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Sneyd JR. Why sedative hypnotics often fail in development. Curr Opin Anaesthesiol 2024; 37:391-397. [PMID: 38841982 DOI: 10.1097/aco.0000000000001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds. RECENT FINDINGS The market is well supported by low-cost generic products and development compounds have not been shown to improve patient outcomes or possess other distinctive characteristics to justify the cost of development. SUMMARY To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
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2
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Šimunović-Erpušina M, Bakarčić D, Cicvarić O, Šimunović L, Sotošek V, Petrović D, Ivančić Jokić N. Postoperative Morbidity after Dental Treatment under General Anesthesia in Children with and without Disabilities. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:668. [PMID: 38674314 PMCID: PMC11051803 DOI: 10.3390/medicina60040668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/04/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: General anesthesia induces reversible unconsciousness, eliminating sensation and enabling painless medical procedures. Vital for dental care, it addresses patients with medical conditions, those needing extensive procedures, and those unable to cooperate due to fear. Dental care for patients with disabilities is a significant unmet need, with studies showing increased oral disease prevalence. This research aims to analyze postoperative morbidity both in healthy and disabled children undergoing dental procedures under general anesthesia. Materials and Methods: This study involved 96 children aged 3 to 15 with dental caries. Two groups were formed: the control group (CTL) (52.94%) included healthy patients requiring general anesthesia due to unsatisfactory cooperation, and the other group included children with physical or intellectual disabilities (CD) (47.96%). Postoperative complications were monitored 1 h after the procedure and 1, 3, 7, and 14 days after the procedure by contacting parents/caregivers by phone. The intensity of postoperative pain was assessed using the Wong-Baker faces pain rating scale. General anesthesia was conducted following a standardized protocol for dental procedures. Results: CTL patients complained more often about postoperative pain 1 h after the procedure (p = 0.03). One day after the procedure, oral bleeding (p = 0.04), fever (p = 0.009), and diarrhea (p = 0.037) occurred more often in CD. In the same period, sore throat appeared more often in CTL (p = 0.036). Three days after the dental treatment, there were statistically significant increases in the occurrence of agitation (p = 0.043) and constipation (p = 0.043) in CD. Seven days later, CD demonstrated a higher occurrence of agitation (p = 0.037). According to the Wong-Baker faces pain rating scale, CTL experienced more frequent and intense pain. Conclusions: CD more frequently reported complications like oral bleeding, fever, and diarrhea. In contrast, the CTL group more often reported pain-related symptoms. The conclusion underscores the need for a pain control protocol for CD and emphasizes the importance of frequent monitoring to prevent unwanted consequences during tooth restoration under general anesthesia.
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Affiliation(s)
- Marija Šimunović-Erpušina
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Rijeka, 51000 Rijeka, Croatia; (M.Š.-E.); (O.C.); (D.P.); (N.I.J.)
- Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
| | - Danko Bakarčić
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Rijeka, 51000 Rijeka, Croatia; (M.Š.-E.); (O.C.); (D.P.); (N.I.J.)
- Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
| | - Odri Cicvarić
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Rijeka, 51000 Rijeka, Croatia; (M.Š.-E.); (O.C.); (D.P.); (N.I.J.)
| | - Luka Šimunović
- Department of Orthodontics, School of Dental Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Vlatka Sotošek
- Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
- Department of Clinical Medical Sciences II, Faculty of Health Studies, University of Rijeka, Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia
| | - Dorotea Petrović
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Rijeka, 51000 Rijeka, Croatia; (M.Š.-E.); (O.C.); (D.P.); (N.I.J.)
| | - Nataša Ivančić Jokić
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Rijeka, 51000 Rijeka, Croatia; (M.Š.-E.); (O.C.); (D.P.); (N.I.J.)
- Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
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3
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Kim SH, Moon YJ, Chae MS, Lee YJ, Karm MH, Joo EY, Min JJ, Koo BN, Choi JH, Hwang JY, Yang Y, Kwon MA, Koh HJ, Kim JY, Park SY, Kim H, Chung YH, Kim NY, Choi SU. Korean clinical practice guidelines for diagnostic and procedural sedation. Korean J Anesthesiol 2024; 77:5-30. [PMID: 37972588 PMCID: PMC10834708 DOI: 10.4097/kja.23745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Abstract
Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.
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Affiliation(s)
- Sang-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yea-Ji Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Eun-Young Joo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yeonmi Yang
- Department of Pediatric Dentistry, Jeonbuk National University School of Dentistry, Jeonju, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Hyun Jung Koh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yang-Hoon Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
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4
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Ditlev M, Loentoft E, Hölmich LR. Breast augmentation under local anesthesia with intercostal blocks and light sedation. J Plast Surg Hand Surg 2023; 57:271-278. [PMID: 35510744 DOI: 10.1080/2000656x.2022.2069789] [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] [Indexed: 10/18/2022]
Abstract
INTRODUCTION This study of breast augmentations performed under local anesthesia with intercostal blocks and light sedation describes the outcomes and evaluates benefits and complications. METHOD From December 2005 until August 2019, 335 women consecutively underwent bilateral breast augmentation procedures. The anesthetic protocol consisted of an initial intravenous bolus of 1 mg midazolam and 0.25 mg alfentanil preoperatively. In 2017, this was changed to 2-4 mg midazolam intramuscularly, 1 mg midazolam intravenously, and 2.5 µg sufentanil intravenously. Intercostal blocks were injected at the midaxillary line into the intercostal spaces two to seven. The operating field was infiltrated with tumescent local anesthesia. Retrospective data extraction from patients' medical charts was done, registering demographics, dosage of anesthesia, surgical characteristics, complications, and reoperation rates. RESULTS Two hundred and eighty-one women underwent primary augmentation and 54 had implant replacement. The most common complications included suboptimal cosmetic results, asymmetry, and healing-related problems. The overall rate of reoperation was 16.1% within an average follow-up period of 2 years, ranging from 0 to 12.5 years. The majority of the reoperations were due to cosmetic reasons. The change in anesthetic regime was associated with a significantly (p < 0.0001) decreased need for supplementary medication with no increased risk of complications. CONCLUSION Breast augmentations in local anesthesia with intercostal blocks and light sedation can be performed safely and can serve as an alternative to procedures in general anesthesia.
