-02606-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/23/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE Procedural sedation and analgesia (PSA) is widely performed outside of the operating theater, often in emergency departments (EDs). The practice and safety of PSA in the ED in an aging society such as in Japan have not been well described. We aimed to characterize the practice pattern of PSA including indications, pharmacology and incidence of adverse events (AEs) in Japan. METHODS We formed the Japanese Procedural Sedation and Analgesia Registry, a multicenter prospective observation registry of ED patients undergoing PSA. We included all patients who received PSA in the ED. PSA was defined as any systemic pharmacological intervention intended to facilitate a painful or uncomfortable procedure. The main variables in this study were patients' demographics, American Society of Anesthesiologists (ASA) physical status, indication of PSA, medication choices, and AEs. The primary outcome measure was overall AEs from PSA. RESULTS We enrolled 332 patients in four EDs during the 12-month period. The median age was 67 years (IQR, 46-78). In terms of ASA physical status, 79 (23.8%), 172 (51.8%), and 81 (24.4%) patients were class 1, 2, 3 or higher, respectively. The most common indication was cardioversion (44.0%). The most common sedative used was thiopental (38.9%), followed by midazolam (34.0%) and propofol (19.6%). Among all patients, 72 (21.7%, 95% confidence interval, 17-26) patients experienced one or more AEs. The most common AE was hypoxia (9.9%), followed by apnea (7.2%) and hypotension (3.5%). All of the AEs were transient and no patient had a serious AE. CONCLUSION In a multicenter prospective registry in Japan, PSA in the ED appears safe particularly since the patients who underwent PSA were older and had a higher risk profile compared to patients in previous studies in different countries.
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Affiliation(s)
- Tatsuya Norii
- Department of Emergency Medicine, University of New Mexico, MSC11 6025, 1 UNM, Albuquerque, NM, 87131-0001, USA.
| | - Yosuke Homma
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Hiroyasu Shimizu
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Hiroshi Takase
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, 880 Kita-Kobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan
| | - Sung-Ho Kim
- Department of Emergency Medicine, Osaka Police Hospital, 10-31, Kitayama-cho, Tennouji-ku, Osaka, 543-0035, Japan
| | - Shimpei Nagata
- Department of Emergency Medicine, Osaka Police Hospital, 10-31, Kitayama-cho, Tennouji-ku, Osaka, 543-0035, Japan
| | - Akihikari Shimosato
- Department of Anesthesiology, Kenwakai Otemachi Hospital, 15-1 Otemachi, Kokurakita-ku, Kitakyushu, Japan
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico, MSC11 6025, 1 UNM, Albuquerque, NM, 87131-0001, USA
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Huppelschoten AG, Bijleveld K, Braams L, Schoot BC, van Vliet HAAM. Laparoscopic Sterilization Under Local Anesthesia with Conscious Sedation Versus General Anesthesia: Systematic Review of the Literature. J Minim Invasive Gynecol 2017; 25:393-401. [PMID: 29180307 DOI: 10.1016/j.jmig.2017.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 11/16/2022]
Abstract
Female sterilization is the most popular and common contraceptive method worldwide. Because hysteroscopic sterilization techniques are used less often due to side effects, the number of laparoscopic sterilization is increasing. A systematic overview concerning the most optimal anesthetic technique for laparoscopic sterilization is lacking. We performed a systematic review to compare conscious sedation with general anesthesia for laparoscopic sterilization procedures with respect to clinical relevant outcome measures, such as operating times, perioperative parameters and complications, patient comfort, recovery, and patient satisfaction. We searched Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized controlled trials comparing general anesthesia with conscious sedation for laparoscopic sterilization. Two authors (AGH and HAAMvV) abstracted and entered data into RevMan. Methodologic quality of the included trials was critically appraised. For our main outcome measures mean differences (continuous variables) and risk ratios (dichotomous variables) with 95% confidence intervals using random-effect models were calculated. Four randomized controlled trials were included comparing general anesthesia versus local anesthesia with conscious sedation for laparoscopic sterilization. The methodologic quality of the studies was moderate to good. Both techniques were comparable with regard to operating times, complications, and postoperative pain. However, local anesthesia with conscious sedation showed better results compared with general anesthesia with respect to recovery times, patient complaints of sore throat, and patient recovery and satisfaction. In conclusion, this systematic review about anesthetic techniques for laparoscopic sterilization showed that both general anesthesia and conscious sedation have no major anesthetic complications and may therefore be safe. Patients might benefit from conscious sedation in terms of recovery times, sore throat, and patient recovery and satisfaction, but only a few studies are included in the review and are relatively old. New research regarding this subject is needed to advise our patients most optimally in the future about the best anesthetic technique to be used when choosing for a laparoscopic sterilization procedure.
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Affiliation(s)
- Aleida G Huppelschoten
- Departments of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands.
| | - Kim Bijleveld
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Loes Braams
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Benedictus C Schoot
- Departments of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands; Department of Obstetrics and Gynecology, University Hospital, Gent, Belgium
| | - Huib A A M van Vliet
- Departments of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands
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