Pharmacokinetic and Pharmacodynamic Characteristics of??Medications Used for Moderate Sedation

Safety and efficacy of dexmedetomidine vs. midazolam in complex gastrointestinal endoscopy: A systematic review and meta-analysis

OBJECTIVE

This study aims to perform a meta-analysis to evaluate the safety and efficacy of dexmedetomidine versus midazolam for complex digestive endoscopy procedures, with the goal of offering comprehensive clinical evidence.

METHODS

Following predefined inclusion criteria, five databases were systematically searched, with a focus on identifying randomized controlled trials (RCTs) that compared the administration of dexmedetomidine and midazolam during complex digestive endoscopy procedures. The statistical software Stata 15.1 was employed for meticulous data analysis.

RESULTS

Sixteen RCTs were encompassed, involving a total of 1218 patients. In comparison to the midazolam group, dexmedetomidine administration was associated with a reduced risk of respiratory depression (RR=0.25, 95 %CI: 0.11-0.56) and hypoxemia (RR=0.22, 95 %CI: 0.12-0.39). Additionally, the dexmedetomidine group exhibited lower incidence rates of choking (RR=0.27, 95 %CI: 0.16-0.47), physical movement (RR=0.16, 95 %CI: 0.09-0.27), and postoperative nausea and vomiting (RR=0.56,95 %CI: 0.34-0.92). Patients and endoscopists in the dexmedetomidine group reported higher levels of satisfaction (patient satisfaction: SMD=0.73, 95 %CI: 0.26-1.21; endoscopist satisfaction: SMD=0.84, 95 %CI: 0.24-1.44). The incidence of hypotension and anesthesia recovery time did not significantly differ between the two groups (hypotension: RR=1.73,95 %CI:0.94-3.20; anesthesia recovery time: SMD=0.02, 95 %Cl: 0.44-0.49). It is noteworthy that the administration of dexmedetomidine was associated with a significant increase in the incidence of bradycardia in patients.

CONCLUSION

Compared to midazolam, dexmedetomidine exhibits a favorable safety profile for use in complex gastrointestinal endoscopy by significantly reducing the risk of respiratory depression and hypoxemia. Despite this, dexmedetomidine is associated with a higher incidence of bradycardia. These findings underscore the need for further research through larger, multi-center studies to thoroughly investigate dexmedetomidine's safety and efficacy.

Evaluating Sedation Strategies for Magnetic Resonance Imaging: A Comprehensive Review of Intravenous Fentanyl, Butorphanol, and Midazolam in Adult and Pediatric Populations

Magnetic resonance imaging (MRI) is a critical diagnostic tool that often requires patient sedation to ensure optimal image quality and patient comfort, particularly in those with anxiety or an inability to remain still. This comprehensive review examines the efficacy, safety, and practical considerations of three commonly used intravenous sedatives, namely, fentanyl, butorphanol, and midazolam, in adult populations undergoing MRI procedures. This review highlights the pharmacological profiles, advantages, and limitations associated with each sedative agent through a detailed analysis of current literature, clinical guidelines, and practice-based evidence. Fentanyl is noted for its potent analgesic properties and rapid onset of action, making it suitable for painful procedures. Butorphanol, with its unique opioid agonist-antagonist activity, presents an alternative with a balance between analgesia and sedation, potentially offering a safer profile for certain patient populations. Midazolam, widely recognized for its anxiolytic and amnestic effects, remains a staple in managing procedure-related anxiety. The review further discusses patient selection criteria, dosing strategies, and the importance of individualized sedation planning to enhance patient experience and procedural outcomes. Future directions highlight the potential of emerging sedation agents and non-pharmacological approaches to improve patient comfort and compliance. The findings underscore the necessity for healthcare providers to adapt sedation practices to the specific needs of each patient, considering both the clinical context and the inherent characteristics of the sedative agents. This review aims to guide clinicians in selecting the most appropriate sedation strategy for adult patients undergoing MRI, optimizing patient care and diagnostic efficacy.

A systematic review and meta-analysis comparing the efficacy and safety of ciprofol (HSK3486) versus propofol for anesthetic induction and non-ICU sedation

Background: Ciprofol (HSK3486) is a novel intravenous anesthetic agent that bears structural similarity to propofol and displays favorable pharmacodynamic characteristics such as rapid onset and offset. The meta-analysis aimed at comparing the efficacy and safety of ciprofol versus propofol in clinical practice. Methods: Medline, EMBASE, Google Scholar, Cochrane Library were searched from inception to April 2023. The primary outcome was success rate of sedation/anesthetic induction and differences in sedation/induction time. The secondary outcomes included risks of hemodynamic instability, respiratory complications, and pain on injection, as well as recovery profiles, satisfaction score, and top-up dose requirement. Results: Twelve RCTs (sedation: n = 6, anesthetic induction, n = 6, all conducted in China) involving 1,793 patients (age: 34-58 years) published from 2021 to 2023 were analyzed. Pooled results revealed no differences in success rate [risk ratio (RR) = 1, 95% confidence interval (CI): 0.99 to 1.01, I2 = 0%, 1,106 patients, p = 1] and time required for successful anesthetic induction/sedation [mean difference (MD) = 7.95 s, 95% CI: -1.09 to 16.99, I2 = 97%, 1,594 patients, p = 0.08]. The risks of top-up dose requirement (RR = 0.94, p = 0.48), cardiopulmonary complications [i.e., bradycardia (RR = 0.94, p = 0.67), tachycardia (RR = 0.83, p = 0.68), hypertension (RR = 1.28, p = 0.2), hypoxemia/pulmonary depression (RR = 0.78, p = 0.24)], and postoperative nausea/vomiting (RR = 0.85, p = 0.72), as well as discharge time (MD = 1.39 min, p = 0.14) and satisfaction score (standardized MD = 0.23, p = 0.16) did not differ significantly between the two groups. However, the ciprofol group had lower risks of hypotension (RR = 0.85, p = 0.02) and pain on injection (RR = 0.17, p < 0.00001) than the propofol group. The time to full alertness was statistically shorter in the propofol group (i.e., 0.66 min), but without clinical significance. Conclusion: Our results demonstrated similar efficacy between ciprofol and propofol for sedation and anesthetic induction, while ciprofol was associated with lower risks of hypotension and pain on injection. Future studies are warranted to evaluate the efficacy and safety of ciprofol in pediatric or the elderly populations. Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/), identifier (CRD42023421278).

The comparison of ketamine-dexmedetomidine (ketadex) and ketamine-propofol (ketofol) for procedural sedation in pediatric patients: A meta-analysis of randomized controlled trials

Introduction

The combination of different agents used for procedural sedation allows a greater range of desirable effects while minimizing side effects. The ketamine-dexmedetomidine combination (ketadex) and ketamine-propofol combination (ketofol) are successful examples. The purpose of this meta-analysis was to compare the safety and efficacy of ketadex with ketofol used for procedural sedation in pediatric patients.

Methods

We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from inception to June 2022. Studies were independently evaluated for inclusion criteria and exclusion criteria by two reviewers. Outcome measures for safety comparison were the incidence of hypotension, bradycardia, respiratory depression, nausea, vomiting, and agitation; Outcome measure for efficacy comparison was clinicians' satisfaction. In addition, we compared the recovery time of ketadex and ketofol.

