Respiratory drive heterogeneity associated with systemic inflammation and vascular permeability in acute respiratory distress syndrome

BACKGROUND

In acute respiratory distress syndrome (ARDS), respiratory drive often differs among patients with similar clinical characteristics. Readily observable factors like acid-base state, oxygenation, mechanics, and sedation depth do not fully explain drive heterogeneity. This study evaluated the relationship of systemic inflammation and vascular permeability markers with respiratory drive and clinical outcomes in ARDS.

METHODS

ARDS patients enrolled in the multicenter EPVent-2 trial with requisite data and plasma biomarkers were included. Neuromuscular blockade recipients were excluded. Respiratory drive was measured as PES0.1, the change in esophageal pressure during the first 0.1 s of inspiratory effort. Plasma angiopoietin-2, interleukin-6, and interleukin-8 were measured concomitantly, and 60-day clinical outcomes evaluated.

RESULTS

54.8% of 124 included patients had detectable respiratory drive (PES0.1 range of 0-5.1 cm H2O). Angiopoietin-2 and interleukin-8, but not interleukin-6, were associated with respiratory drive independently of acid-base, oxygenation, respiratory mechanics, and sedation depth. Sedation depth was not significantly associated with PES0.1 in an unadjusted model, or after adjusting for mechanics and chemoreceptor input. However, upon adding angiopoietin-2, interleukin-6, or interleukin-8 to models, lighter sedation was significantly associated with higher PES0.1. Risk of death was less with moderate drive (PES0.1 of 0.5-2.9 cm H2O) compared to either lower drive (hazard ratio 1.58, 95% CI 0.82-3.05) or higher drive (2.63, 95% CI 1.21-5.70) (p = 0.049).

CONCLUSIONS

Among patients with ARDS, systemic inflammatory and vascular permeability markers were independently associated with higher respiratory drive. The heterogeneous response of respiratory drive to varying sedation depth may be explained in part by differences in inflammation and vascular permeability.

Development of a predictive model for hypoxia due to sedatives in gastrointestinal endoscopy: a prospective clinical study in Korea

Background/Aims

Sedation has become a standard practice for patients undergoing gastrointestinal (GI) endoscopy. However, considering the serious cardiopulmonary adverse events associated with sedatives, it is important to identify patients at high risk. Machine learning can generate reasonable prediction for a wide range of medical conditions. This study aimed to evaluate the risk factors associated with sedation during GI endoscopy and develop a predictive model for hypoxia during endoscopy under sedation.

Methods

This prospective observational study enrolled 446 patients who underwent sedative endoscopy at the Korea University Ansan Hospital. Clinical data were used as predictor variables to construct predictive models using the random forest method that is a machine learning algorithm.

Results

Seventy-two of the 446 patients (16.1%) experienced life-threatening hypoxia requiring immediate medical intervention. Patients who developed hypoxia had higher body weight, body mass index (BMI), neck circumference, and Mallampati scores. Propofol alone and higher initial and total dose of propofol were significantly associated with hypoxia during sedative endoscopy. Among these variables, high BMI, neck circumference, and Mallampati score were independent risk factors for hypoxia. The area under the receiver operating characteristic curve for the random forest-based predictive model for hypoxia during sedative endoscopy was 0.82 (95% confidence interval, 0.79-0.86) and displayed a moderate discriminatory power.

Conclusions

High BMI, neck circumference, and Mallampati score were independently associated with hypoxia during sedative endoscopy. We constructed a model with acceptable performance for predicting hypoxia during sedative endoscopy.

Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis

BACKGROUND

In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial.

OBJECTIVES

We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children.

METHODS

We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic.

RESULTS

A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists.

CONCLUSIONS

In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.

[Safe discontinuation of psychotropic drugs in older people? : New evidence and practical approach]

BACKGROUND

Many older patients are permanently prescribed one or more psychotropic drugs for treatment of symptoms, such as behavioral and psychological symptoms in dementia, depressive symptoms, anxiety, and insomnia. They therefore contribute to the risk of polypharmacy. Recently, deprescribing studies have been published in order to clarify if inadequate medications can be safely discontinued. This mini-review summarizes the study results and derives practical recommendations for routine use.

METHOD

A literature search was carried out in PubMed for clinical studies on deprescribing in association with psychotropic substances.

RESULTS

After removal of duplications, 12 heterogeneous clinical studies were identified and reduction of psychotropic substances could be successfully achieved in 8 studies. In four of these studies psychological, behavioral and functional endpoints were reported. Criteria for successful deprescribing of sedatives were in particular motivation, information and sufficient cooperation of the patients and for antipsychotic drugs in people with dementia, the sustainable establishment of nonpharmaceutical treatment strategies. Deprescribing was not attempted in cases of a history of severe chronic mental illness and in cases of severe behavioral symptoms in dementia. Evidence for antidepressants was not sufficient to extract practical recommendations.

CONCLUSION

Safe deprescribing of antipsychotic drugs in patients with dementia is justified if non-pharmacological treatment options are sustainably implemented, and for sedative drugs in well-informed, highly motivated and cooperative patients.

Expert-approved best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care (SedPall)

BACKGROUND

The use of sedative drugs and intentional sedation in end-of-life care is associated with clinical, ethical and legal challenges. In view of these and of the issue's great importance to patients undergoing intolerable suffering, we conducted a project titled SedPall ("From anxiolysis to deep continuous sedation - Development of recommendations for sedation in palliative care") with the purpose of developing best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care and obtaining feedback and approval from experts in this area.

DESIGN

Our stepwise approach entailed drafting the recommendations, obtaining expert feedback, conducting a single-round Delphi study, and convening a consensus conference. As an interdisciplinary group, we created a set of best practice recommendations based on previously published guidance and empirical and normative analysis, and drawing on feedback from experts, including patient representatives and of public involvement participants. We set the required agreement rate for approval at the single-round Delphi and the consensus conference at ≥80%.