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Affiliation(s)
- Martine Ditlev
- Plastic Surgery Clinic, Erik Loentoft, Odense, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Erik Loentoft
- Plastic Surgery Clinic, Erik Loentoft, Odense, Denmark
| | - Lisbet R Hölmich
- Department of Plastic Surgery, Copenhagen University, Herlev and Gentofte, Copenhagen, Denmark
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5
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Martinez-Dolz L, Pajares A, López-Cantero M, Osca J, Díez JL, Paniagua P, Argente P, Arana E, Alonso C, Rodriguez T, Vicente R, Anguita M, Alvarez J. Consensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:309-337. [PMID: 34147407 DOI: 10.1016/j.redare.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Affiliation(s)
- L Martinez-Dolz
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, IIS La Fe, CIBERCV, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
| | - M López-Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
| | - J Osca
- Unidad de Arritmias, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
| | - J L Díez
- Unidad de Hemodinámica, Servicio de Cardiología del Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
| | - P Paniagua
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - P Argente
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
| | - E Arana
- Unidad de Arritmias, Servicio de Cardiología, Hospital Virgen del Rocío, Sevilla, Spain
| | - C Alonso
- Unidad de Arritmias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - T Rodriguez
- Unidad de Hemodinámica, Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain
| | - R Vicente
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
| | - M Anguita
- Servicio de Cardiología, Hospital Reina Sofía de Córdoba, Córdoba, Spain
| | - J Alvarez
- Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario de Santiago, Universidad de Santiago, Santiago de Compostela, Spain
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Sahyoun C, Cantais A, Gervaix A, Bressan S, Löllgen R, Krauss B. Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice. Eur J Pediatr 2021; 180:1799-1813. [PMID: 33511466 PMCID: PMC8105204 DOI: 10.1007/s00431-021-03930-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022]
Abstract
Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.Conclusion: Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space. What is Known: • Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures. • We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms "pediatrics," "hypnotics and sedatives," "conscious sedation," and "ambulatory surgical procedures" and the non-MeSH term "procedural sedation" and found no reports describing the current practice of pediatric PSA in Europe. What is New: • This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia. • Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.
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Affiliation(s)
- Cyril Sahyoun
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Aymeric Cantais
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Alain Gervaix
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Silvia Bressan
- Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Ruth Löllgen
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Baruch Krauss
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
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7
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Martinez-Dolz L, Pajares A, López-Cantero M, Osca J, Díez JL, Paniagua P, Argente P, Arana E, Alonso C, Rodriguez T, Vicente R, Anguita M, Alvarez J. Consensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:309-337. [PMID: 33931263 DOI: 10.1016/j.redar.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/01/2020] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Affiliation(s)
- L Martinez-Dolz
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. IIS La Fe. CIBERCV, Valencia, España.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe. IIS La Fe, Valencia, España
| | - M López-Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe. IIS La Fe, Valencia, España
| | - J Osca
- Unidad de Arritmias, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. IIS La Fe, Valencia, España
| | - J L Díez
- Unidad de Hemodinámica, Servicio de Cardiología del Hospital Universitari i Politècnic La Fe. IIS La Fe, Valencia, España
| | - P Paniagua
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - P Argente
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe. IIS La Fe, Valencia, España
| | - E Arana
- Unidad de Arritmias, Servicio de Cardiología, Hospital Virgen del Rocío, Sevilla, España
| | - C Alonso
- Unidad de Arritmias, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - T Rodriguez
- Unidad de Hemodinámica, Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, España
| | - R Vicente
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe. IIS La Fe, Valencia, España
| | - M Anguita
- Servicio de Cardiología, Hospital Reina Sofía de Córdoba., Córdoba, España
| | - J Alvarez
- Servicio Anestesia y Reanimación. Complejo Hospitalario Universitario de Santiago. Universidad de Santiago, Santiago de Compostela, España
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Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review. Br J Anaesth 2021; 127:41-55. [PMID: 33965206 DOI: 10.1016/j.bja.2021.03.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 12/19/2022] Open
Abstract
Anaesthesiologists and non-anaesthesiologist sedationists have a limited set of available i.v. hypnotics, further reduced by the withdrawal of thiopental in the USA and its near disappearance in Europe. Meanwhile, demand for sedation increases and new clinical groups are using what traditionally are anaesthesiologists' drugs. Improved understanding of the determinants of perioperative morbidity and mortality has spotlighted hypotension as a potent cause of patient harm, and practice must be adjusted to respect this. High-dose propofol sedation may be harmful, and a critical reappraisal of drug choices and doses is needed. The development of remimazolam, initially for procedural sedation, allows reconsideration of benzodiazepines as the hypnotic component of a general anaesthetic even if their characterisation as i.v. anaesthetics is questionable. Early data suggest that a combination of remimazolam and remifentanil can induce and maintain anaesthesia. Further work is needed to define use cases for this technique and to determine the impact on patient outcomes.
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9
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Chen W, Chen S, Huang Y. Induction and maintenance of procedural sedation in adults: focus on remimazolam injection. Expert Rev Clin Pharmacol 2021; 14:411-426. [PMID: 33686920 DOI: 10.1080/17512433.2021.1901575] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.
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Affiliation(s)
- Weiyun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Shaohui Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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10
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Linz D, Homberg M, van der Velden RMJ, Bouman E, Buhre W, Simons SO. Sleep apnea, obesity and COPD depress respiration during catheter ablation procedures: Implications for transcutaneous carbon dioxide monitoring. Int J Cardiol 2020; 327:102-104. [PMID: 33152419 DOI: 10.1016/j.ijcard.2020.10.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands; Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Anesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Marloes Homberg
- Department of Anesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rachel M J van der Velden
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Esther Bouman
- Department of Anesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Wolfgang Buhre
- Department of Anesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sami O Simons
- Department of Pulmonology, Maastricht University Medical Centre, Maastricht, the Netherlands
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11
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Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: A European survey. Eur J Anaesthesiol 2020; 36:946-954. [PMID: 31268913 DOI: 10.1097/eja.0000000000001043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. OBJECTIVE To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. DESIGN Online survey. SETTING A total of 38 countries within Europe. PARTICIPANTS Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. MAIN OUTCOME MEASURES Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. RESULTS We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. CONCLUSION Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement.