Results

Nine studies were included in this meta-analysis. Compared with ketofol, ketadex sedation in pediatric patients had lower risk of respiratory depression (RR: 0.51, 95% CI: 0.34–0.76, P = 0.0009). However, ketadex displayed significant effect on recovery time (MD: 8.38 min, 95% CI: 7.55–9.22 min, P < 0.00001). Ketadex had similar incidence of hypotension (RR: 0.95, 95% CI: 0.33–2.67, P = 0.92) and bradycardia (RR: 1.80, 95% CI: 0.64–5.06, P = 0.26) compared to those with ketofol. Clinicians' satisfaction rate of ketadex and ketofol were both high (RR: 0.93, 95% CI: 0.69–1.25, P = 0.62). Also, no significant difference was observed between ketadex and ketofol on the incidence of nausea, vomiting, and agitation.

Conclusions

Both ketadex and ketofol can provide effective sedation and maintain stable hemodynamics. In consideration of good safety profile in respiratory problems, we suggest ketadex is a better option for procedural sedation in pediatric patients.

Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department

BACKGROUND

Dexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic.

OBJECTIVE

Our aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department.

METHODS

This prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale.

RESULTS

Thirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment.

CONCLUSIONS

The combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine-ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.

Sedation level with midazolam: a pediatric surgery approach

Midazolam (MDZ) is a short-acting benzodiazepine that is widely used to induce and maintain general anesthesia during diagnostic and therapeutic procedures in pediatric patients due to its sedative properties. The aim of this study was to perform a systematic review without a meta-analysis to identify scientific articles and clinical assays concerning MDZ-induced sedation for a pediatric surgery approach. One hundred and twenty-eight results were obtained. After critical reading, 37 articles were eliminated, yielding 91 publications. Additional items were identified, and the final review was performed with a total of 106 publications.

In conclusion, to use MDZ accurately, individual patient characteristics, the base disease state, comorbidities, the treatment burden and other drugs with possible pharmacological interactions or adverse reactions must be considered to avoid direct alterations in the pharmacokinetics and pharmacodynamics of MDZ to obtain the desired effects and avoid overdosing in the pediatric population.

The effect of Propofol versus Dexmedetomidine as anesthetic agents for oocyte pick-up on in vitro fertilization (IVF) outcomes

This study aimed to evaluate the effects of propofol and dexmedetomidine over different timescales on the IVF outcomes for transvaginal oocyte retrieval (TVOR). Twenty-four rats included in the study were divided into two main groups and three subgroups were subjected to the ovulation induction process. Group 1 was administered propofol (100 mg/kg i.v.) and group 2 were administered dexmedetomidine (25 µg/kg i.p.) The oviduct collection procedure was completed within 15 min for subgroup Pro15min, Dex15min (n = 4), within 16 to 30 min for subgroup Pro30min, Dex30min (n = 4) and within 31 to 60 min for subgroup Pro60min, Dex60min (n = 4) after euthanasia. The total number of oocytes was counted. After in vitro fertilization, the number and quality of embryos were evaluated. The number of pups born were evaluated after embryo transfer. The embryo number, quality and pup count decreased as the administration time for propofol increased (p < 0.05). No statistically significant difference was found between the dexmedetomidine subgroups for embryo number, quality and pup count(p > 0.05). As the exposure time to propofol increased, the number and quality of embryos obtained, and the pup count, decreased. The use of dexmedetomidine had no negative impacts on the number of embryos, their quality or the number of pups.

Sedation/analgesia techniques for nonoperating room anesthesia: new drugs and devices

PURPOSE OF REVIEW

The purpose of this article is to review new drugs and devices for nonoperating room anesthesia (NORA).

RECENT FINDINGS

Remimazolam is an ultra-short-acting, water-soluble intravenous benzodiazepine with a fast onset and offset that has been approved recently for use in procedural sedation. Phase III trials have established the effectiveness of remimazolam sedation compared with placebo and midazolam in gastrointestinal endoscopy and bronchoscopy. More research is required investigating remimazolam in real-world NORA settings, including comparisons with propofol sedation. Oliceridine is a μ-agonist with selectivity for the G protein pathway and low potency for β-arrestin recruitment. As such it may be associated with less nausea, vomiting and respiratory depression than traditional opioids used. Although no studies have been published about oliceridine use in NORA to date, results from surgical studies indicate a potential place in nonoperating room practice. Research continues into alternative methods of drug delivery, such as patient-controlled sedation but no new devices are described.

SUMMARY

Further studies are required before these new drugs and devices are embraced in NORA.

Magnetic Resonance Imaging in Neurocritically Ill Patients: Who Fails and How?

OBJECTIVES

Performing magnetic resonance imaging (MRI) in neurocritically ill patients is challenging because it often requires sedation and withholding care in the neurological intensive care unit. This study investigated the incidence of and reasons for failed or complicated MRI (MRI-FC) in such patients.

METHODS

A consecutive series of 218 neurocritically ill patients who underwent brain MRI were retrospectively evaluated. Failed or complicated MRI included failure to obtain all ordered sequences, unscheduled sedative administration, decrease in oxygen saturation to less than 90%, hypotension (≥40-mm Hg decrease and/or use of inotropic agents), and cardiac or respiratory arrest.

RESULTS

Failed or complicated MRI occurred in 66 patients (30.3%) and included failure to obtain MRI sequences (n = 13), unscheduled use of sedatives (n = 62), oxygen desaturation (n = 9), and hypotension (n = 6). Cardiac or respiratory arrest did not occur. Use of sedative agents while in intensive care (P < 0.01), high Acute Physiology and Chronic Health Evaluation II score (P = 0.031), and low Glasgow Coma Scale score on admission (P = 0.047) were associated with MRI-FC. Scan times were longer (P = 0.004) and Glasgow Coma Scale (P < 0.001) and Richmond Agitation Sedation Scale (P = 0.003) scores were lower (P = 0.004) after imaging in patients with MRI-FC. Previous use of sedative agents was independently associated with MRI-FC (adjusted odds ratio = 3.57, 95% confidence interval = 1.78 to 7.24, P < 0.001).

CONCLUSIONS

Failed or complicated MRI was common and was associated with the use of sedative agents, severity of illness, and lower level of consciousness. Studies to ensure effective and safe performance of MRI in neurocritically ill patients are needed.

A Prospective Randomized Controlled Trial Using Propofol or Dexmedetomidine for Conscious Sedation in Pediatric Patients Undergoing Sclerotherapy

Aim:

Sodium tetradecyl sulfate (STS) sclerotherapy in pediatric patients is usually undertaken under sedation inside digital subtraction angiography (DSA) suite. These patients are day-care patients and need adequate sedation for small duration. We performed this study to compare propofol and dexmedetomidine as sedative agents in these patients.

Materials and Methods:

Seventy American Society of Anesthesiologists (ASA) physical status I patients scheduled to undergo sclerotherapy for low-flow venous malformations under sedation were randomized to be administered either dexmedetomidine (Group D) or propofol (Group P). In Group D, initially 2 µg/kg of dexmedetomidine was administered over 10min (or till attainment of a Ramsay sedation score [RSS] of 5), followed by an infusion at the rate of 0.3 µg/kg/h. In Group P, propofol 1mg/kg bolus followed by an infusion at 100 µg/kg/min was administered, titrated to an RSS of 5. We measured intraoperative heart rate, blood pressure, respiratory rate, duration of procedure, and incidence of arterial desaturation, bradycardia, and respiratory depression in the two groups.