RESULTS

Ten experts commented on the recommendations' first draft. The Delphi panel comprised 50 experts and patient and public involvement participants, while 46 participants attended the consensus conference. In total, the participants in these stages of the process approved 66 recommendations, covering the topics "indications", "intent/purpose [of sedation]", "decision-making", "information and consent", "medication and type of sedation", "monitoring", "management of fluids and nutrition", "continuing other measures", "support for relatives", and "team support". The recommendations include suggestions on terminology and comments on legal issues.

CONCLUSION

Further research will be required for evaluating the feasibility of the recommendations' implementation and their effectiveness. The recommendations and the suggested terminology may serve as a resource for healthcare professionals in Germany on the use of sedative drugs and intentional sedation in specialist palliative care and may contribute to discussion on the topic at an international level.

TRIAL REGISTRATION

DRKS00015047 (German Clinical Trials Register).

Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis

BACKGROUND

Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population.

METHODS

A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others.

RESULTS

A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%).

CONCLUSION

DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.

Assessment of high-risk opioid use metrics among individuals with spinal cord injury: A brief report

OBJECTIVE

To examine high-risk opioid prescription metrics among individuals with chronic spinal cord injury (SCI) living in South Carolina.

DESIGN

Cohort Study.

SETTING

Two statewide population-based databases, an SCI Surveillance Registry and state prescription drug monitoring program (PDMP).

PARTICIPANTS

Linked data was obtained for 503 individuals with chronic (>1year-post injury) SCI who were injured in 2013 or 2014 and who survived at least 3 years post-injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Opioid prescription metrics were obtained from the PDMP. Fill data during the period between January 1, 2014 and December 31, 2017 were analyzed to assess high-risk opioid use. Outcomes included: percentage of individuals prescribed chronic opioids, high-dose chronic opioid therapy (daily morphine milligram equivalents (MME) ≥50 and ≥90), and chronic concurrent opioids and benzodiazepines, sedatives, or hypnotics (BSH).

RESULTS

Over half (53%) of the individuals filled an opioid in years 2-3 after injury. Of those, 38% had a concurrent BSH fill during the study period, 76% of which were for benzodiazepines. In any given quarter over the two-year timeframe, over half of the opioid prescriptions were for 60 days or more (chronic opioid prescriptions). Of those, roughly 40% of the individuals had high-dose chronic opioid prescriptions ≥50 MME/d and 25% were ≥90 MME/d. Over 33% had a concurrent BSH prescription for ≥60 days.

CONCLUSIONS

While the number of individuals receiving high-risk opioid prescriptions may not be large, it is a concerning number of prescriptions. The findings suggest a need for more cautious opioid prescribing and monitoring of high-risk use in adults with chronic SCI.

Deep Sedation in Traumatic Brain Injury Patients

Traumatic brain injury (TBI) is one of the leading causes of mortality and disability in adults. In cases of severe TBI, preventing secondary brain injury by managing intracranial hypertension during the acute phase is a critical treatment challenge. Among surgical and medical interventions to control intracranial pressure (ICP), deep sedation can provide comfort to patients and directly control ICP by regulating cerebral metabolism. However, insufficient sedation does not achieve the intended treatment goals, and excessive sedation can lead to fatal sedative-related complications. Therefore, it is important to continuously monitor and titrate sedatives by measuring the appropriate depth of sedation. In this review, we discuss the effectiveness of deep sedation, techniques to monitor the depth of sedation, and the clinical use of recommended sedatives, barbiturates, and propofol in TBI.

"At the time I only wanted to relieve stress": Exploring motivation for behaviour change in long-term hypnotic users

Background

Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model.

Aim

Exploring primary care patients' views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework.

Design and setting

A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021.

Method

Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method.

Results

The success of discontinuation interventions does not solely rely on patients' spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users.

Conclusion

Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Psychotropic consumption before and during COVID-19 in Asturias, Spain

BACKGROUND

Spain as multiple other countries has been experiencing an increasing and sustained trend in the use of psychotropic medications since the mid 90s. Recent studies show public health measures implemented to control SARS-Cov2, such as mobility restrictions and the shutdown of nonessential activities increased mental suffering, even contributing to a higher number of anxiety, depression and insomnia disorders that could lead to an increase in the consumption of psychotropics. The aims were: 1) Evaluate the temporal trend in psychotropic consumption by pharmacological subgroup, sex, and age group 2) Estimate the effect of the COVID-19 pandemic in the use of psychotropic drugs.

METHODS

We conducted a retrospective observational study, retrieving all prescriptions of anxiolytics, hypnotics and sedatives, and antidepressants dispensed in pharmacies of Asturias (Northern Spain) for Primary Care patients for the period 2018-2021. We presented the data expressed in Daily Defined Doses (DDDs) for 1000 persons/day (DHD). To estimate changes in DHDs by year and age group we conducted two multiple linear regressions (one for males and one for females) for every pharmacological subgroup studied. Changes were considered statistically significant when the regression coefficient was p < 0.05. We used the Software R 4.1.0.

RESULTS

For the studied period, the highest DHDs are for antidepressants, although all of the subgroups experienced an increase in consumption rates. Women consumed more psychotropic drugs than men. In 2021, 372 out of every 1000 women were taking daily 1 DDD of these drugs versus 184 out of every 1000 men. Consumption rates for all psychotropic drugs progressively increases with age. Conversely, the biggest increases in consumption were among the youngest age groups (0-14 and 15-29 years) for women, while for men there is more variability. The regression models suggest an upward trend in psychotropic consumption during all the period, especially remarkable from 2020, for both genders and all age groups.

CONCLUSIONS

- The consumption of psychotropic drugs has gradually increased over the last 4 years, with a significant boost starting in 2020 for both sexes, matching the start of the SARS-COV2 pandemic and the implementation of strict Public Health measures to contain it. - The increase observed on children and adolescents is a matter of concern.