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Rubinstein-Aguñín P, García-Choque MA, López-Araoz A, Fernández-Bussy S. Sedation for bronchoscopy: current practices in Latin America. J Bras Pneumol 2020. [PMCID: PMC7462680 DOI: 10.1590/1806-3713/e20180240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: To evaluate current practices in sedation for bronchoscopy in Latin America. Methods: This was an anonymous survey of select members of the Latin American Thoracic Association. The questionnaire, made available online from November of 2015 through February of 2016, was designed to collect data on demographic characteristics; type of facility (public or private); type/volume of bronchoscopies; type of sedation; and type of professional administering the sedation. Results: We received 338 completed questionnaires from 19 countries; 250 respondents (74.0%) were male. The mean respondent age was 36.0 ± 10.5 years. Of the 338 respondents, 304 (89.9%) were pulmonologists; 169 (50.0%) worked at public facilities; and 152 (45.0%) worked at teaching facilities. All of the respondents performed diagnostic fiberoptic bronchoscopy, 206 (60.9%) performed therapeutic fiberoptic bronchoscopy, 125 (37.0%) performed rigid bronchoscopy, 37 (10.9%) performed endobronchial ultrasound, and 3 (0.9%) performed laser therapy/thermoplasty/cryotherapy. Sedation for bronchoscopy was employed by 324 respondents (95.6%). Of the 338 respondents, 103 (30.5%) and 96 (28.4%) stated, respectively, that such sedation should “usually” and “never” be administered by a bronchoscopist; 324 (95.9%) supported training bronchoscopists in sedation. Sedation administered by a bronchoscopist was reported by 113 respondents, conscious sedation being employed by 109 (96.2%). The use of benzodiazepines, propofol, and opiates was reported, respectively, by 252 (74.6%), 179 (52.9%), and 132 (39.0%) of the 338 respondents. Deep sedation and general anesthesia were more common at private facilities. Conclusions: The consensus seems to be that a well-trained bronchoscopist can safely administer sedation for bronchoscopy. However, approximately 40% of bronchoscopists do not do so regularly.
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Oubenyahya H, Bouhabba N. General anesthesia in the management of early childhood caries: an overview. J Dent Anesth Pain Med 2019; 19:313-322. [PMID: 31942447 PMCID: PMC6946837 DOI: 10.17245/jdapm.2019.19.6.313] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/13/2019] [Accepted: 10/30/2019] [Indexed: 11/22/2022] Open
Abstract
Early childhood caries is a global healthcare concern in developing and industrialized countries. If left untreated, it leads to immediate and long-term complications that affect the well-being and quality of life of concerned families. Therefore, many preventive and treatment approaches are available to the healthcare provider to curb this virulent form of caries. After behavioral interventions, general anesthesia is used in specific settings when a young patient presents with extensive teeth damage and exhibits a lack of cooperation that is incompatible with conventional dental office care. However, without proper follow-up, any positive results might be lost over time.
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Affiliation(s)
- Hanan Oubenyahya
- Department of Dentistry, Military Hospital Agadir, Agadir, Morocco
| | - Najib Bouhabba
- Department of Anesthesiology, Military Hospital Agadir, Agadir, Morocco
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Cabadas Avión R, Baluja A, Ojea Cendón M, Leal Ruiloba MS, Vázquez López S, Rey Martínez M, Magdalena López P, Álvarez-Escudero J. Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 111:199-208. [PMID: 30507244 DOI: 10.17235/reed.2018.5713/2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training. METHODS a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure. RESULTS a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups. CONCLUSIONS our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.
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Affiliation(s)
| | - Aurora Baluja
- Anestesiología, Hospital universitario Santiago Compostela, España
| | | | | | | | | | | | - Julián Álvarez-Escudero
- Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela. Universidad de Santiago de Compostela, España
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Cabadas Avión R, Leal Ruiloba MS, Vázquez López S, Ojea Cendón M, Wi Hijazi I, Baluja González MA, Álvarez-Escudero J. A descriptive monitoring study of a non-anesthetist sedation quality program. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 111:55-62. [PMID: 30424678 DOI: 10.17235/reed.2018.5763/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION sedation substantially improves the quality of digestive endoscopy procedures but may result in severe complications. METHODS a joint commission-based multidisciplinary protocol was used to define a protocol for sedation by non-anesthesiologists. ASA 4 patients were excluded, as well as patients with a difficult airway, complex procedures and deep sedation. Quality based on the analysis of 9 indicators were monitored. Incomplete procedures were also monitored in order to assess efficacy. RESULTS patient safety was established based on a very low incidence of complications and a rate of respiratory events of 1.07. Furthermore, a low rate of hypotension and bradycardia was found, as well as a low rate of pain, either during or after endoscopy and an incidence of unexpected admissions lower than 0.5%. The quality indicators measured reflect the evolution of the results of the program. CONCLUSIONS ongoing sedation program monitoring in endoscopy allows the control of different quality dimensions and the implementation of steps for process improvement.