Results:

All the patients in both groups completed the procedure. The mean anesthesia time was significantly longer in Group D. Intraoperative heart rates remained comparable in the two groups, whereas systolic and diastolic BP were significantly higher in Group D throughout the procedure. No patient in Group D experienced arterial desaturation, whereas five patients in Group P reported a SpO₂ of <90%.

Conclusion:

Both propofol and dexmedetomidine can be used for administering sedation in pediatric patients undergoing sclerotherapy for superficial venous malformations in DSA suite. Although propofol provides a rapid onset and reduced duration of action, dexmedetomidine provides reduced episodes of arterial desaturation and respiratory depression.

Sevoflurane leads to learning and memory dysfunction via breaking the balance of tPA/PAI-1

Exposure to general anesthesia in early childhood may lead to adverse effects on adolescent neurocognition. This study investigated the effects of multiple inhalations of sevoflurane on long-term learning and memory in developing rats, and explored the mechanistic role of the tissue plasminogen activator (tPA)/plasminogen activator inhibitor-1 (PAI-1) fibrinolysis system and its regulatory relationship with the brain derived neurotrophic factor (BDNF) by activation of tropomysin related kinase B (TrkB). After rats were inhaled with sevoflurane for 2 h/d for three days, the expression levels of tPA, PAI-1, BDNF, its precursor(proBDNF), TrkB and phosphorylation of TrkB (p-TrkB) were detected at different time points. After 28 d, Morris water maze was used to examine learning and memory function; Golgi staining was used to investigate synaptic plasticity and synaptic-related proteins, such as Synapsin I(SYN1), growth associated protein 43(GAP-43), and postsynaptic density protein 95(PSD-95). Rats were given exogenous tPA and an inhibitor of PAI-1, TM5275. The results showed multiple inhalation of sevoflurane led to learning and memory dysfunction, downregulated the expression of the synaptic-related proteins, decreased dendritic spine density in the hippocampus, increased the expression level of proBDNF and PAI-1, and reduced expression of BDNF, tPA, and p-TrkB. Interestingly, tPA or TM5275 partially reversed the learning and memory dysfunction and the reduction of synaptic plasticity induced by sevoflurane exposure. Furthermore, they blocked the upregulation of proBDNF and PAI-1 protein expression and increased the expression of BDNF, tPA, and p-TrkB. The protective effect of tPA or TM5275 on rats following multiple sevoflurane inhalation was blocked by a TrkB inhibitor. Multiple inhalation of sevoflurane in rats inhibited the cleavage of proBDNF by disrupting the balance of the tPA/PAI-1 fibrinolysis system. This blocked the activation of the downstream TrkB signaling pathway and reduced hippocampal synaptic plasticity, leading to long-term learning and memory dysfunction. Therefore, Sevoflurane exposure could lead to learning and memory dysfunction by inhibiting BDNF cleavage via breaking the balance of tPA/PAI-1.

Efficacy and safety of remimazolam in procedural sedation and analgesia: A protocol for systematic review and meta analysis

BACKGROUND

Remimazolam is a newly developed benzodiazepine as an alternative of conventional sedatives in the procedure of anesthesia. For the purpose of evaluating the efficacy and safety of remimazolam sedation during an endoscopy, we will perform a systematic review and meta-analysis of randomized controlled trials that compared remimazolam with midazolam and/or placebo.

METHODS

We will search PubMed, Embase, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) from inception to December 2019 for randomized controlled trials that investigated efficacy and safety of remimazolam during an endoscopy. The job will be performed without language restriction. Experimental groups will include the interventions of remimazolam, while control groups will involve midazolam, placebo, or no controls. The primary outcome will be the onset time, followed by the secondary outcomes of the recovery time, the incidence of hypotension, the incidence of hypoxia and the incidence of bradycardia. Relative ratio or standardized mean difference will be used to measure the effect size of remimazolam. We will use I statistics to assess the between-study heterogeneity in each meta-analysis, Eager's test to detect publication bias.

RESULTS

The results of this study will be published in a peer-reviewed journal.

ETHICS AND DISSEMINATION

There is no need for ethical approval because all data used in this meta-analysis have been published. In addition, all data will be analyzed anonymously during the review process.

PROTOCOL REGISTRATION NUMBER

CRD42020170745.

Echocardiography in the Era of Obesity

Patients with obesity are at increased risk for coronary artery disease and heart failure and often present with symptoms of dyspnea, fatigue, edema, or chest pain. Echocardiography is frequently used to help distinguish whether these symptoms are due to cardiac disease. Unfortunately, obesity has a significant impact on image quality because of signal attenuation. Ultrasound-enhancing agents may improve the detection of structural remodeling and subclinical left ventricular dysfunction in patients with obesity. Assessment of chamber sizes and cardiac remodeling in severely obese subjects must be interpreted with caution, however, as the current recommendations for indexing cardiac chamber sizes to body size may lead to false conclusions about chamber volumes or mass, particularly in settings in which weight is changing. As a result of increases in stroke volume and cardiac output, obesity may exacerbate hemodynamic compromise in obstructive structural or valvular disease. With regard to assessment of ischemic heart disease, stress echocardiography can effectively risk-stratify patients with obesity and may have advantages over other noninvasive modalities. In general, transesophageal echocardiography is safe in patients with obesity, although some precautions should be observed. Stress echocardiography using the transesophageal approach is an alternative for preoperative or ischemia evaluation in patients with suboptimal transthoracic views.

[Drugs for intravenous induction of anesthesia: ketamine, midazolam and synopsis of current hypnotics]

Ketamine and midazolam form the endpoint of a series of articles about intravenous induction of anesthesia . Both substances can be used as single induction hypnotic drugs; however, in practice, this is unusual. Both substances, with the exception of a few very specific indications and clinical situations, are more frequently used in combination or with one of the more common alternatives propofol, barbiturates and etomidate. The reasons are the activity and side effects of both substances and their positive characteristics are used more as a supplement. In the concluding comparison the five discussed induction hypnotics are judged against each other. The use in certain clinical constellations and in special patient populations is evaluated individually for each substance. It is highlighted which drug appears most appropriate in which situation. As methohexital is nowadays only administered in very few clinical situations, this substance is not included in the comparative assessment.

Comparative Evaluation of Dexmedetomidine versus Midazolam as Premedication to Propofol Anesthesia in Endoscopic Retrograde Cholangiopancreatography

Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreaticobiliary diseases. It is a potentially uncomfortable procedure that needs to be performed under conscious sedation. Safe and effective sedation protocol is the need of an hour.

Aims:

This study aims to evaluate the requirement of propofol using midazolam and dexmedetomidine as premedication for ERCP. The degree of comfort experienced by endoscopist and the patients was also assessed.

Materials and Methods:

A total of sixty patients were enrolled in a randomized, assessor-blinded study in the age group of 40–80 years, American Society of Anesthesiologists physical class II–III undergoing elective ERCP procedures. They were divided into two groups of 30 each. Group D (n = 30): Dexmedetomidine (100 μg/mL + 18 mL saline) loading dose at 1 μg/kg intravenous (IV) over 10 min followed by 0.5 μg/kg/h infusion, and Group M (n = 30): Midazolam at 0.05 mg/kg IV bolus over 10 min followed by normal saline infusion under hemodynamic monitoring. Satisfaction scores, total propofol requirement, and complications such as gagging, restlessness, agitation, postoperative nausea and vomiting were noted and analyzed statistically.

