Evaluation of Sedation Failure in the Outpatient Oral and Maxillofacial Surgery Clinic

Audit of flumazenil use in special care and oral surgery sedation services

Background The National Patient Safety Agency (2008) has advised against routine reliance on flumazenil for reversal of sedation and encourages regular audit to help identify issues with excessive dosing of midazolam. This multi-centre audit of flumazenil use across both community-based special care and dental hospital oral surgery specialist services was conducted to compare practice against that reported from other UK sedation services.Methods A six-year retrospective audit was conducted using controlled drug records and patient case notes.Results Both services used flumazenil at very infrequent levels and far below the agreed standard. The dose of flumazenil and justification for its use was recorded in all records. There was variability in the nature of the justifications between the two services, which likely relates to the differing patient groups seen by the specialties. The majority of cases related to supporting the patient's escort for their journey home; however, this was not always pre-planned.Conclusions There was a low level of flumazenil use over an extended period of time, supporting the concept of a culture of safe sedation provision in both services. The audit highlighted variation in record-keeping and need for improved communication with patients about escort requirements.

Awake craniotomy. A patient`s perspective

Objective:

To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection.

Methods:

We carried out a qualitative descriptive survey of patients’ experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital.

Results:

Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated.

Conclusion:

Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations.

Sedation for children with intraoral injuries in the emergency department: a case-control study

OBJECTIVE

Intraoral procedures (IOPs) are performed within the oral cavity of a spontaneously breathing, deeply sedated child. The objective of this study was to retrospectively evaluate the safety of sedation for IOP in a pediatric emergency department.

METHODS

An unmatched, case-control study was conducted. The records of patients who had an IOP between January 1, 2012, and December 31, 2012, were analyzed. We evaluated the rate of serious adverse events during sedation (SAEDS) in patients who had an IOP (case subjects) and in patients who had a closed reduction of a forearm fracture (controls) and compared the 2 cohorts.

RESULTS

Forty-one study subjects and 38 controls had complete records. Demographic characteristics were similar for both groups. Cases and controls were treated with the combination of propofol-ketamine for most of the cases (30/41 [73.2%] and 32/38 [84.2%]), and doses were similar between the groups. Study subjects had 5 hypoxic events and 2 apneic events; controls had 4 hypoxic events and 2 apneic events. No aspiration events were recorded. There were no statistically significant differences in the rate of SAEDS between the 2 groups (P = 0.55 and P = 0.54, respectively). All SAEDS were successfully managed in the emergency department, and no patient required hospitalization due to an adverse reaction.

CONCLUSIONS

Findings of this study suggest that when performed by a skilled provider, sedation for an IOP is as safe as sedation for a fracture reduction.

Increase of paradoxical excitement response during propofol-induced sedation in hazardous and harmful alcohol drinkers

BACKGROUND

Paradoxical excitement response during sedation consists of loss of affective control and abnormal movements. Chronic alcohol abuse has been proposed as a predisposing factor despite lack of supporting evidence. Because alcohol and propofol have a common site of action, we postulated that paradoxical excitement responses during propofol-induced sedation occur more frequently in hazardous and harmful alcohol drinkers than in social or non-drinkers.

METHODS

One hundred and ninety patients undergoing orthopaedic knee joint surgery were enrolled in this prospective and observational study. Subjects were divided into Group HD (hazardous and harmful drinkers) or Group NHD (no hazardous drinkers) according to the alcohol use disorder identification test (AUDIT). In study 1, propofol infusion was adjusted to achieve the bispectral index at 70-80 using target-controlled infusion. In study 2, the target concentration of propofol was fixed at 0.8 (study 2/Low) or 1.4 μg ml(-1) (study 2/High). Paradoxical excitement responses were categorized by intensity into mild, moderate, or severe.

RESULTS

The overall incidence of paradoxical excitement response was higher in Group HD than in Group NHD in study 1 (71.4% vs 43.8%; P=0.022) and study 2/High (70.0% vs 34.5%; P=0.006) but not in study 2/Low. The incidence of moderate-to-severe response was significantly higher in Group HD of study 1 (28.6% vs 3.1%; P=0.0005) and study 2/High (23.3% vs 3.4%; P=0.029) with no difference in study 2/Low. Severe excitement response occurred only in Group HD of study 1 and study 2/High.

CONCLUSIONS

Paradoxical excitement occurred more frequently and severely in hazardous and harmful alcohol drinkers than in social drinkers during propofol-induced moderate-to-deep sedation, but not during light sedation.