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Affiliation(s)
| | | | | | | | | | | | - Julián Álvarez-Escudero
- Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela. Universidad de Santiago de Compostela, España
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Alvarez Escudero J, Rabanal LLevot JM. Sedations: Safety, competency, efficiency. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:483-485. [PMID: 30100088 DOI: 10.1016/j.redar.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 06/08/2023]
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Cabadas Avion R, Rabanal LLevot JM, Gil de Bernabé MÀ, Guasch Arévalo E, Aldecoa Álvarez-Santullano C, Echevarría Moreno M. Sedations in diagnostic and/or therapeutic procedures: quality and safety recommendations. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:520-524. [PMID: 30033045 DOI: 10.1016/j.redar.2018.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Affiliation(s)
| | - J M Rabanal LLevot
- Servicio de Anestesiología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - M À Gil de Bernabé
- Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - E Guasch Arévalo
- Servicio de Anestesiología, Hospital Universitario La Paz, Madrid, España
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Safety and quality of procedural sedation and analgesia practice for adult patients throughout Europe: A step forward. Eur J Anaesthesiol 2018; 35:1-3. [PMID: 29658896 DOI: 10.1097/eja.0000000000000737] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wantanakorn P, Harintajinda S, Chuthapisith J, Anurathapan U, Rattanatamrong P. A New Mobile Application to Reduce Anxiety in Pediatric Patients Before Bone Marrow Aspiration Procedures. Hosp Pediatr 2018; 8:643-650. [PMID: 30213798 DOI: 10.1542/hpeds.2018-0073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Insufficient preparation for children who are undergoing bone marrow aspiration can cause anxiety and negative outcomes. Nonpharmacological therapies have been proven to reduce fear in children who are undergoing painful procedures. We have therefore developed a mobile application to help reduce these patients' anxiety by providing them with procedural information and coping skills. METHODS This single-blinded, randomized controlled trial included 60 patients age 5 to 12 years old who were undergoing bone marrow aspiration procedures in Thailand that were conducted between May 2015 and May 2016. Sixty participants were randomly assigned to the intervention group (mobile application added to usual care) or the control group (usual care only). Preprocedural anxiety levels were evaluated by visual analog scales (child anxiety visual analog scale); this was repeated in the intervention group immediately after patients used the mobile application. On the day of the procedure, the patients' cooperation levels were assessed by using the modified Yale Preoperative Anxiety Scale. The total amount of sedative drugs that were used was also recorded. The paired t test and the Wilcoxon signed rank test were used to analyze within-person change, whereas the t test and the Wilcoxon rank sum test were used for group comparisons. RESULTS The child anxiety visual analog scale score of patients in the intervention group decreased significantly after they used the mobile application (P < .0012). The modified Yale Preoperative Anxiety Scale score of patients in the intervention group was significantly lower than that in the control group (P < .01). There was no difference in sedative use between the 2 groups. CONCLUSIONS This mobile application possibly had effectiveness in routine use for reducing anxiety and increasing patients' cooperation in bone marrow aspiration procedures.
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Affiliation(s)
- Pornchanok Wantanakorn
- Chakri Naruebodindra Medical Institute, and .,Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and
| | - Supamas Harintajinda
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and
| | - Jariya Chuthapisith
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and
| | - Usanarat Anurathapan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and
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European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol 2018; 35:6-24. [DOI: 10.1097/eja.0000000000000683] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Practice Guidelines for Intravenous Conscious Sedation in Dentistry (Second Edition, 2017). Anesth Prog 2018; 65:e1-e18. [PMID: 30702348 PMCID: PMC6318731 DOI: 10.2344/anpr-65-04-15w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Sneyd J. Thiopental to desflurane - an anaesthetic journey. Where are we going next? Br J Anaesth 2017; 119:i44-i52. [DOI: 10.1093/bja/aex328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 01/06/2023] Open
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Baehner T, Dewald O, Heinze I, Mueller M, Schindler E, Schirmer U, Baumgarten G, Hoeft A, Ellerkmann RK. The provision of pediatric cardiac anesthesia services in Germany: current status of structural and personnel organization. Paediatr Anaesth 2017; 27:801-809. [PMID: 28419616 DOI: 10.1111/pan.13153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anesthesia for pediatric cardiac surgery requires a high level of expert knowledge. There are currently no recommendations and standards for anesthetic management for congenital cardiac surgery in Germany. AIM The aim of the present study was to assess the current status of structural and personnel anesthetic standards at pediatric cardiac surgery centers in Germany. METHODS All cardiac surgical centers in Germany were reviewed for an active program for congenital heart surgery. Centers with an active program were invited to respond to an online survey. The questionnaire containing 55 items in 16 categories assessed current practice in pediatric cardiac anesthesia. RESULTS An active program for pediatric cardiac surgery was identified at 27 centers. The response rate to the survey was 96.3%. A specialized group of anesthesiologists for pediatric cardiac anesthesia was reported from 26 centers (92.3%). The mean size of this group was 4.8 anesthesiologists per center. However, the annual case load of centers and relative annual case load per specialized anesthesiologist varied considerably between 12.5 and 250. Nonanesthesiologists performed sedation and general anesthesia for diagnostic and therapeutic interventions outside the operating theater in children with congenital heart diseases in 24 centers (77%). Although special equipment, for example, pediatric TEE, near-infrared spectroscopy, and devices for mechanical auto transfusion were available in most centers, their routine use was not always part of standard operating procedures. The proposal for mean adequate training in pediatric cardiac anesthesia as estimated by the participating centers was 10.8 months. CONCLUSION The present study represents the current structural situation for anesthesia at German pediatric cardiac surgery centers.