Statistical Analysis:

Statistical analysis was performed using SSPS 17.0 software (SPSS Inc., 233 South Wacker Drive, Chicago, USA). The Chi-square test was applied for nonparametric data and parametric numerical data, unpaired t-test for intergroup comparison, and repeated measures ANOVA for intragroup comparison. Results were expressed as a mean ± standard deviation. Value of P < 0.05 was considered statistically significant and <0.001 as highly significant.

Results:

Surgeons and patients were more satisfied and comfortable along with less requirement of propofol in the dexmedetomidine group. The incidence of complications was also less in the dexmedetomidine group as compared to that of midazolam group.

Conclusion:

Both dexmedetomidine and midazolam can be safely administered as an anesthetic adjuvant to propofol for short procedures like ERCP's. Dexmedetomidine provided intense and better sedation quality along with lesser requirement of propofol doses. Moreover, it provided stable hemodynamic conditions and good recovery characteristics as compared to midazolam group.

A collaborative educational intervention on procedural sedation and analgesia across the Pacific

Aim

Worldwide, health‐care providers carry out procedural sedation and analgesia (PSA) in the emergency department. However, training opportunities are limited in many Asian countries, including Japan. We formed an educational group consisting of board‐certified emergency physicians in the USA and Japanese physicians and developed a PSA training module. The aims of our study were to demonstrate the effectiveness of training and to describe PSA practice in Japan.

Methods

We undertook a pretest of PSA knowledge questions and a retest immediately after the training intervention. We also carried out a survey and asked about participants' PSA practice. The training module consisted of four didactic hours and three simulation and skills laboratory hours. Results of all pre‐ and post‐intervention knowledge questions were analyzed with McNemar's test, and overall scores were analyzed with a paired t‐test.

Results

One hundred and forty‐four health‐care providers including 123 physicians, 16 nurses, two pharmacists, and three medical students participated in the training. A total of 119 (83%) completed both the pre‐ and post‐intervention knowledge questions. Before the training, participants scored an average 66% (63%–69%) on the written knowledge test. After the intervention, participants showed significant improvement on the knowledge test (improvement 17%; 14%–20%). Among participants who answered the practice survey, 121 (88%) have undertaken PSA. Only 14 (12%) participants always or often use a continuous capnography for PSA. Only 32 (26.4%) participants undertook pre‐PSA systematic evaluation.

Conclusion

Our educational intervention successfully increased participants' knowledge. Only the minority of health‐care providers use capnography routinely for PSA, and pre‐PSA evaluation is not commonly carried out.

Pregabalin and dexmedetomidine conscious sedation for flexible bronchoscopy: a randomized double-blind controlled study

BACKGROUND

Conscious sedation is usually required during flexible bronchoscopy. Sedation should be achieved without respiratory depression or loss of consciousness. The present study was designed to evaluate the effect of pregabalin premedication on reducing the amount of sedatives and to show its advantages for patients undergoing flexible bronchoscopy with dexmedetomidine.

METHODS

Seventy patients undergoing elective flexible bronchoscopy were randomly divided into two groups of 35 patients each. All patients received premedication one hour before the procedure. PG group received 150 mg pregabalin and C group received placebo. All patients were sedated with dexmedetomidine infusion to achieve optimum sedation. During the procedure peripheral oxygen saturation, respiratory rate, hemodynamics, Ramsay sedation Score, cough score, and total amount of dexmedetomidine used were recoded. After the procedure patients' and pulmonologists' satisfaction were compared.

RESULTS

The total amount of dexmedetomidine used in PG was less compared to C group (P=0.01). Sedation score was higher in PG group at the time of theatre admission (P<0.001). Cough score was higher, but insignificant in group C (P=0.08). Patients' and pulmonologists' satisfaction scores were higher in group PG (P=0.007 and 0.001 respectively). The heart rate and mean arterial pressure were lower in the C group (P=0.02 and 0.03 respectively). Postoperative care unit stay was less in group PG with less analgesic requirements.

CONCLUSIONS

Conscious sedation facilitates flexible bronchoscopy. Premedication with pregabalin can reduce the amount of sedatives. Dexmedetomidine with pregabalin premedication has many advantages over dexmedetomidine alone.

Metabolic Profiles of Propofol and Fospropofol: Clinical and Forensic Interpretative Aspects

Propofol is an intravenous short-acting anesthetic widely used to induce and maintain general anesthesia and to provide procedural sedation. The potential for propofol dependency and abuse has been recognized, and several cases of accidental overdose and suicide have emerged, mostly among the health professionals. Different studies have demonstrated an unpredictable interindividual variability of propofol pharmacokinetics and pharmacodynamics with forensic and clinical adverse relevant outcomes (e.g., pronounced respiratory and cardiac depression), namely, due to polymorphisms in the UDP-glucuronosyltransferase and cytochrome P450 isoforms and drugs administered concurrently. In this work the pharmacokinetics of propofol and fospropofol with particular focus on metabolic pathways is fully reviewed. It is concluded that knowing the metabolism of propofol may lead to the development of new clues to help further toxicological and clinical interpretations and to reduce serious adverse reactions such as respiratory failure, metabolic acidosis, rhabdomyolysis, cardiac bradyarrhythmias, hypotension and myocardial failure, anaphylaxis, hypertriglyceridemia, renal failure, hepatomegaly, hepatic steatosis, acute pancreatitis, abuse, and death. Particularly, further studies aiming to characterize polymorphic enzymes involved in the metabolic pathway, the development of additional routine forensic toxicological analysis, and the relatively new field of ‘‘omics” technology, namely, metabolomics, can offer more in explaining the unpredictable interindividual variability.

Sedation After Cardiac Surgery: Is One Drug Better Than Another?

The classic high-dose narcotic-based cardiac anesthetic has been modified to facilitate a fast-track, rapid recovery in the intensive care unit (ICU). Postoperative sedation is consequently now an essential component in recovery of the patient undergoing cardiac surgery. It must facilitate the patient's unawareness of the environment as well as reduce the discomfort and anxiety caused by surgery, intubation, mechanical ventilation, suction, and physiotherapy. Benzodiazepines seem well suited for this role, but propofol, opioids, and dexmedetomidine are among other agents commonly used for sedation in the ICU. However, what is an ideal sedative for this application? When compared with benzodiazepine-based sedation regimens, nonbenzodiazepines have been associated with shorter duration of mechanical ventilation and ICU length of stay. Current sedation guidelines recommend avoiding benzodiazepine use in the ICU. However, there are no recommendations on which alternatives should be used. In postcardiac surgery patients, inotropes and vasoactive medications are often required because of the poor cardiac function. This makes sedation after cardiac surgery unique in comparison with the requirements for most other ICU patient populations. We reviewed the current literature to try to determine if 1 sedative regimen might be better than others; in particular, we compare outcomes of propofol and dexmedetomidine in postoperative sedation in the cardiac surgical ICU.

Novel anesthetic technique for combined intracavitary and interstitial brachytherapy for cervix cancer in an outpatient setting

Purpose

To determine the feasibility and safety of outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia.

Material and methods

We included patients diagnosed with non-metastatic cervix cancer and have completed brachytherapy between December 2015 and December 2016. Moderate to deep sedation was achieved using intravenous midazolam, propofol, fentanyl, and oxycodone. Local anesthesia was achieved with 2% lignocaine gel and a paracervical block containing a mixture of 1% ropivacaine, 2% lignocaine, and 1 : 1,000 adrenaline. Ceftriaxone and ondansetron were given prophylactically. Physiologic monitoring was performed throughout and pain scores were recorded using the Numeric Rating Scale. Follow-up was conducted at 8 weeks from the last fraction of brachytherapy. The feasibility and safety endpoints were a post-anesthesia discharge score (PADS) of 9 or above, and no grade 3 or above adverse events, respectively.