[Safe discontinuation of psychotropic drugs in older people? : New evidence and practical approach]

BACKGROUND

Many older patients are permanently prescribed one or more psychotropic drugs for treatment of symptoms, such as behavioral and psychological symptoms in dementia, depressive symptoms, anxiety, and insomnia. They therefore contribute to the risk of polypharmacy. Recently, deprescribing studies have been published in order to clarify if inadequate medications can be safely discontinued. This mini-review summarizes the study results and derives practical recommendations for routine use.

METHOD

A literature search was carried out in PubMed for clinical studies on deprescribing in association with psychotropic substances.

RESULTS

After removal of duplications, 12 heterogeneous clinical studies were identified and reduction of psychotropic substances could be successfully achieved in 8 studies. In four of these studies psychological, behavioral and functional endpoints were reported. Criteria for successful deprescribing of sedatives were in particular motivation, information and sufficient cooperation of the patients and for antipsychotic drugs in people with dementia, the sustainable establishment of nonpharmaceutical treatment strategies. Deprescribing was not attempted in cases of a history of severe chronic mental illness and in cases of severe behavioral symptoms in dementia. Evidence for antidepressants was not sufficient to extract practical recommendations.

CONCLUSION

Safe deprescribing of antipsychotic drugs in patients with dementia is justified if non-pharmacological treatment options are sustainably implemented, and for sedative drugs in well-informed, highly motivated and cooperative patients.

Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care

BACKGROUND

Iatrogenic withdrawal syndrome (IWS) is a complication of prolonged sedation/analgesia in pediatric intensive care unit (PICU) patients. The epidemiology of IWS is poorly understood, as validated diagnostic tools are rarely used. The main objective of our study was to use the WAT-1 score to assess the incidence of IWS in our unit. The secondary objectives were to evaluate the consequences of IWS, associated factors, and management modalities.

MATERIAL AND METHODS

From July 2018 to January 2019, 48 children receiving endotracheal ventilation and sedation/analgesia by continuous infusion (>48 h) of benzodiazepines and/or opioids were included. As soon as sedation/analgesia was decreased and until 72 h after its complete discontinuation, the WAT-1 score was determined every 12 h. Substitution therapy was used for 98% of patients upon opioid and/or benzodiazepine withdrawal. IWS was defined as a WAT-1 score ≥3. Factors associated with IWS were assessed by univariate analysis.

RESULTS

IWS occurred in 25 (52%) patients. IWS was associated with a higher number of ventilator-associated pneumonia episodes (17 [68%] vs. one [4%]) and a longer PICU stay (13 [7; 25] vs. 9.0 [5.0; 10.5]) (p<0.001). Overall, 11 patients developed IWS after less than 5 days of sedation/analgesia. Severe head injury was associated with IWS (p = 0.03). Neither sedation discontinuation nor IWS prevention was standardized.

CONCLUSION

The high incidence and adverse consequences of IWS require improved prevention. Risk groups should be defined and a standardized withdrawal protocol established. The occurrence of IWS should be monitored routinely using a validated score.

Mechanisms and implications in gene polymorphism mediated diverse reponses to sedatives, analgesics and muscle relaxants

Responses to sedatives, analgesics and muscle relaxants vary among patients under general anesthesia, which could be ascribed to the disparities of clinical characteristics and genetic factors of individuals. Accumulating researches have indicated that gene polymorphisms of the receptors, transporters and metabolizing enzymes associated with anesthetics play a considerable role in their efficacy. However, a systematically summarized study on the mechanisms of gene polymorphisms on pharmacodynamics and pharmacokinetics of anesthetics is still lacking. In this paper, the recent researches on pharmacogenomics of sedatives, analgesics and muscle relaxants are comprehensively reviewed, and the contributions and mechanisms of polymorphisms to the differences of individual efficacy of these drugs are discussed, so as to provide guidance for the formulation of a rational anesthesia regimen for patients with various genotypes.

Determination of the 95% effective dose of remimazolam to achieve loss of consciousness during anesthesia induction in different age groups

BACKGROUND

Remimazolam is a new ultra short-acting benzodiazepine originally developed as an improved version of midazolam. Recent studies have demonstrated non-inferiority of remimazolam to propofol in general anesthesia. However, to date, few studies have investigated the induction bolus dose of remimazolam required to achieve general anesthesia. We aimed to determine the 95% effective dose (ED95) of remimazolam bolus required to achieve loss of consciousness (LOC) and the appropriate doses for different age groups.

METHODS

Patients aged 20-79 years with the American Society of Anesthesiologists physical status of I or II were enrolled in this study. A total of 120 patients were included representing young, middle-aged, and elderly groups. Loss of eyelash reflex and verbal response after the administration of remimazolam was considered successful LOC. The ED95 of remimazolam was determined using a biased coin up-and-down design with sequential allocation and the isotonic regression method.

RESULTS

The ED95 of remimazolam for induction of general anesthesia was 0.367 mg/kg (95% CI [0.277, 0.392]) in the young group, 0.369 mg/kg (95% CI [0.266, 0.394]) in the middle-aged group, and 0.249 mg/kg (95% CI [0.199, 0.288]) in the elderly group. During the study period, none of the patients required rescue medications for hypotension or bradycardia.

CONCLUSIONS

This study investigated the ED95 of remimazolam bolus for anesthesia induction. The precise dosing of the ED95 can help maintain hemodynamic stability during the induction of anesthesia.

A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation

INTRODUCTION

Rapid sequence intubation is an airway rescue and protection technique in which different sedatives are used to perform orotracheal intubation. Etomidate, due to its pharmacokinetic and pharmacodynamic qualities, particularly hemodynamic stability, is the most widely used sedative in this scenario. However, its superiority over other sedatives is controversial.

MATERIALS AND METHODS

We performed a meta-analysis using a pre-designed protocol and PRISMA guidelines to evaluate the mean difference between systolic blood pressure before and after administration of the sedative. We also analyzed the relative risks of hypotension.