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Affiliation(s)
- Torsten Baehner
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Oliver Dewald
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Ingo Heinze
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Matthias Mueller
- Pediatric Heart Centre, Justus-Liebig University, Giessen, Germany
| | - Ehrenfried Schindler
- Department of Pediatric Anesthesiology and Critical Care Medicine, Asklepios Children's Hospital Sankt Augustin, Sankt Augustin, Germany
| | - Uwe Schirmer
- Department of Anesthesiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Georg Baumgarten
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Richard K Ellerkmann
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
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Johnson OG, Taylor DM, Lee M, Ding JL, Ashok A, Johnson D, Peck D, Knott J, Weinberg L. Patient satisfaction with procedural sedation in the emergency department. Emerg Med Australas 2017; 29:303-309. [DOI: 10.1111/1742-6723.12762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 12/01/2016] [Accepted: 12/28/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Olivia G Johnson
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
| | - David McD Taylor
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Emergency Department; Austin Hospital; Melbourne Victoria Australia
| | - Marina Lee
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
| | - Juen-Li Ding
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
| | - Aadith Ashok
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
| | - Damian Johnson
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
| | - Daniel Peck
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
| | - Jonathan Knott
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Emergency Department; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Laurence Weinberg
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Anaesthesia; Austin Hospital; Melbourne Victoria Australia
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Kim KN, Lee HJ, Kim SY, Kim JY. Combined use of dexmedetomidine and propofol in monitored anesthesia care: a randomized controlled study. BMC Anesthesiol 2017; 17:34. [PMID: 28253863 PMCID: PMC5335826 DOI: 10.1186/s12871-017-0311-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/23/2017] [Indexed: 02/13/2023] Open
Abstract
Backgroud Although propofol and dexmedetomidine have been widely used for monitored anesthesia care, their adverse effects necessitate the search for better methods. Therefore, we performed this randomized controlled trial to evaluate the combined use of propofol and dexmedetomidine. Methods Eighty-seven adult patients undergoing hand surgery under brachial plexus block were randomly allocated to receive 1.6 μg/ml of the target effect site concentration of propofol (P group) and infusion of 0.4 μg/kg/h dexmedetomidine following a loading dose of 1.0 μg/kg for 10 min (D group). The M group received a half-dose of both drugs simultaneously. The maintenance dose was adjusted to maintain an Observer Assessment of Alertness/Sedation score of 3. Cardiorespiratory variables, adverse effects, and drug efficacy were observed. Results The significantly higher mean arterial pressure (mmHg) in the D group [P group 86.9 (12.6), D group 96.0 (12.2), M group 85.6 (10.6), p = 0.004)] and a significantly higher heart rate (beat/min) in the P group were observed [P group 67.3 (9.0), D group 57.8 (6.9), M group 59.2 (7.4), p < 0.001)]. The M group had a significant lower incidence of airway obstruction (p < 0.001) and the D group had a higher incidence of bradycardia requiring atropine (p = 0.001). The P group had higher incidences of hypoxia (p = 0.001), spontaneous movement (p < 0.001) and agitation (p = 0.001). The satisfaction scores of the patients (p = 0.007) and surgeon (p < 0.001) were higher in the M group. Onset time was significantly longer in the D group (p < 0.001). Conclusions The combined use of propofol and dexmedetomidine provided cardiovascular stability with decreased adverse effects. Additionally, it led to a similar onset time of propofol and achieved higher satisfaction scores. Trial registration KCT0001284. Retrospectively registered 25 November 2014.
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Affiliation(s)
- Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
| | - Hee Jong Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea.
| | - Soo Yeon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
| | - Ji Yoon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
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Anesthesia Practices for Interventional Radiology in Europe. Cardiovasc Intervent Radiol 2017; 40:803-813. [PMID: 28097415 DOI: 10.1007/s00270-017-1576-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/05/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) prompted an initiative to frame the current European status of anesthetic practices for interventional radiology, in consideration of the current variability of IR suite settings, staffing and anesthetic practices reported in the literature and of the growing debate on sedation administered by non-anesthesiologists, in Europe. METHODS Anonymous online survey available to all European CIRSE members to assess IR setting, demographics, peri-procedural care, anesthetic management, resources and staffing, pain management, data collection, safety, management of emergencies and personal opinions on the role CIRSE should have in promoting anesthetic care for interventional radiology. RESULTS Predictable differences between countries and national regulations were confirmed, showing how significantly many "local" factors (type and size of centers, the availability of dedicated inpatient bed, availability of anesthesia staff) can affect the routine practice and the expansion of IR as a subspecialty. In addition, the perception of the need for IR to acquire more sedation-related skills is definitely stronger for those who practice with the lowest availability of anesthesia care. CONCLUSION Significant country variations and regulations along with a controversial position of the anesthesia community on the issue of sedation administered by non-anesthesiologists substantially represent the biggest drawbacks for the expansion of peri-procedural anesthetic care for IR and for potential initiatives at an European level.
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Grunwell JR, Marupudi NK, Gupta RV, Travers CD, McCracken CE, Williamson JL, Stockwell JA, Fortenberry JD, Couloures K, Cravero J, Kamat PP. Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies. Paediatr Anaesth 2016; 26:628-36. [PMID: 27061749 PMCID: PMC5024537 DOI: 10.1111/pan.12903] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. METHODS We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. RESULTS A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). CONCLUSIONS More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.
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Affiliation(s)
- Jocelyn R. Grunwell
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Neelima K. Marupudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Rohan V. Gupta
- Department of Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Curtis D. Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Julie L. Williamson
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA,Department of Anesthesia, Emory University School of Medicine, Atlanta, GA, USA
| | - Jana A. Stockwell
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - James D. Fortenberry
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Kevin Couloures
- Pediatric Sedation Services, Yale School of Medicine and Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Joseph Cravero
- Department of Anesthesia, Harvard School of Medicine and Boston Children's Hospital, Boston, MA, USA
| | - Pradip P. Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
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CSANZ Position Statement on Sedation for Cardiovascular Procedures (2014). Heart Lung Circ 2015; 24:1041-8. [DOI: 10.1016/j.hlc.2015.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/04/2015] [Indexed: 11/17/2022]
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Guerra F, Pavoni I, Romandini A, Baldetti L, Matassini MV, Brambatti M, Luzi M, Pupita G, Capucci A. Feasibility of a cardiologist-only approach to sedation for electrical cardioversion of atrial fibrillation: A randomized, open-blinded, prospective study. Int J Cardiol 2014; 176:930-5. [DOI: 10.1016/j.ijcard.2014.08.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/05/2014] [Accepted: 08/09/2014] [Indexed: 11/28/2022]
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Astoul P, Maldonado F. Anesthetic drugs managed by pulmonologists during medical thoracoscopy: one size does not fit all! Respiration 2014; 88:265-7. [PMID: 25196379 DOI: 10.1159/000365663] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, and Aix-Marseille University, Marseille, France
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Park WY, Shin YS, Lee SK, Kim SY, Lee TK, Choi YS. Bispectral index monitoring during anesthesiologist-directed propofol and remifentanil sedation for endoscopic submucosal dissection: a prospective randomized controlled trial. Yonsei Med J 2014; 55:1421-9. [PMID: 25048506 PMCID: PMC4108833 DOI: 10.3349/ymj.2014.55.5.1421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications. MATERIALS AND METHODS A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded. RESULTS The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications. CONCLUSION BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.