Results

A total of thirty-five brachytherapy insertions were carried out on nine patients. The median age of the patients was 56 years (range, 40-65). Eight patients had American Society of Anesthesiologists’ physical status of I or II, and one had a status of III. The mean duration of the insertion was 39 minutes (standard deviation [SD] = 14), during which no adverse events occurred. There was no significant nausea or vomiting post-sedation. The median pain scores post-insertion and during recovery were 0 (range, 0-6) and 0 (range, 0-7), respectively. At discharge, all patients had pain scores of 0 and maximum PADS of 10. The mean time to discharge was 4.1 hours (SD = 0.95). There were no brachytherapy-related admissions or complications.

Conclusions

Outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia is feasible and safe. This could potentially lead to significant cost savings.

Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.

A Prospective Randomized Trial Comparing Dexmedetomidine and Midazolam for Conscious Sedation During Oocyte Retrieval in An In Vitro Fertilization Program

Background:

Various sedative and analgesic techniques have been used for pain relief during oocyte retrieval which is the most painful part of in vitro fertilization (IVF) procedures.

Aim:

This study aimed at comparing dexmedetomidine and midazolam for conscious sedation in women undergoing transvaginal oocyte retrieval during an IVF program.

Settings and Design:

Prospective randomized double-blinded comparative study.

Patients and Methods:

Fifty-two patients undergoing oocyte retrieval in their first IVF cycle were randomly allocated into two equal groups. The intervention started with giving fentanyl1 mcg/kg intravenous (IV) followed by paracervical block in both groups. Then, subjects in group (D) received dexmedetomidine at a loading dose of 1 μg/kg IV over 10 min followed by 0.5 μg/kg/h infusion until Ramsay Sedation Scale (RSS) reached 3–4. Patients in group (M) received a loading dose of midazolam 0.06 mg/kg IV over 10 min followed by 0.5 mg incremental doses until RSS reached 3–4.

Statistical Analysis:

Statistical analysis was performed using SPSS program version 19 and EP 16 program.

Results:

Visual analog scale scores significantly decreased in group D than group M at 5 and 10 min during the procedure (P = 0.03 and 0.01, respectively), and at 20 min during postanesthesia care unit (PACU) time (P = 0.04). Intraoperative rescue sedation by propofol and postoperative rescue analgesia by acetaminophen showed a highly significant decrease (P < 0.01) in group D compared with group M. Furthermore, the time of PACU stay was significantly less (P < 0.01) in group D (49.03 ± 12.8 min) compared to group M (62.5 ± 18.34 min). Although significant bradycardia was noted in group D (23% of patients) during the procedure (P = 0.02), no cases were reported in group M. Patient satisfaction was significantly higher in group D (P < 0.1).

Conclusion:

Dexmedetomidine is an effective analgesic alternative to midazolam during oocyte retrieval for IVF. It offered not only a shorter PACU stay without significant side effects, but also better overall patient satisfaction scores.

Comparison of Dexmedetomidine Versus Midazolam-Fentanyl Combination for Monitored Anesthesia Care During Burr-Hole Surgery for Chronic Subdural Hematoma

BACKGROUND

Intraoperative movements are marker of inadequate level of sedation and are undesirable during burr-hole surgery under monitored anesthesia care (MAC). It distracts surgeon, hinders surgical procedure, and may lead to iatrogenic complication. Dexmedetomidine has shown to provide excellent analgesia, cooperative sedation with fewer fluctuations in sedation level during MAC. We compared the effect of dexmedetomidine on intraoperative patient movement, postoperative recovery time, and the surgeon and patient satisfaction scores with commonly used midazolam-fentanyl combination.

METHODS

Fifty-two patients undergoing burr-hole surgery for chronic subdural hematoma under MAC were randomly assigned to receive either IV dexmedetomidine 1 μg/kg over 10 minutes followed by continuous infusion 0.03 to 0.07 μg/kg/h (group D) or IV fentanyl 0.5 μg/kg and midazolam 0.03 mg/kg over 10 minutes followed by continuous infusion of 0.5 to 1.16 μg/kg/h fentanyl and 0.03 to 0.07 mg/kg/h midazolam (group M/F) titrated to maintain Ramsay sedation scale 3. Total number of intraoperative patient movements, postoperative recovery time, and patient and surgeon satisfaction scores were recorded.

RESULTS

Demographic and baseline characteristics were comparable between the 2 groups. Intraoperative patient movements were significantly less in group D than group M/F (median interquartile range, 1.00 [0.00 to 2.00] vs. 3.00 [1.00 to 3.25], P=0.007). Group D patients showed faster postoperative recovery (mean ± SD, 7.00 ± 6.96 vs. 13.69 ± 6.18 min, P=0.000). Surgeon satisfaction scores were better in group D compared with group M/F (median interquartile range, 1.00 [1.00 to 1.25] vs. 2.00 [1.00 to 2.00], P=0.014). However, patient satisfaction score and hemodynamic parameters were comparable (P>0.05) between both the groups.

CONCLUSIONS

Use of dexmedetomidine for MAC is associated with lesser number of intraoperative patient movements, faster postoperative recovery, better surgeon satisfaction score, and comparable patient's satisfaction compared with midazolam-fentanyl combination.

Clustering of capnogram features to track state transitions during procedural sedation

Procedural sedation has allowed many painful interventions to be conducted outside the operating room. During such procedures, it is important to maintain an appropriate level of sedation to minimize the risk of respiratory depression if patients are over-sedated and added pain or anxiety if under-sedated. However, there is currently no objective way to measure the patient's evolving level of sedation during a procedure. We investigated the use of capnography-derived features as an objective measure of sedation level. Time-based capnograms were recorded from 30 patients during sedation for cardioversion. Through causal k-means clustering of selected features, we sequentially assigned each exhalation to one of three distinct clusters, or states. Transitions between these states correlated to events during sedation (drug administration, procedure start and end, and clinical interventions). Similar clustering of capnogram recordings from 26 healthy, non-sedated subjects did not reveal distinctly separated states.

Sedation in oral and maxillofacial day care surgery: A comparative study between intravenous dexmedetomidine and midazolam

Introduction:

Sedation is an important component of day care oral and maxillofacial surgical procedures under local anesthesia. Although various sedative drugs in different regimens have been used for sedation, an ideal agent and regimen are yet to be established.

Aim:

The aim of this study is to compare the efficacy of intravenous (IV) dexmedetomidine and midazolam as a sedative agent for day care oral and maxillofacial surgical procedures.

Settings:

The study was conducted in the Department of Oral and Maxillofacial Surgery, SCB Dental College and Hospital, Cuttack, Odisha, India.

Materials and Methods:

A total of sixty adult patients of age group 18–65 years, of either sex were randomly selected equally in two groups for the study. One group named Group D received dexmedetomidine and the other named Group M received midazolam. Patients were evaluated for oxygen saturation (SPO₂), respiration rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), Ramsay sedation score, bispectral index (BIS) score, amnesia, Aldrete score, relaxation during the surgery, and drug preference.