RESULTS

Ten studies were included. The incidence of hypotension in patients receiving etomidate ranged from 6.4% to 75.2%, and between 24.0% and 65.9% in patients receiving other sedatives. No significant differences were found in the mean difference in systolic blood pressure during pre-intubation 0.01 mm Hg (95% CI: -0.90; 0.92) or in post-intubation 0.98 mmHg (95% CI: -0.24; 2.20). The relative risk analysis showed that the risk of hypotension is equal to an RR of 1.19 (95% CI: 0.92-1.54) between those who received etomidate and those who received the other sedatives.

CONCLUSIONS

The risk of hypotension after rapid intubation sequence with etomidate does not differ significantly compared to other sedatives. However, the studies included in this review were heterogeneous.

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea

PURPOSE

Rapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications.

MATERIALS AND METHODS

This multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted.

RESULTS

A total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120-1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093-4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257-11.626).

CONCLUSION

RSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.

Do palliative care patients and relatives think it would be acceptable to use Bispectral index (BIS) technology to monitor palliative care patients' levels of consciousness? A qualitative exploration with interviews and focus groups for the I-CAN-CARE research programme

BACKGROUND

Bispectral index (BIS) monitoring uses electroencephalographic data as an indicator of patients' consciousness level. This technology might be a useful adjunct to clinical observation when titrating sedative medications for palliative care patients. However, the use of BIS in palliative care generally, and in the UK in particular, is under-researched. A key area is this technology's acceptability for palliative care service users. Ahead of trialling BIS in practice, and in order to ascertain whether such a trial would be reasonable, we conducted a study to explore UK palliative care patients' and relatives' perceptions of the technology, including whether they thought its use in palliative care practice would be acceptable.

METHODS

A qualitative exploration was undertaken. Participants were recruited through a UK hospice. Focus groups and semi-structured interviews were conducted with separate groups of palliative care patients, relatives of current patients, and bereaved relatives. We explored their views on acceptability of using BIS with palliative care patients, and analysed their responses following the five key stages of the Framework method.

RESULTS

We recruited 25 participants. There were ten current hospice patients in three focus groups, four relatives of current patients in one focus group and one individual interview, and eleven bereaved relatives in three focus groups and two individual interviews. Our study participants considered BIS acceptable for monitoring palliative care patients' consciousness levels, and that it might be of use in end-of-life care, provided that it was additional to (rather than a replacement of) usual care, and patients and/or family members were involved in decisions about its use. Participants also noted that BIS, while possibly obtrusive, is not invasive, with some seeing it as equivalent to wearable technological devices such as activity watches.

CONCLUSIONS

Participants considered BIS technology might be of benefit to palliative care as a non-intrusive means of assisting clinical assessment and decision-making at the end of life, and concluded that it would therefore be acceptable to trial the technology with patients.

Long-term ketamine infusion-induced cholestatic liver injury in COVID-19-associated acute respiratory distress syndrome

Background

A higher-than-usual resistance to standard sedation regimens in COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) has led to the frequent use of the second-line anaesthetic agent ketamine. Simultaneously, an increased incidence of cholangiopathies in mechanically ventilated patients receiving prolonged infusion of high-dose ketamine has been noted. Therefore, the objective of this study was to investigate a potential dose–response relationship between ketamine and bilirubin levels.

Methods

Post hoc analysis of a prospective observational cohort of patients suffering from COVID-19-associated ARDS between March 2020 and August 2021. A time-varying, multivariable adjusted, cumulative weighted exposure mixed-effects model was employed to analyse the exposure–effect relationship between ketamine infusion and total bilirubin levels.

Results

Two-hundred forty-three critically ill patients were included into the analysis. Ketamine was infused to 170 (70%) patients at a rate of 1.4 [0.9–2.0] mg/kg/h for 9 [4–18] days. The mixed-effects model revealed a positively correlated infusion duration–effect as well as dose–effect relationship between ketamine infusion and rising bilirubin levels (p < 0.0001). In comparison, long-term infusion of propofol and sufentanil, even at high doses, was not associated with increasing bilirubin levels (p = 0.421, p = 0.258). Patients having received ketamine infusion had a multivariable adjusted competing risk hazard of developing a cholestatic liver injury during their ICU stay of 3.2 [95% confidence interval, 1.3–7.8] (p = 0.01).

Conclusions

A causally plausible, dose–effect relationship between long-term infusion of ketamine and rising total bilirubin levels, as well as an augmented, ketamine-associated, hazard of cholestatic liver injury in critically ill COVID-19 patients could be shown. High-dose ketamine should be refrained from whenever possible for the long-term analgosedation of mechanically ventilated COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04019-8.

Benzodiazepines and Related Sedatives

Benzodiazepine and related sedative use has been increasing. There has been a growing number of unregulated novel psychoactive substances, including designer benzodiazepines. Benzodiazepines have neurobiological and pharmacologic properties that result in a high potential for misuse and physical dependence. Options for discontinuing long-term benzodiazepine use include an outpatient benzodiazepine taper or inpatient withdrawal management at a hospital or detoxification facility. The quality of evidence on medications for benzodiazepine discontinuation is overall low, whereas cognitive behavioral therapy has shown the most benefit in terms of behavioral treatments. Benzodiazepines may also have significant adverse effects, increasing the risk of overdose and death.

Verification of the performance of the Bispectral Index as a hypnotic depth indicator during dexmedetomidine sedation

Background

Differences in the effects of propofol and dexmedetomidine sedation on electroencephalogram patterns have been reported previously. However, the reliability of the Bispectral Index (BIS) value for assessing the sedation caused by dexmedetomidine remains debatable. The purpose of this study is to evaluate the correlation between the BIS value and the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale in patients sedated with dexmedetomidine.

Methods

Forty-two patients aged 20–80 years, who were scheduled for surgery under spinal anesthesia were enrolled. Spinal anesthesia was performed using 0.5% bupivacaine, which was followed by dexmedetomidine infusion (loading dose, 0.5–1 μg/kg for 10 min; maintenance dose, 0.3–0.6 μg/kg/h). The MOAA/S score was used to evaluate the level of sedation.