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Affiliation(s)
- Woo Young Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yang-Sik Shin
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Tai Kyung Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Lee TH, Lee CK. Endoscopic sedation: from training to performance. Clin Endosc 2014; 47:141-50. [PMID: 24765596 PMCID: PMC3994256 DOI: 10.5946/ce.2014.47.2.141] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 12/24/2022] Open
Abstract
Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang Kyun Lee
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
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Tschirdewahn S, Rübben H, Schenck M. [Urological surgery with analogosedation and local anesthesia. What makes sense?]. Urologe A 2013; 52:1302-11. [PMID: 23959458 DOI: 10.1007/s00120-013-3316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Analogosedation and local anesthesia, including regional nerve blocks are used for endoscopic diagnostic or radiological and ultrasound-guided procedures in which the patient should not move or has to be free of pain. We retrospectively analyzed patient satisfaction, complications and the risk of urological interventions with analgosedation and/or local anesthesia between 2008 and 2012. MATERIAL AND METHODS In total 21,690 urological patients underwent surgical treatment at the Department of Urology of the University Hospital of Essen between 2008 and 2012 and 3,327 of these cases were performed by urologists with the patient under analogosedation (n=1484) and local anesthesia (n=1843). In total 13 surgical and endoscopic procedures were separately analyzed and evaluated for safety and practicability. RESULTS In five cases (0.15%) the procedures with analgosedation or local anesthesia were interrupted because of agitation (n=3) and in one case the transurethal resection was stopped due to a large bladder tumor. One patient suffered anaphylactic shock after preoperative intravenous application of cefuroxim 1.5 g. After cardiopulmonary resuscitation and a short stay on the intensive care unit the patient was discharged after 2 days.Conclusions. Local anesthesia and analgosedation should be performed by urologists for minor surgery, endoscopic procedures and radiological or ultrasound-guided treatment. For safety reasons there should always be a second medical doctor present for assistance. Analgesia with deep sedation or loss of defensive reflexes should be administered by anesthesiologists.
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Kim J, Jang GD, Kim DS, Min KT. Small dose of propofol combined with dexamethasone for postoperative vomiting in pediatric Moyamoya disease patients: a prospective, observer-blinded, randomized controlled study. Korean J Anesthesiol 2013; 64:127-32. [PMID: 23459562 PMCID: PMC3581781 DOI: 10.4097/kjae.2013.64.2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/02/2012] [Accepted: 10/07/2012] [Indexed: 11/29/2022] Open
Abstract
Background For effective postoperative antiemetic management in pediatric moyamoya disease patients receiving fentanyl based postoperative analgesia, a multimodal approach has been recommended. The uncertain efficacy of ondansetron for pediatric neurosurgical patients or the possible antiemetic effect of small dose of propofol motivated us to evaluate the preventive effect of a subhypnotic dose of propofol combined with dexamethasone on postoperative vomiting (POV), especially during immediate postoperative periods. Methods In a prospective observer-blind randomized controlled study, we compared dexamethasone 0.15 mg/kg alone (Group D) with dexamethasone combined with propofol of 0.5 mg/kg (Group DP) in 60 pediatric patients, aged 4-17 years, who underwent indirect bypass surgery and received fentanyl-based postoperative analgesia. Occurrence of vomiting and pain score (Wong-Baker facial score) and requirement of rescue analgesic and antiemetic were continually measured (0-2, 2-6, 6-12 and 12-24 postoperative hours). For statistical analysis, in addition to the Fisher's exact test, a generalized linear mixed model (GLMM) and the linear mixed model (LMM) for repeated measures were used for vomiting and pain scores, respectively. Results There was no statistical significance of POV incidence, requirement of rescue analgesic and pain score between the two groups at any measured intervals. The incidence of POV was 53.3% during 24 hours in both groups, and was especially 6.7% and 13.3% (P = 0.671) during 0-2 hr and 16.7% and 23.3% (P = 0.748) during 2-6 hr in group D and group DP, respectively. Conclusions A small dose of propofol combined with dexamethasone appears ineffective to preventing POV in pediatric moyamoya patients receiving continuous fentanyl infusion.
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Affiliation(s)
- Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University Health System, Seoul, Korea. ; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Affiliation(s)
- Ho-Geol Ryu
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea
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NILSSON A, NILSSON L, USTAAL E, SJÖBERG F. Alfentanil and patient-controlled propofol sedation - facilitate gynaecological outpatient surgery with increased risk of respiratory events. Acta Anaesthesiol Scand 2012; 56:1123-9. [PMID: 22897508 DOI: 10.1111/j.1399-6576.2012.02749.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Widespread use of patient-controlled sedation (PCS) demands simplicity and a predictable outcome. We evaluated patients' safety and ease of use of PCS for gynaecological outpatient procedures. METHODS In a prospective double-blind study, 165 patients were randomized to use propofol or propofol with alfentanil as PCS combined with local anaesthetic for pain control. Data on cardiopulmonary function, consciousness, and need for interventions were collected at baseline and every fifth minute. The surgeons' evaluation of the ease and the duration of the procedure were recorded. RESULTS One hundred and fifty-five patients used PCS for the entire procedure, 76 patients propofol, and 79 patients propofol/alfentanil. Fifteen procedures in the propofol group were limited or could not be done, compared with four in the propofol/alfentanil group (P = 0.02). The duration of surgery was not affected. The addition of alfentanil affected respiratory function compared with the propofol group: five patients compared with none were manually ventilated (P = 0.03), and two thirds, compared with a quarter, were given supplementary oxygen as their saturation decreased below 90% (P < 0.001). Overall cardiovascular stability was maintained. The propofol group had deeper conscious sedation as measured by the bispectral index (P = 0.03), but all patients could be roused. In the propofol/alfentanil group, five patients became apnoeic and could not be roused. CONCLUSIONS PCS using propofol alone supports patients' safety, as the addition of alfentanil increased the need for specific interventions to maintain respiratory stability. However, alfentanil increases the feasibility of the procedure, as complementary doses of propofol were not required.