Results:

Midazolam was associated with greater amnesia. Dexmedetomidine was associated with lower heart rate, SBP, and DBP. There was no significant difference in SPO₂, RR, Aldrete score, Ramsay sedation score, and BIS score between the two drugs. Patient preference and relaxation were more in dexmedetomidine group.

Conclusion:

IV dexmedetomidine is a comparable alternative to midazolam for sedation in day care oral and maxillofacial surgery under local anesthesia. It is the preferred drug when a lower heart rate and blood pressure or less amnesia is needed without any serious side effects.

An Audit of the Haemodynamic and Emergence Characteristics of Single-Shot ‘ketofol’

‘Ketofol’, the single-syringe combination of ketamine and propofol (50 mg of ketamine and 90 mg of propofol in a 10 ml syringe) is becoming increasingly popular for short procedures, progressively replacing the more traditional use of ketamine and diazepam in some settings. This audit examined the haemodynamic, emergence and other characteristics of ketofol administration in 42, otherwise fit, women undergoing bilateral post-partum tubal ligation at Vila Central Hospital in Vanuatu. The combination of ketamine and propofol had no clinically important adverse haemodynamic effects. Wake-up from ketofol was favourable, with low rates of nausea and minimal emergence delirium. However, 43% of patients required airway support. For short procedures such as post-partum tubal ligation in fit patients, ketofol appears to have minimal adverse haemodynamic effects and favourable emergence characteristics.

A comparative study on monitored anesthesia care

Aim:

The aim of this study is to compare the effectiveness, hemodynamic changes and duration of sedation and analgesia between combinations of fortwin-phenergan-midazolam (FPM) and ketamine - midazolam (KM) along with local anesthesia for the surgeries done under the umbrella of monitored anesthesia care.

Materials and Methods:

A total of 50 patients undergoing surgeries as tympanoplasty, septoplasty, lip repair, dacrocystectomy and cataract under local anesthesia, randomly received either intravenous (IV) fortwin 0.3 mg/kg over 1 min followed by IV midazolam 0.04 mg/kg plus IV phenergan 12.5 mg (Group FPM) or IV ketamine 0.3 mg/kg over 1 min plus IV midazolam 0.04 mg/kg (Group KM). Sedation was titrated to Ramsay sedation score (RSS) of 3. Patients’ mean arterial pressure (MAP), heart rate (HR), saturation peripheral pulse, duration of sedation and need for intraoperative rescue sedation/analgesic were recorded and compared. Satisfaction of patients (using a 1-7 point Likert verbal rating scale) and readiness for discharge towards (time to Aldrete score of 10) were also determined.

Result:

Group KM had significant rise in HR (20-25%) and MAP (25-30%) from 30 min after the bolus dose given until the end of the surgery in contrast to Group FPM. The target sedation level (RSS ≥ 3) was higher in Group FPM (n = 23 [92%]) as compared with Group KM (n = 12 [48%]). Time until need for rescue sedation was 66.96 ± 17.19 min in FPM and 32.80 ± 8.90 min in KM group. The patient satisfaction (Likert scale) is more with the FPM group (6.12 ± 0.83 vs. 4.40 ± 1.20).

Conclusion:

We found that the combination of FPM is superior to the KM combination as per the hemodynamic changes, duration of analgesia, patients’ satisfaction and efficacy of the drugs are concerned.

Synergistic antinociceptive interactions between fospropofol and alfentanil in mice

BACKGROUND

Combination therapy, which provides the opportunity to achieve optimal analgesia with reduced side effects at lower drug doses, is a valid approach for the treatment of pain. The analgesic interaction between fospropofol and alfentanil has not been investigated till date. We sought to determine the nature of the interaction between fospropofol and alfentanil in mice models of the formalin test, hot-plate test and the tail-flick test.

METHODS

The effects of fospropofol, alfentanil and their combinations were examined in the formalin-induced paw inflammatory hyperalgesia, the hot-plate test and the tail-flick test in mice. In the three models, dose-response curves were established and their respective ED50 (50% effective dose) values were determined separately for each agent. Fixed-ratio combinations of fospropofol and alfentanil were tested for their combined antinociceptive effects, and the type of interaction was determined by the isobolographic analysis.

RESULTS

Fospropofol, alfentanil and their combination produced a dose-dependent decrease in the number of flinches during phase 1 of the formalin test. In the hot-plate test and in the tail-flick test, fospropofol, alfentanil and their combination significantly and dose dependently prolonged the latency of withdrawal. In the three models, isobolographic analysis revealed a significant synergistic interaction between fospropofol and alfentanil. The ED50 value for the drug combination was significantly lower than the theoretical additive value (p<0.05).

CONCLUSIONS

The results demonstrate that fospropofol and alfentanil provide synergistic antinociceptive interactions in the formalin, hot-plate, and tail-flick tests. The observed synergistic interaction between fospropofol and alfentanil are indicative of the effectiveness of the combination treatment in pain management and should be explored further in patients undergoing minor surgical procedures.

Concomitant drugs with low risks of drug-drug interactions for use in oncology clinical trials

BACKGROUND

Drug-drug interactions (DDIs) may occur with investigational drugs and affect patient safety, trial outcomes, and drug development. A list of preferred drugs with minimal risks of DDIs for treatment of symptoms or comorbidities frequently encountered by cancer patients would be helpful.

METHODS

We reviewed the literature to assess DDIs reported for the main drugs available for treatment of symptoms/comorbidities frequently encountered by cancer patients. Reviews and relevant original articles cited were retrieved and analyzed, and the following data were collected and double-checked: pharmacological properties; effects, if any, of drugs on CYP enzymes, membrane transporters, and QT interval; and involvement in significant DDIs.

RESULTS

A list of preferred drugs with minimal risks of DDIs was compiled.

CONCLUSION

Acknowledging for heterogeneity in data sources, prevention of unexpected DDIs during clinical trials may be improved by using this list of preferred drugs for the management of study patient's symptoms.

Dexmedetomidine versus midazolam for gastrointestinal endoscopy: a meta-analysis

BACKGROUND AND AIM

Patients who undergo gastrointestinal endoscopy often require sedatives such as midazolam and the more recently developed alpha-2 agonist, dexmedetomidine. To assess the efficacy and safety of dexmedetomidine sedation for gastrointestinal endoscopy, we conducted a systematic review and meta-analysis of randomized controlled trials comparing dexmedetomidine with midazolam.

METHODS

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database in order to identify randomized trials eligible for inclusion in our meta-analysis. Data from the eligible studies were combined to calculate pooled odds ratios (OR) or weighted mean differences (WMD).

RESULTS

We identified nine randomized trials from the database search. Compared to that of midazolam, the pooled OR for restlessness of dexmedetomidine was 0.078 (95% confidence interval [CI]: 0.013-0.453, P < 0.0001), and there was no significant heterogeneity among the trial results. Dexmedetomidine significantly increased Ramsay sedation score compared with midazolam (WMD: 0.401, 95% CI: 0.110-0.692, P = 0.0069), without significant heterogeneity. Compared with midazolam, the pooled OR for hypoxia, hypotension, and bradycardia with dexmedetomidine sedation were 0.454 (95% CI: 0.098-2.11), 1.370 (95% CI: 0.516-3.637), and 2.575 (95% CI: 0.978-6.785), respectively, with no significant differences detected between the groups.

CONCLUSION

This meta-analysis shows that dexmedetomidine is a safe and effective sedative agent for gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography and endoscopic submucosal dissection.