Results

A total of 215082 MOAA/S scores and BIS data pairs were analyzed. The baseline variability of the BIS value was 7.024%, and BIS value decreased, as the MOAA/S scored decreased. The correlation coefficient and prediction probability between the two measurements were 0.566 (P < 0.0001) and 0.636, respectively. The mean ± standard deviation values of the BIS were 87.22 ± 7.06, 75.85 ± 9.81, and 68.29 ± 12.65 when the MOAA/S scores were 5, 3, and 1, respectively. Furthermore, the cut-off BIS values in the receiver operating characteristic analysis at MOAA/S scores of 5, 3, and 1 were 82, 79, and 73, respectively.

Conclusions

The BIS values were significantly correlated with the MOAA/S scores. Thus, the BIS along with the clinical sedation scale might prove useful in assessing the hypnotic depth of a patient during sedation with dexmedetomidine.

Is there a link between the use of benzodiazepines and related drugs and dementia? A systematic review of reviews

PURPOSE

Benzodiazepines (BZDs) and related drugs (BZRDs) are commonly used to treat diverse psychiatric disorders due to their anxiolytic, hypnotic and sedative properties, despite their known associated side effects, including acute consequences on cognition. Recently, some studies have also suggested that long-term cognitive effects may coexist, as the increased risk of cognitive decline and dementia. This review aims to appraise and summarise published synthesis studies on the risk of dementia development due to BZDs/BZRDs use.

METHODS

A comprehensive systematic search was carried out in PubMed, Web of Science, Cochrane Library and Epistemonikos databases. Grey literature and hand search of the studies' reference lists were undertaken. Meta-analysis, systematic and non-systematic reviews were included. Neither language nor date restrictions were applied. Search results other than synthesis studies were excluded. The methodological quality of the included reviews was analysed with AMSTAR-2 and SANRA tools.

RESULTS

Overall, 877 records were initially retrieved and 15 complied with the inclusion criteria. From these, five were systematic reviews with meta-analysis, two were systematic reviews and eight were non-systematic reviews. Most of the primary studies included in the analysed reviews found an association between BZDs/BZRDs use and subsequent dementia, with meta-analysis studies reporting an increased risk for users (ORs ranging from 1.38 to 1.78). However, the considerable clinical and methodological heterogeneity of the primary studies makes it difficult to establish a causal relationship.

CONCLUSION

Although hampered by the heterogeneity between the studies, the present findings suggest an association between BZDs/BZRDs use and increased risk of dementia in older adults.

Influence of Patient-Specific Covariates on Test Validity of Two Delirium Screening Instruments in Neurocritical Care Patients (DEMON-ICU)

Background

Delirium screening instruments (DSIs) should be used to detect delirium, but they only show moderate sensitivity in patients with neurocritical illness. We explored whether, for these patients, DSI validity is impacted by patient-specific covariates.

Methods

Data were prospectively collected in a single-center quality improvement project. Patients were screened for delirium once daily using the Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference was the daily assessment using criteria from the Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR). In a two-step receiver operating characteristics regression analysis adjusting for repeated measurements, the impact of acute diagnosis of stroke or transient ischemic attack (TIA), neurosurgical intervention, Richmond Agitation Sedation Scale, and ventilation status on test validity was determined.

Results

Of 181 patients screened, 101 went into final analysis. Delirium incidence according to DSM-IV-TR was 29.7%. For the first complete assessment series (CAM-ICU, ICDSC, and DSM-IV-TR), sensitivity for the CAM-ICU and the ICDSC was 73.3% and 66.7%, and specificity was 91.8% and 94.1%, respectively. Consideration of daily repeated measurements increased sensitivity for the CAM-ICU and ICDSC to 75.7% and 73.4%, and specificity to 97.3% and 98.9%, respectively. Receiver operating characteristics regression revealed that lower Richmond Agitation Sedation Scale levels significantly impaired validity of the ICDSC (p = 0.029) and the CAM-ICU in its severity scale version (p = 0.004). Neither acute diagnosis of stroke or TIA nor neurosurgical intervention or mechanical ventilation significantly influenced DSI validity.

Conclusions

The CAM-ICU and ICDSC perform well in patients requiring neurocritical care, regardless of the presence of acute stroke, TIA, or neurosurgical interventions. Yet, even very light or moderate sedation can significantly impair DSI performance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-021-01319-9.

Midazolam exposure in the paediatric intensive care unit predicts acute post-traumatic stress symptoms in children

BACKGROUND

Clinically significant post-traumatic stress symptoms (PTSS) have been reported in up to a quarter of paediatric intensive care unit (PICU) survivors. Ongoing PTSS negatively impacts children's psychological development and physical recovery. However, few data regarding associations between potentially modifiable PICU treatment factors, such as analgosedatives and invasive procedures, and children's PTSS have been reported.

OBJECTIVES

We sought to investigate the medical treatment factors associated with children's PTSS after PICU discharge.

METHODS

A prospective longitudinal cohort study was conducted in two Australian tertiary referral PICUs. Children aged 2-16 y admitted to the PICU between June 2008 and January 2011 for >8 h and <28 d were eligible for participation. Biometric and clinical data were obtained from medical records. Parents reported their child's PTSS using the Trauma Symptom Checklist for Young Children at 1, 3, 6, and 12 months after discharge. Logistic regression was used to assess potential associations between medical treatment and PTSS.

RESULTS

A total of 265 children and their parents participated in the study. In the 12-month period following PICU discharge, 24% of children exhibited clinically elevated PTSS. Median risk of death (Paediatric Index of Mortality 2 [PIM2]) score was significantly higher in the PTSS group (0.31 [IQR 0.14-1.09] v 0.67 [IQR 0.20-1.18]; p = 0.014). Intubation and PICU and hospital length of stay were also significantly associated with PTSS at 1 month, as were midazolam, propofol, and morphine. After controlling for gender, reason for admission, and PIM2 score, only midazolam was significantly and independently associated with PTSS and only at 1 month (adjusted odds ration (aOR) 3.63, 95% CI 1.18, 11.12, p = 0.024). No significant relationship was observed between the use of medications and PTSS after 1 month.

