Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study

Korean clinical practice guidelines for diagnostic and procedural sedation

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.

Serial transurethral cystometry: A novel method for longitudinal evaluation of reflex lower urinary tract function in adult female rats

AIMS

The aim of the study is to develop a minimally invasive method for longitudinal evaluation of lower urinary tract function that allows for simultaneous measurements of bladder pressure and external urethral sphincter (EUS) electromyographic (EMG) activity.

METHODS

To evaluate the reliability of serial transurethral cystometry (STUC), rats (n = 12) underwent three sessions of STUC, one session a week for 3 weeks. During each session, rats were anesthetized with ketamine-xylazine (90 mg/kg and 10 mg/kg), and micturition reflex data were acquired using transurethral cystometry and percutaneous recording of EUS (EMG) activity during continuous infusion of saline into the bladder. The reliability and consistency of the STUC method were assessed using intra-class correlation (ICC) analysis and repeated measures ANOVA.

RESULTS

ICC values calculated from five successive events during the first micturition session indicate good to excellent reliability for measurements of peak bladder pressure, threshold bladder pressure, minimum bladder pressure, volume threshold, duration of EUS bursting, and number of EUS burst events. Across the three recording sessions no significant difference was observed in peak bladder pressure, threshold bladder pressure, minimum bladder pressure, volume threshold, number of EUS burst events, and duration of EUS bursting using repeated measures ANOVA.

CONCLUSION

Serial transurethral cystometry under ketamine-xylazine anesthesia with simultaneous percutaneous EUS EMG recording is a novel, reliable, accurate, and minimally invasive method for quantitative assessment of lower urinary tract (LUT) function in adult female rats over extended periods of time.

Evaluation of the effects of sedation administered via three different routes on the procedure, child and parent satisfaction during cystometry

Purpose

In this study, we retrospectively investigated case reports with and without midazolam administration via oral, intranasal and rectal before cystometry procedure. We aimed to compare the data to evaluate the effects of sedation before cystometry on the pediatric patients and parents’ satisfaction.

Methods

A total of 124 ASA I-II pediatric cases aged 5–14 years were retrospectively investigated from the hospital records. One of the three administration routes was chosen; oral midazolam at a dose of 0.5 mg/kg and nasal or rectal midazolam at a dose of 0.3 mg/kg (maximum 15 mg). Heart rate, blood pressure, oxygen saturation, the Wisconsin Hospital of Children Sedation Scale (CHWSS) score and the Groningen Distress Rating Scale (GDRS) score were recorded. Cystometry measurement values, diagnoses of the cases and procedure durations were recorded from the urodynamic laboratory records.

Results

80 female, 44 male cases were evaluated. The CHWSS score at the 10th and 20th minutes after the drug administeration was higher in the oral group than the others (p = 0.001). The duration between the administration of the drug and the start of the procedure was shorter in the nasal group (p = 0.01). Parents satisfaction for sedation was 77 % when comparison of the cystometry with and without sedation. Comparison of the cystometry results with or without sedation no significant difference was found between all parameters (p > 0.01).

Conclusion

We believe that sedation with midazolam administered through all three routes is a safe, effective and convenient option during cystometry, especially in the young age group.

The effect of bladder diverticula on bladder function: An experimental study in rabbits

OBJECTIVE

This study aims to evaluate the effect of bladder diverticula (BD) on bladder function using a rabbit model, based on urodynamic findings.

METHODS

A total of 32 New Zealand white rabbits were randomly assigned to four groups: (1) sham surgery; (2) a single, 1-cm-diameter BD; (3) a single, large, 3-cm-diameter BD; and (4) four (multi) 1-cm-diameter BD. Urodynamic evaluations were performed preoperatively, and 1week and 1month postoperatively, to measure the postmicturition residual (PMR), maximum bladder capacity (MBC), filling and voiding detrusor pressure (Pdet), compliance, and unstable detrusor contractions. At the end of the study, the animals were sacrificed and assessed for pathologic evaluation and stone formation.

RESULTS

In groups 3 and 4, the rabbits all had PMR. At 30days postsurgery, the MBC was found to be 28% and 31% lower than the reference range in groups 3 and 4 and compliance was decreased (p<0.05). Further, the filling Pdet was significantly higher for large and multiple BD than in the 1-cm diverticula or sham groups (6.33±1.73, 4±1.26, p=0.0001). Groups 3 (62%) and 4 (50%) had unstable detrusor contractions. There was also a muscular/collagen ratio increase in the large and multiple BD groups. Four rabbits in the large group and one rabbit in the multiple BD group exhibited stone formation.

CONCLUSIONS

Large or multiple BD can alter bladder storage and emptying, and can decrease the capacity of the bladder and reduce its elasticity. Large or multiple bladder diverticula can lead to involuntary contractions, causing dysfunctional voiding.

A modified device to facilitate flow measurements during voiding cystometry studies in infants

INTRODUCTION

Urodynamic studies (UDS) in infants are traditionally hampered by technique and flow collection; both are difficult and have not yet been standardized.

METHODS

A very simple device has been developed to collect urine during the voiding phase in UDS. It is based on a urine-collection adhesive bag, which is connected to a tube that conducts the urine to a flowmeter.

RESULTS

Eleven infants (4-23 months) were selected and a complete UDS was performed on all of them. A diagnosis was obtained for all of the infants.

DISCUSSION

This device is easily available in every pediatric clinic; it is also disposable and inexpensive. It enables UDS in infants to be complete and achievable.

Management of anesthetic emergencies and complications outside the operating room

PURPOSE OF REVIEW

Anesthesia outside the operating room is commonly uncomfortable and risky. In this setting, anesthetic emergencies or complications may occur. This review aims to report the most recent updates regarding the management of prehospital anesthesia, anesthesia in the trauma and emergency rooms, and anesthesia for endoscopy and interventional radiology.

RECENT FINDINGS

After tracheal intubation failure, airway control of outpatients could be achieved by pharmacologically assisted laryngeal mask insertion. Management of traumatic injured patients is best guided in the frame of checklists. Monitoring sedation in this setting is challenging notably because of the threat of haemodynamic instability. Unfortunately, BIS monitoring cannot be recommended to guide sedation in this setting. Ketamine can be used to prevent hypotension during prehospital anesthesia or procedural sedation, especially as its neuroprotective effects have been recently best understood. Target-controlled infusion propofol administration with small concentration increments is adapted to prevent hypotension and hypoxaemia during sedation for gastrointestinal endoscopy and interventional radiology. Target-controlled infusion remifentanil administration is also adapted to many procedures.

SUMMARY

Anesthesia outside the operating room requires careful monitoring to avoid side-effects and education of nonanaesthetists when they are involved. A useful tool is to continuously improve the protocols and checklists to make anesthesia in this setting safer.

Discontinuance of life sustaining treatment utilizing ketamine for symptom management

We present the case of an otherwise healthy 21-year-old female who developed severe respiratory failure following a minor procedure requiring ECMO and bi-level ventilation. During her protracted ICU course, she had significant difficulties with agitation and was titrated to the following regimen: hydromorphone 30 mg/hour, fentanyl 200 mcg/hour, dexmedetomidine 1.5 mcg/kg/hour, propofol at 70 mcg/kg/min, and midazolam at 20 mg/hour. We were consulted to assist in withdrawal of life prolonging measures at the family's request and given high doses of commonly used opioid and sedative medications successfully utilized methadone and ketamine for symptom control. This case study would indicate that in selected patients on high dose opioid and sedative medications prior to withdrawal of life prolonging measures ketamine may be considered for symptom management.