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Affiliation(s)
| | | | - E. USTAAL
- Department of Obstetrics and Gynecology; Linköping University Hospital; Linköping; Sweden
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Procedural pain in children: education and management. The approach of an Italian pediatric pain center. Eur J Pediatr 2012; 171:1175-83. [PMID: 22395564 DOI: 10.1007/s00431-012-1693-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 02/07/2012] [Indexed: 12/11/2022]
Abstract
Pain management should be warranted for all children in every situation. Italian legislation proposes a model for pain assistance based on specialized tertiary centers which provide direct clinical management for complex cases and assure continuous cooperation with hospitals and family pediatricians for managing painful conditions every day. The Procedural Pain Service of the University of Padua Department of Pediatrics applies such model for procedural pain management. We describe activities of Service since January 1, 2006 on two levels: education and training for territorial services and sedation-analgesia when required for invasive and painful procedures. Since 2006 to date, the Service team produced an internal protocol for procedural sedation, developed two master courses, and organized a training program for procedural pain management in the territorial context. Procedural sedation-analgesia service provided overall 10,832 sedations to perform 14,264 procedures for 3,815 patients, median age of 6 years old. The most frequently performed procedures were lumbar puncture and bone marrow aspiration, followed by gastroscopy and bronchoscopy. Most frequently administered drug combinations were local analgesia + intravenous midazolam alone or midazolam and propofol or midazolam and propofol and ketamine; most frequently used non-pharmacological methods were distraction using cartoons and bubbles. Minor adverse events were recorded in 281 cases (2.5%), the most common being desaturation (2.1%). In conclusion, our model functions on two integrated levels, and it can be considered generally applicable as a solution for pain management.
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Goeters C. Anesthetic management of children undergoing hematologic-oncologic procedures outside the operating room. Curr Opin Anaesthesiol 2012; 25:493-7. [PMID: 22732421 DOI: 10.1097/aco.0b013e328354ff81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW There is an increasing demand on anesthetic services to provide care for children undergoing hematologic-oncologic procedures outside the operation room; in particular, to mitigate the pain and unpleasant side-effects of these treatments. This review provides an update of the latest findings on this topic. RECENT FINDINGS An Italian survey of the management of procedural pain in children undergoing hematologic-oncologic interventions indicates that international guidelines are still not completely realized. It is essential to weigh safety concerns against patient comfort when deciding where the procedure will take place and who will perform it. An approach that addresses individual patient as well as institutional issues is optimum. Nonpharmacologic interventions combined with standard pharmacological ones are essential to reduce fear and distress in the children and their relatives. Psychological interactions as well as the child's development have to be considered. Special training for providers and an interdisciplinary approach are likely to be effective in improving treatment modalities and quality. SUMMARY Treatment of children undergoing hematologic-oncologic procedures outside the operation room is challenging. Expertise and high standards are essential to assure patient safety.
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Affiliation(s)
- Christiane Goeters
- Department of Anesthesiology and Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany.
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Eberl S, Preckel B, Fockens P, Hollmann MW. Analgesia without sedatives during colonoscopies: worth considering? Tech Coloproctol 2012; 16:271-6. [PMID: 22669482 PMCID: PMC3398250 DOI: 10.1007/s10151-012-0834-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 04/17/2012] [Indexed: 12/25/2022]
Abstract
Colonoscopy is a proven method for bowel cancer screening and is often experienced as a painful procedure. Today, there are two main strategies to facilitate colonoscopy. First, deep sedation results in satisfied patients but increases sedation-associated risks and raises costs for healthcare providers. Second, there is the advocacy for colonoscopies without any form of sedation. This might be an option for a special group of patients, but does not hold true for everybody. Following Moerman’s hypothesis: “If pain is the crucial point, why do we need sedation?” this review shows the analgesic options for a painless procedure, increasing success rates without increasing risk of sedation. There are two agents, with the potential to be a nearly ideal analgesic agent for colonoscopy: alfentanil and nitrous oxide (N2O). Administration of either substance causes the patient to be comfortable yet alert and facilitates a short turnover. Advantages of these drugs include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level, rapid recovery, and an excellent safety profile.
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Affiliation(s)
- S Eberl
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.
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Sayfo S, Vakil KP, Alqaqa'a A, Flippin H, Bhakta D, Yadav AV, Miller JM, Groh WJ. A retrospective analysis of proceduralist-directed, nurse-administered propofol sedation for implantable cardioverter-defibrillator procedures. Heart Rhythm 2012; 9:342-6. [DOI: 10.1016/j.hrthm.2011.10.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Indexed: 11/26/2022]
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Vemulapalli KC, Rex DK. Guidelines for an Optimum Screening Colonoscopy. CURRENT COLORECTAL CANCER REPORTS 2012. [DOI: 10.1007/s11888-011-0109-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Po' C, Benini F, Sainati L, Farina MI, Cesaro S, Agosto C. The management of procedural pain at the Italian Centers of Pediatric Hematology-Oncology: state-of-the-art and future directions. Support Care Cancer 2011; 20:2407-14. [PMID: 22210474 DOI: 10.1007/s00520-011-1347-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 12/05/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE The quality of life of children with cancer can be affected by the experience of cancer-related pain, treatment-related pain, procedural pain, generalized pain, and long-term chronic pain, and the consequences may be permanent. Treatment-related pain and procedural pain are often reportedly the most painful experiences relating to their illness. Procedural pain treatment is therefore now considered essential. This multicenter survey investigated how procedural pain is managed at Italian Pediatric Hematology-Oncology Centers. METHODS From April to October 2010, questionnaires were collected from the directors and/or referent of the Italian Centers of Pediatric Hematology-Oncology about the management of lumbar punctures, bone marrow aspirates, and biopsies. RESULTS We received responses from 67% of the centers (which performed a total of 13,271 procedures per year). Fifty percent of the procedures were performed in the operating room. The sedation-analgesia was provided "almost always" for 84% of procedures. Non-pharmacological treatments were used in 55% of the centers. The specialist who practiced analgesia was the anesthetist in 83.3% of the cases. CONCLUSIONS A nationwide multicentre survey has been conducted for the first time to verify the management of procedural pain in Pediatric Hematology-Oncology patients. The results indicate that many aspects in the management of procedural pain appear consistent with the international guidelines. Some problems still remain, including the inability to ensure adequate sedation-analgesia in all the patients--often due to the lack of adequate staff, the frequent use of the operating room, and an underdeveloped use of non-pharmacological therapies.