CONCLUSIONS

Elevated PTSS were evident in one quarter (24%) of children during the 12 months after PICU discharge. One month after discharge, elevated PTSS were most likely to occur in children who had received midazolam therapy.

Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review

BACKGROUND

Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role.

OBJECTIVES

The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU.

METHODS

A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715.

RESULTS

Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues.

CONCLUSIONS

This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.

Relationship between ambient temperature and severe acute poisoning by alcohol and drugs

AIM

To test the hypothesis that severe acute poisoning by alcohol and drugs is more frequent at higher rather than at lower ambient temperatures.

METHOD

This was a prospective observational study performed in a prehospital setting under marine west coast climate conditions. Data from the Emergency Medical Service in Hamburg (Germany) and data from the local weather station were evaluated over a 5-year period. Temperature data were obtained and matched with the associated rescue mission data, which were divided into the following groups: 1) alcohol poisoning, 2) opioid poisoning, 3) poisoning by sedatives/hypnotics, multiple drugs, volatile solvents, and other psychoactive substances. Lowess-Regression analysis was performed to assess the relationship between ambient temperature and frequency of severe acute poisoning. Additionally, three temperature ranges were defined in order to compare them with each other with regard to frequency of severe poisoning (<10 °C vs. 10-20 °C vs. >20 °C). The severity of emergencies was assessed using the National Advisory Committee for Aeronautics (NACA) scoring system.

RESULTS

In 1535 patients, severe acute alcohol or drug poisoning associated with loss of consciousness, hypotension, and impaired respiratory function was treated (alcohol: n = 604; opioids: n = 295; sedatives/hypnotics/multiple drugs: n = 636). Compared to mild temperatures (10-20 °C), the frequency of poisoning increased in all three groups at higher temperatures and decreased at lower temperatures (p < 0.01). No significant correlation was found between severity of emergencies and temperature.

CONCLUSIONS

Our results suggest a continuously increasing probability of occurrence of severe acute poisoning by alcohol and drugs with rising temperature.

Effects of Mindfulness-Based Relapse Prevention on the Chronic use of Hypnotics in Treatment-Seeking Women with Insomnia: a Randomized Controlled Trial

BACKGROUND

Hypnotics are one of the most frequently prescribed drugs worldwide, especially for women, and their chronic use may lead to tolerance, dosage escalation, dependence, withdrawal syndrome, and cognitive impairments, representing a significant public health problem. Consistent evidence from previous studies shows benefits of mindfulness-based interventions (MBIs) for substance use disorders (SUD) and insomnia. However, to date, there is a lack of research about effects of MBIs on reduction/cessation of chronic hypnotic use among women with insomnia.

METHOD

The present randomized trial evaluated the efficacy of the 8-week group-delivered mindfulness-based relapse prevention (MBRP) program in an intervention group (IG, n = 34) compared with weekly phone monitoring only in the control group (CG, n = 36) in reducing hypnotic use and insomnia severity over a 6-month follow-up period.

RESULTS

There were significant differences between groups at baseline regarding hypnotic use but not insomnia. Group effects on hypnotic use were found immediately after the intervention (bT1 = 2.01, p < 0.001) and at the 2-month follow-up (bT2 = 2.21, p < 0.001), favoring the IG. The IG also had a greater reduction from baseline levels than the control group in insomnia severity at the 4-month (bT3 = 0.21, p = 0.045) and 6-month (bT4 = 0.32, p = 0.002) follow-ups.

CONCLUSIONS

The findings provide preliminary evidence of benefits of MBRP for reducing insomnia severity and potentially chronic hypnotic use. However, IG effects on chronic hypnotic use may have resulted from IG and control group differences in chronic hypnotic use at baseline.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02127411.

Effects of dexmedetomidine sedation for magnetic resonance imaging in children: a systematic review and meta-analysis

PURPOSE

Pediatric sedation is commonly required to obtain high-quality images in magnetic resonance imaging (MRI). We performed a systematic review and meta-analysis to assess the effects of dexmedetomidine sedation for MRI in children.

METHODS

A systematic review was conducted to find all randomized controlled trials concerning dexmedetomidine sedation for MRI in children. We searched databases using the Ovid platform in the Cochrane Controlled Trials Register, MEDLINE, and EMBASE. This study was registered in the PROSPERO database: CRD42020198368.

RESULTS

Seven studies and 753 participants were included. Dexmedetomidine sedation showed a significantly delayed onset time [weighted mean differences (WMD) = 8.13 min, 95% confidence interval (CI) 4.64 to 11.63, I² = 98%] and recovery time (WMD = 5.22 min, 95% CI 0.35 to 10.09, I² = 92%) compared to propofol, ketamine, and midazolam sedation. There was no difference in quality of sedation [risk ratio (RR) = 1.25, 95% CI 0.92 to 1.69, I² = 89%], or incidence of sedation failure (RR = 1.39, 95% CI 0.53 to 3.66, I² = 83%) between groups. Although a significantly decreased heart rate (WMD = - 17.34 beats/minute, 95% CI - 22.42 to - 12.26, I² = 96%) was observed, bradycardia that required treatment was not increased (RR = 8.00, 95% CI 1.02 to 62.64, I² = 0%). Dexmedetomidine sedation had a lower incidence of desaturation events (RR = 0.42, 95% CI 0.20 to 0.86, I² = 4%). However, there was no difference in incidence of postoperative vomiting (RR = 0.42, 95% CI 0.15 to 1.17, I² = 17%) between groups.