The effect of midazolam on the recovery quality, recovery time and the minimum alveolar concentration for extubation in the isoflurane-anesthetized pig

There are no reported studies evaluating the effect of midazolam on recovery quality, recovery time or minimum alveolar concentration (MAC) at which extubation occurs (MAC extubation). Our hypotheses were that midazolam administered prior to recovery would decrease MAC extubation, prolong recovery time but provide a smoother recovery. Sixteen Yorkshire pigs were anesthetized with isoflurane for approximately 5 h. The end-tidal isoflurane concentration was then stabilized at 1.4% for 20 min. Pigs were randomly assigned to receive midazolam or saline. The vaporizer was decreased by 10% every 10 min until extubation. Pigs were declared awake by a blinded observer and were assigned a recovery score by the same observer. Mean MAC extubation was not significantly different for pigs receiving saline prior to recovery compared with those pigs receiving midazolam. The overall mean MAC extubation for both groups was 0.6 ± 0.4 vol%. Time to extubation was not significantly longer with midazolam (124 ± 36 min) compared with the saline group (96 ± 61 min; P = 0.09). Recovery score was not significantly different between groups (midazolam, 0.86 ± 1.1; saline 0.5 ± 0.5; P = 0.26). In conclusion, midazolam did not affect MAC extubation. There was no advantage of administering midazolam in the recovery period when performing step-down titration of isoflurane anesthesia.

Valeriana officinalis L. for conscious sedation of patients submitted to impacted lower third molar surgery: A randomized, double-blind, placebo-controlled split-mouth study

Introduction:

Anxiety is one of the components of patient stress in the dental office and is recognized as one of the main factors that negatively affect treatment. The control of anxiety can be performed through conscious sedation, for which benzodiazepine is the drug of choice in dental practice, however present side-effects.

Objective:

The objective of the following study is to evaluate the efficacy of Valeriana officinalis L. (Valerian) for control of anxiety during the third molar surgery.

Materials and Methods:

A single oral dose of either Valerian (100 mg) or placebo was randomly administered 1 h before each surgical procedure to 20 volunteers between 17 and 31 years of age. Anxiety level was assessed by physiological parameters (blood pressure and heart rate [HR]) and the observation of signs. Descriptive analysis, Chi-square test, Friedman test, Wilcoxon test and effect size test were performed (P < 0.05).

Results:

According to the researcher's (80%) and surgeon's (75%) evaluations, the patients treated with Valerian were calmer and more relaxed during surgery. Valerian had a greater effect on the maintenance of systolic blood pressure and HR after surgery.

Conclusion:

Valerian was more effective at controlling anxiety than a placebo when used for the conscious sedation of adult patients submitted to impacted lower third molar surgery.

Impact of CYP3A5 genotype on tacrolimus versus midazolam clearance in renal transplant recipients: new insights in CYP3A5-mediated drug metabolism

BACKGROUND & AIM

In vitro studies have identified both midazolam and tacrolimus as dual CYP3A4 and CYP3A5 substrates. In vivo; however, the CYP3A5 genotype has a marked impact on tacrolimus pharmacokinetics, whereas it seems not to affect midazolam pharmacokinetics. The aim of the current study was to explore this paradigm in a relevant clinical setting.

PATIENTS & METHODS

A case-control study in 80 tacrolimus-treated renal transplant recipients comparing systemic and apparent oral midazolam clearance and tacrolimus pharmacokinetics in CYP3A5 expressers (CYP3A5*1 allele carriers) and CYP3A5 nonexpressers (CYP3A5*3/*3) was performed.

RESULTS

CYP3A5 expressers display an approximately 2.4-fold higher tacrolimus clearance as compared with CYP3A5 nonexpressers, whereas there are no differences in systemic and apparent oral midazolam clearance.

CONCLUSION

These data confirm that in vivo CYP3A5 plays an important role in tacrolimus metabolism, while its contribution to midazolam metabolism in a relevant study population is limited. Furthermore, these data suggest that midazolam is to be considered as a phenotypic probe for in vivo CYP3A4 activity rather than combined CYP3A4 and CYP3A5 activity.

A prospective randomized double-blind study comparing dexmedetomidine vs. combination of midazolam-fentanyl for tympanoplasty surgery under monitored anesthesia care

Background:

Analgesia and sedation are usually required for the comfort of the patient and surgeon during tympanoplasty surgery done under local anesthesia. In this study, satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine were compared with a combination of midazolam-fentanyl.

Materials and Methods:

Ninety patients undergoing tympanoplasty under local anesthesia randomly received either IV dexmedetomidine 1 μg kg^-1 over 10 min followed by 0.2 μg kg^-1h^-1 infusion (Group D) or IV midazolam 0.06 mg kg^-1 plus IV fentanyl 1 μg kg^-1 over 10 min (Group MF) followed by normal saline infusion at 0.2 ml kg^-1h^-1. Sedation was titrated to Ramsay sedation score (RSS) of three. Vital parameters, rescue analgesics (fentanyl 1 μg kg^-1) and sedatives (midazolam 0.01 mg kg^-1), patient and surgeon satisfaction scores were recorded.

Results:

Patient and surgeon satisfaction score was better in Group D than Group MF (median interquartile range (IQR) 9 (8-10) vs. 8 (6.5-9.5) and 9 (8.5-9.5) vs. 8 (6.75-9.25), P = 0.0001 for both). Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group MF (P < 0.05). Percentage of patients requiring rescue fentanyl was higher in Group MF than Group D (40% vs. 11.1%, P = 0.01). One patient in Group D while four in Group MF (8.8%) required rescue sedation with midazolam (P > 0.17). Seven patients in Group D had dry mouth vs. none in Group MF (P = 0.006). One patient in Group D had bradycardia with hypotension which was effectively treated.

Conclusion:

Dexmedetomidine is comparable to midazolam-fentanyl for sedation and analgesia in tympanoplasty with better surgeon and patient satisfaction. Hemodynamics need to be closely monitored.

Safety of midazolam for sedation of HIV-positive patients undergoing colonoscopy

OBJECTIVES

Because of concerns regarding interactions between midazolam and antiretroviral therapy (ART), alternative sedatives are sometimes used during procedural sedation. Our objective was to compare outcomes in patients on ART who received intravenous (iv) midazolam vs. iv diazepam, a second-line agent, during colonoscopy.

METHODS

We conducted a retrospective analysis of adult HIV-positive patients who underwent colonoscopy over a 3.5-year period. Primary outcomes were sedation duration, nadir systolic blood pressure (SBP), nadir oxygen saturation, abnormal cardiac rhythm, and change in level of consciousness using a standardized scale. We calculated rates of adverse events according to benzodiazepine use and identified risk factors for complications using univariate and multivariate analyses.

RESULTS

We identified 136 patients for this analysis: 70 received midazolam-based sedation and 66 received a diazepam-based regimen. There were no significant differences between the two groups with respect to sedation duration (mean 48.0 vs. 45.7 minutes for the midazolam and diazepam groups, respectively; P = 0.68), nadir SBP (mean 97.0 vs. 101.6 mmHg; P = 0.06), nadir oxygen saturation (mean 94.6 vs. 94.8%; P = 0.72) or rate of abnormal cardiac rhythm (11.4 vs. 19.7%; P = 0.18). More patients in the midazolam group experienced a depressed level of consciousness (91% vs. 74% in the diazepam group; P = 0.0075), but no patient required reversal of sedation or became unresponsive.

