Determination of the maximum tolerated dose of intranasal sufentanil and midazolam in Chinese: a pilot study

Determination of the ED95 of intranasal sufentanil combined with intranasal dexmedetomidine for moderate sedation during endoscopic ultrasonography

BACKGROUND

Sedation during endoscopic ultrasonography (EUS) poses many challenges and moderate-to-deep sedation are often required. The conventional method to preform moderate-to-deep sedation is generally intravenous benzodiazepine alone or in combination with opioids. However, this combination has some limitations. Intranasal medication delivery may be an alternative to this sedation regimen.

AIM

To determine, by continual reassessment method (CRM), the minimal effective dose of intranasal sufentanil (SUF) when combined with intranasal dexmedetomidine (DEX) for moderate sedation of EUS in at least 95% of patients (ED₉₅).

METHODS

Thirty patients aged 18-65 and scheduled for EUS were recruited in this study. Subjects received intranasal DEX and SUF for sedation. The dose of DEX (1 μg/kg) was fixed, while the dose of SUF was assigned sequentially to the subjects using CRM to determine ED₉₅. The sedation status was assessed by modified observer’s assessment of alertness/sedation (MOAA/S) score. The adverse events and the satisfaction scores of patients and endoscopists were recorded.

RESULTS

The ED₉₅ was intranasal 0.3 μg/kg SUF when combined with intranasal 1 μg/kg DEX, with an estimated probability of successful moderate sedation for EUS of 94.9% (95% confidence interval: 88.1%-98.9%). When combined with intranasal 1 μg/kg DEX, probabilities of successful moderate sedation at each dose level of intranasal SUF were as follows: 0 μg/kg SUF, 52.8%; 0.1 μg/kg SUF, 75.4%; 0.2 μg/kg SUF, 89.9%; 0.3 μg/kg SUF, 94.9%; 0.4 μg/kg SUF, 98.0%; 0.5 μg/kg SUF, 99.0%.

CONCLUSION

The ED₉₅ needed for moderate sedation for EUS is intranasal 0.3 μg/kg SUF when combined with intranasal 1 μg/kg DEX, based on CRM.

Delivery of End-of-Life Care in Patients Requesting Withdrawal of a Left Ventricular Assist Device Using Intranasal Opioids and Benzodiazepines

With the increasing prevalence of the left ventricular assist device (LVAD) in patients with end-stage cardiomyopathies, an increasing number of these patients are dying of noncardiac conditions. It is likely that the palliative care clinician will have an ever-increasing role in managing end of life for patients with LVADs, including discontinuation of LVAD support. There exists a paucity of literature describing strategies for effective delivery of palliative care in patients requesting discontinuation of LVAD therapy. Here, we present a case of a patient with metastatic cancer who requested LVAD discontinuation. Because of practical concerns and patient preference, the patient did not have intravenous (IV) access and medications requiring IV administration could not be used. Therefore, a strategy using intranasal midazolam and sufentanil was applied, the LVAD was deactivated, and the patient died comfortably. This case is, to our knowledge, the first to describe a strategy for delivery of palliative care in patients requesting discontinuation of LVAD support, particularly in the absence of IV access. Such a strategy may be applicable to patients wishing to die at home, and therefore allow greater latitude for patients and clinicians in their approach to the end of life.