CONCLUSIONS

Dexmedetomidine sedation provided a similar sedation quality with a reduced incidence of desaturation events. However, the delayed onset and recovery times were drawbacks. The clinical significance of bradycardia is considered to be low. GRADE assessment revealed the quality of the evidence in this meta-analysis ranged from very low to moderate.

Misuse and dependence of dimenhydrinate: A mixed studies systematic review

BACKGROUND

Dimenhydrinate (DMH) is an antihistamine used to treat nausea and vomiting. Although widely available in pharmacies as an over the counter medication, there have been reports of potential DMH tolerance and dependence and a possible euphoric potential accompanying heavy use (>100 mg/day). Despite the potential for misuse, there is a gap in the literature concerning patterns, characteristics, and potential mechanisms of DMH misuse.

AIMS

This review aimed to synthesize evidence on the pharmacology, clinical effects, and management of DMH misuse and dependence to inform clinical decision making and relevant drug policy.

METHODS

We conducted a systematic review in accordance with the PRISMA guidelines and using Cochrane collaboration methods. We searched seven databases from their inception through July 2019. To be included in the review, studies needed to measure or focus on one or more dimensions of morbidity or mortality related to the misuse of DMH. Quantitative, qualitative and mixed-method studies were included in order to capture the breadth of possible studies. Studies were excluded if they did not fit into the conceptual framework of the study of if they focused primarily on the misuse of other substances. A narrative synthesis of study findings was pursued given the limited capacity for a quantitative meta-analysis.

FINDINGS

We identified 24 studies, which described a range of neuropsychiatric sequelae related to DMH consumption, including seizures, psychosis, depression, intoxication (resembling anticholinergic syndrome) and withdrawal. The sedative and euphoric properties, readily available nature, and low cost of DMH appear to facilitate DMH dependence, which were more commonly reported among individuals who had concurrent psychiatric disorders, displaying symptoms such as low motivation, poor concentration, and delirium. The overall quality of studies identified by this review was low-largely because the majority of studies were case reports or review articles, with few intervention or cohort studies.

CONCLUSIONS

There is some evidence to suggest the existence of DMH-related syndromes involving intoxication, withdrawal, and dependence, more commonly among long-term, heavy DMH consumers. However, higher quality studies are needed to confirm preliminary findings that there may be a biological basis for such syndromes.

Should the CIWA-Ar be the standard monitoring strategy for alcohol withdrawal syndrome in the intensive care unit?

BACKGROUND

The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is commonly used in hospitals to titrate medications for alcohol withdrawal syndrome (AWS), but may be difficult to apply to intensive care unit (ICU) patients who are too sick or otherwise unable to communicate.

OBJECTIVES

To evaluate the frequency of CIWA-Ar monitoring among ICU patients with AWS and variation in CIWA-Ar monitoring across patient demographic and clinical characteristics.

METHODS

The study included all adults admitted to an ICU in 2017 after treatment for AWS in the Emergency Department of an academic hospital that standardly uses the CIWA-Ar to assess AWS severity and response to treatment. Demographic and clinical data, including Richmond Agitation-Sedation Scale (RASS) assessments (an alternative measure of agitation/sedation), were obtained via chart review. Associations between patient characteristics and CIWA-Ar monitoring were tested using logistic regression.

RESULTS

After treatment for AWS, only 56% (n = 54/97) of ICU patients were evaluated using the CIWA-Ar; 94% of patients had a documented RASS assessment (n = 91/97). Patients were significantly less likely to receive CIWA-Ar monitoring if they were intubated or identified as Black.

CONCLUSIONS

CIWA-Ar monitoring was used inconsistently in ICU patients with AWS and completed less often in those who were intubated or identified as Black. These hypothesis-generating findings raise questions about the utility of the CIWA-Ar in ICU settings. Future studies should assess alternative measures for titrating AWS medications in the ICU that do not require verbal responses from patients and further explore the association of race with AWS monitoring.

Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice

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.

Evaluation of dexmedetomidine withdrawal in critically ill adults

BACKGROUND

Dexmedetomidine (DEX) withdrawal syndrome has been reported in the pediatric population, but literature describing DEX withdrawal in critically ill adults is limited. The purpose of this study was to determine the incidence of DEX withdrawal in adult patients and to identify factors associated with DEX withdrawal syndrome.

METHODS

A retrospective chart review was performed in the adult intensive care units of two tertiary medical centers. Eligible patients were at least 18 years of age and received DEX for 24 h or more. Patients were excluded if they presented with a primary neurologic diagnosis, had a history of substance abuse, or received any other α2-agonists 24 h before discontinuation of DEX. The primary outcome was the percentage of patients who developed withdrawal as defined by the presence of two or more symptoms (tachycardia, hypertension, vomiting, agitation) within the 24 h following DEX discontinuation.

RESULTS

Of the 165 patients included, 50 patients experienced withdrawal (30.3%), lasting a median of two days. The incidence of withdrawal was higher in surgical (40%) compared to medical (28%) or cardiac (32%) patients (p = 0.004). Median duration of infusion was 52.5 h (interquartile range [IQR], 37.8 to 102.8) in the withdrawal group and 52 h (IQR, 41 to 87) in the non-withdrawal group (p = 0.887). Median DEX dose was 0.56 μg/kg/h (IQR, 0.39 to 0.83) in the withdrawal group and 0.48 μg/kg/h (0.36 to 0.65) in the non-withdrawal group (p = 0.12). Weaning did not reduce the incidence of withdrawal as compared to abrupt discontinuation (p = 0.68). The withdrawal group was more likely to have concomitantly discontinued opioids (54% vs 12.2%) and benzodiazepines (36% vs 0%) at the time of DEX discontinuation compared to the non-withdrawal group (p = 0.004).

CONCLUSION

Development of DEX-associated withdrawal occurred in approximately 30% of adult patients, comparable to rates reported in pediatric literature. There appeared to be no correlation between dose, exposure, and weaning in the occurrence of withdrawal, but concomitant discontinuation of opioids or benzodiazepines as well as ICU admission type could highlight cases requiring closer monitoring.