CONCLUSIONS

We did not find evidence that patients who received midazolam for procedural sedation had clinical outcomes statistically different from those who received diazepam. These findings should be confirmed in prospective studies or in a randomized controlled trial.

Dexmedetomidine: a guide to its use for sedation in the US

Intravenous dexmedetomidine (Precedex(®)) provides both effective sedation in mechanically ventilated patients in an intensive care setting and effective procedural sedation. In these patient populations, it reduces the need for rescue sedation with intravenous propofol or intravenous midazolam and reduces opioid requirements. In addition, patients receiving dexmedetomidine are calm and easy to arouse and manage. Intravenous dexmedetomidine is generally well tolerated and is not associated with respiratory depression. Although the utilization of dexmedetomidine is associated with hypotension and bradycardia, both usually resolve without intervention.

Comparison of effects of dexmedetomidine-ketamine and dexmedetomidine-midazolam combinations in transurethral procedures

OBJECTIVE

To compare the effects of dexmedetomidine-ketamine and dexmedetomidine-midazolam combinations on the recovery time, hemodynamic and respiratory variables, and side effects in patients undergoing transurethral procedures.

METHODS

Sixty patients scheduled for elective outpatient transurethral procedure were randomized into 2 groups. In the group K, a ketamine-dexmedetomidine combination was administered, and in the group M, midazolam-dexmedetomidine was administered, to provide sedation/analgesia. Pain and sedation levels were assessed using visual analog score (VAS) and Ramsey Sedation Scale, respectively. The recovery time was assessed with the scale of Aldrete. Time was measured and recorded to the moment at which patient responses brought the Aldrete score to 10 points. Time to eye opening and length of stay in the recovery room were recorded.

RESULTS

Group M showed significantly lower mean arterial pressure (MAP) values at 5 and 10 minutes during the procedure when compared with group K (P = .02 and P = .01, respectively). Visual analogue scale scores were greater in group M than in group K at 5 and 10 minutes for the transurethral procedure (P = .039 and P = .028, respectively). Sedation scores were similar between groups during the procedure. Time to eye opening and length of recovery room stay were shorter (P < .001 and P < .001, respectively), and Aldrete scores were greater in group K than group M.

CONCLUSION

Both combinations provided satisfactory sedation levels, but the dexmedetomidine-ketamine combination provided better analgesia and hemodynamic stability, with less nausea and vomiting and shorter recovery time, than the dexmedetomidine-midazolam combination.

Clinical and critical care concerns in severely ill obese patient

The incidence of obesity has acquired an epidemic proportion throughout the globe. As a result, increasing number of obese patients is being presented to critical care units for various indications. The attending intensivist has to face numerous challenges during management of such patients. Almost all the organ systems are affected by the impact of obesity either directly or indirectly. The degree of obesity and its prolong duration are the main factors which determine the harmful effect of obesity on human body. The present article reviews few of the important clinical and critical care concerns in critically ill obese patients.

Pain management for tubal sterilization by hysteroscopy

BACKGROUND

Tubal sterilization by hysteroscopy involves inserting a foreign body in both fallopian tubes. Over a three-month period, the tubal lumen is occluded by tissue growth stimulated by the insert. Tubal sterilization by hysteroscopy has advantages over laparoscopy or mini-laparotomy, including the avoidance of abdominal incisions and the convenience of performing the procedure in an office-based setting. Pain, an important determinant of procedure acceptability, can be a concern when tubal sterilization is performed in the office.

OBJECTIVES

To review all randomized controlled trials that evaluated interventions to decrease pain during tubal sterilization by hysteroscopy.

SEARCH METHODS

From January to March 2011, we searched the computerized databases of MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, and CINAHL for relevant trials. We searched for current trials via Clinicaltrials.gov. We also examined the reference lists of pertinent articles and wrote to known investigators for information about other published or unpublished trials.

SELECTION CRITERIA

We included all randomized controlled trials that evaluated pain management at the time of sterilization by hysteroscopy. The intervention could be compared to another intervention or placebo.

DATA COLLECTION AND ANALYSIS

Initial data were extracted by one review author. A second review author verified all extracted data. Whenever possible, the analysis was conducted with all women randomized and in the original assigned groups. Data were analyzed using RevMan software. Pain was measured using either a 10-cm or 100-point visual analog scale (VAS). When pain was measured at multiple points during the procedure, the overall pain score was considered the primary treatment effect. If this was not measured, a summation of all pain scores for the procedure was considered to be the primary treatment effect. For continuous variables, the mean difference with 95% confidence interval was computed.

MAIN RESULTS

Two trials met the inclusion criteria. The total number of participants was 167. Using a 10-cm VAS to measure pain, no significant difference emerged in overall pain for the entire procedure between women who received a paracervical block with lidocaine versus normal saline (mean difference -0.77; 95% CI -2.67 to 1.13). No significant difference in pain score was noted at the time of injection of study solution to the anterior lip of the cervix (mean difference -0.6; 95% CI -1.3 to 0.1), placement of the device in the tubal ostia (mean difference -0.60; 95% CI -1.8 to 0.7), and postprocedure pain (mean difference 0.2; 95% CI -0.8 to 1.2). Procedure time (mean difference -0.2 minutes; 95% CI -2.2 to 1.8 minutes) and successful bilateral placement (OR 1.0; 95% CI 0.19 to 5.28) was not significantly different between groups. During certain portions of the procedure, such as placement of the tenaculum (mean difference -2.03; 95% CI -2.88 to -1.18), administration of the paracervical block (mean difference -1.92; 95% CI -2.84 to -1.00), and passage of the hysteroscope through the external (mean difference -2.31; 95% CI -3.30 to -1.32) and internal os (mean difference -2.31; 95% CI -3.39 to -1.23), use of paracervical block with lidocaine resulted in lower pain scores.Using a 600-point scale calculated by adding 100-point VAS scores from six different portions of the procedure, no significant difference emerged in overall pain between women who received intravenous conscious sedation versus oral analgesia (mean difference -23.00; CI -62.02 to 16.02). Using a 100-point VAS, no significant difference emerged at the time of speculum insertion (mean difference 4.0; 95% CI -4.0 to 12.0), cervical injection of lidocaine (mean difference -1.8; 95% CI -10.0 to 6.4), insertion of the hysteroscope (mean difference -8.7; 95% CI -19.7 to 2.3), placement of the first device (mean difference -4.4; 95% CI -15.8 to 7.0), and removal of the hysteroscope (mean difference 0.9; 95% CI -3.9 to 5.7). Procedure time (mean difference -0.2 minutes; 95% CI -2.0 to 1.6 minutes) and time in the recovery area (mean difference 3.6 minutes; 95% CI -11.3 to 18.5 minutes) was not different between groups. However, women who received intravenous conscious sedation had lower pain scores at the time of insertion of the second tubal device compared to women who received oral analgesia (mean difference -12.60; CI -23.98 to -1.22).

AUTHORS' CONCLUSIONS

The available literature is insufficient to determine the appropriate analgesia or anesthesia for sterilization by hysteroscopy. Compared to paracervical block with normal saline, paracervical block with lidocaine reduced pain during some portions of the procedure. Intravenous sedation resulted in lower pain scores during insertion of the second tubal device. However, neither paracervical block with lidocaine nor conscious sedation significantly reduced overall pain scores for sterilization by hysteroscopy.