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Affiliation(s)
- Chiara Po'
- Pediatric Pain and Palliative Care Service, Department of Pediatrics, University of Padua, Padua, Italy
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Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol 2011; 28:580-4. [PMID: 21705907 DOI: 10.1097/eja.0b013e328348a977] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Propofol, which is the most commonly used drug for induction of general anaesthesia, has also become a popular drug for procedural sedation. Because its use may be associated with serious and potentially fatal side-effects, the manufacturers of propofol restrict its use solely to personnel trained in general anaesthesia. In spite of this warning, the use of propofol for procedural sedation by non-anaesthesiologists is rapidly expanding in many countries. Recently, the US Food and Drugs Administration (FDA) denied a petition from gastroenterologists seeking the removal of this particular restriction. This unequivocal ruling of the FDA received strong support from the American Society of Anesthesiologists (ASA). At about the same time, the European Society of Anaesthesiology (ESA), together with various European gastroenterology societies, published new guidelines entitled 'Non-anaesthesiologist Administration of Propofol for Gastrointestinal Endoscopy' (NAAP). Following publication of the NAAP guidelines, many reservations have been expressed by ESA member societies and individuals, dealing with professional, political, procedural and safety-oriented concerns. Out of concern for patient safety, and in order to officially and publicly dissociate themselves from the NAAP guidelines, 21 national societies of anaesthesiology in Europe, all of whom are ESA members, have signed a Consensus Statement confirming that due to its significant well known risks, propofol should be administered only by those trained in the administration of general anaesthesia.
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Po' C, Benini F, Sainati L, Farina MI, Cesaro S, Agosto C. Procedural pain management in Italy: learning from a nationwide survery involving centers of the Italian Association of Pediatric Hematology-Oncology. Pediatr Rep 2011; 3:e34. [PMID: 22355519 PMCID: PMC3283202 DOI: 10.4081/pr.2011.e34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 10/24/2011] [Indexed: 12/01/2022] Open
Abstract
Procedural pain is an important aspect of care in pediatrics, and particularly in pediatric oncology where children often consider this to be the most painful experience during their illness. Best recommended practice to control procedural pain includes both sedative-analgesic administration and non-pharmacological treatments, practiced in an adequate and pleasant setting by skilled staff. A nationwide survey has been conducted among the Italian Centers of Pediatric Hematology-Oncology to register operators' awareness on procedural pain, state of the art procedural pain management, operators' opinions about pain control in their center, and possible barriers impeding sedation-analgesia administration. Based on indications in the literature, we discuss the results of the survey to highlight critical issues and suggest future directions for improvement. Future objectives will be to overcome differences depending on size, improve operators' beliefs about the complexity of pain experience, and promote a global approach to procedural pain.
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Affiliation(s)
- Chiara Po'
- Pediatric Pain and Palliative Care Service, Department of Pediatrics, University of Padua
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Guidelines on non-anaesthesiologist administration of propofol for gastrointestinal endoscopy. Eur J Anaesthesiol 2011; 28:553-5. [DOI: 10.1097/eja.0b013e328348a9db] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patient-controlled analgesia and sedation with alfentanyl versus fentanyl for colonoscopy: a randomized double blind study. J Clin Gastroenterol 2011; 45:e72-5. [PMID: 21135703 DOI: 10.1097/mcg.0b013e318201fbce] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE The aim of this study was to evaluate whether sedo-analgesia with alfentanyl/fentanyl, using a patient-controlled analgesia (PCA) pump, may have positive outcomes in terms of safety, postprocedural workload, and expectations of the colonoscopist, nurse, and patients in elective colonoscopy. PATIENTS One hundred American Society of Anesthesiology physical status I and II adult patients. INTERVENTIONS Patients were randomized in a double-blind trial to receive either alfentanyl (n=50) or fentanyl (n=50) by PCA, and incremental doses of midazolam. MEASUREMENTS Patient expectations were assessed using hemodynamic variables, willingness to have a repeat colonoscopy in the same way, adverse events, discomfort scores, and patient/operator/nurse satisfaction associated with sedo-analgesia. RESULT All patients in both groups had adequate sedo-analgesia with high satisfaction and willingness scores. There were no serious adverse effects and except for a few events, no required medication. The total sedation times were shorter in the alfentanyl group compared with the fentanyl group. CONCLUSIONS PCA and sedation with alfentanyl and fentanyl for colonoscopy are safe, feasible, and acceptable to most patients. However, shorter sedation times make alfentanyl more attractive for postprocedural workload.
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Po' C, Benini F, Sainati L, Frigo AC, Cesaro S, Farina MI, Agosto C. The opinion of clinical staff regarding painfulness of procedures in pediatric hematology-oncology: an Italian survey. Ital J Pediatr 2011; 37:27. [PMID: 21663631 PMCID: PMC3127832 DOI: 10.1186/1824-7288-37-27] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/10/2011] [Indexed: 01/15/2023] Open
Abstract
Background Beliefs of caregivers about patient's pain have been shown to influence assessment and treatment of children's pain, now considered an essential part of cancer treatment. Painful procedures in hematology-oncology are frequently referred by children as the most painful experiences during illness. Aim of this study was to evaluate professionals' beliefs about painfulness of invasive procedures repeatedly performed in Pediatric Hemato-Oncology Units. Methods Physicians, nurses, psychologists and directors working in Hemato-Oncology Units of the Italian Association of Pediatric Hematology-Oncology (AIEOP) were involved in a wide-nation survey. The survey was based on an anonymous questionnaire investigating beliefs of operators about painfulness of invasive procedures (lumbar puncture, bone marrow aspirate and bone marrow biopsy) and level of pain management. Results Twenty-four directors, 120 physicians, 248 nurses and 22 psychologists responded to the questionnaire. The score assigned to the procedural pain on a 0-10 scale was higher than 5 in 77% of the operators for lumbar puncture, 97.5% for bone marrow aspiration, and 99.5% for bone marrow biopsy. The scores assigned by nurses differed statistically from those of the physicians and directors for the pain caused by lumbar puncture and bone marrow aspiration. Measures adopted for procedural pain control were generally considered good. Conclusions Invasive diagnostic-therapeutic procedures performed in Italian Pediatric Hemato-Oncology Units are considered painful by all the caregivers involved. Pain management is generally considered good. Aprioristically opinions about pain depend on invasiveness of the procedure and on the professional role.
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Affiliation(s)
- Chiara Po'
- Pediatric Pain and Palliative Care Service, Department of Pediatrics, University of Padua, Italy
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