Emerging from tabloid scandal: Dr. U.K. Mayo's Vegetable Vapor extends nitrous oxide's anesthetic duration

Urial K. Mayo (1816-1900) was a successful Boston dentist who was plagued by personal scandal. In 1883 he patented extending the duration of nitrous-oxide anesthesia with an alcoholic tincture of hops and poppies.

[Anesthesia for electroconvulsive therapy]

Electroconvulsive therapy (ECT) is an important component in the treatment of depression and schizophrenia in Germany. For this intervention patients undergo short-term general anesthesia and muscle relaxation. Before anesthesia can be carried out patients are subject to a comprehensive examination. For general anesthesia all established hypnotics can be used, but differences with respect to the success of the ECT have been described. Short-acting or reversible relaxants should be preferentially used. The risks of general anesthesia during ECT are estimated to be low but a transient hemodynamic instability of patients can occur. Treatment can be performed as an inpatient but also as an outpatient procedure.

Long-term users of benzodiazepines in Colombia: Patterns of use and cessation of treatment

BACKGROUND

Benzodiazepines have low abuse potential, but patients often develop physical dependence and neurological impairments. The objective of this study was to investigate treatment cessation and use of high doses in long-term benzodiazepine users in Colombia.

METHODS

Retrospective study. Patients who used benzodiazepines for at least six months (long-term) were selected from a prescription database and followed from initiation of benzodiazepine treatment for up to 30 months. We investigated treatment duration and compared patients who received normal and high (≥2 mean prescribed daily dose) doses.

RESULTS

Only 1255 (6.1 %) out of 20,567 patientsprescribed benzodiazepines became long-term users; their mean age was 60.6 years (SD=20.0) and 61.7 % were women. Mean high doses were used by 42.5 % (n=534) of the sample. Age under 20 years was a protector, whereas the long half-life benzodiazepines and use of other neurological medications were predictors of high dosage. Overall, 44.8 % (n=563) of the sample was still using benzodiazepines at the end of the study period. The use of antidepressants, antipsychotics, and anticonvulsants were negatively associated with cessation of benzodiazepine treatment.

CONCLUSIONS

A low proportion of patients starting benzodiazepines became long-term users. Nearly half of them used high doses and continued the medication for up to 30 months. Use of concomitant neurological drugs was associated with higher doses and less cessation.

Why Z-drugs are used even if doctors and nurses feel unable to judge their benefits and risks-a hospital survey

BACKGROUND

Many patients receive Z-drugs for hospital-associated sleep problems, in spite of well-known risks. The aim of this study was to learn more about the attractiveness of Z-drugs, seen from the doctors' and nurses' perspective.

METHODS

Using a standardized questionnaire, doctors (63/116) and nurses (73/243) in a German general hospital were surveyed about the risks and benefits of Z-drugs, compared with benzodiazepines.

RESULT

"Reduced time to get to sleep" was perceived by doctors (51%) and nurses (53%) to be a strong benefit of Z-drugs; "confusion" and "falls" were perceived by ca. 10% of doctors and ca. 15% of nurses to be a frequent problem. Compared with benzodiazepines, respondents more often answered "unable to judge" for Z-drugs; e.g. for doctors, 18% (benzodiazepines) vs. 45% (Z-drugs) were unable to judge "improved daytime functioning" and 12% (benzodiazepines) vs. 37% (Z-drugs) were unable to judge "falls."

CONCLUSION

Z-drugs seem to be attractive because experiential knowledge overemphasizes their benefits and fails to take risks such as drug-related falls and confusion into account. Difficulties to judge a drug's risk-benefit ratio do not prevent doctors and nurses from using them. Interventions for reducing Z-drug usage should incorporate local quality assurance data about relevant patient risks.

The Effect of Hypnotics on Sleep Quality and Cognitive Function in Patients with Brain Tumors

Objective

We investigated the effect of hypnotics on sleep quality, cognitive function, and depressive mood in patients with insomnia following brain tumor resection.

Methods

From patients who underwent brain tumor resection, we recruited 10 patients with insomnia who received hypnotics for more than 1 week during a 3-week follow-up period (insomnia group). We also recruited 12 control patients with brain tumors but without insomnia (control group). We evaluated sleep quality at baseline and 3 weeks later using the Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index (PSQI), the Stanford Sleepiness Scale (SSS), and the Epworth Sleepiness Scale (ESS) and investigated cognitive function and depression using the Computerized Neuropsychological Test and the Beck Depression Inventory (BDI).

Results

At baseline, SSS, ISI, PSQI, and BDI scores were significantly higher and visual continuous performance test (VCPT) and auditory continuous performance test (ACPT) scores were significantly lower in the insomnia than in the control group. Three weeks later, the patients who had received hypnotics had significantly higher ISI, PSQI, ESS, VCPT, ACPT, visual span forward and backward, and visual recognition test scores, and significantly lower BDI scores.

Conclusion

Quality of sleep in patients with insomnia following brain tumor resection was initially poor but improved significantly after taking hypnotic medication. Further, the hypnotic medications appeared to contribute to the amelioration of cognitive impairments and depressive moods in patients who previously underwent brain tumor resection. We thus recommend the use of hypnotics for patients with brain tumors with insomnia.

Use of non-benzodiazepine hypnotics is associated with falls in nursing home residents: a longitudinal cohort study

BACKGROUND

Falls and related injuries are common among older people, and several drug classes are considered to increase fall risk.

AIMS

This study aimed to investigate the association between the use of certain drug classes and falls in older nursing home residents in Sweden, and relate these to different age groups.

METHODS

Information on falls that occurred in the previous year and regular use of possible fall risk drugs including non-benzodiazepine hypnotics (zopiclone and zolpidem) was collected from 331 nursing home residents during 2008-2011. Over the following 6 months, the occurrence of serious falls, requiring a physician visit or hospital care, was registered. Association between serious falls and drug use was compared between an older (≥ 85 years) and a younger group.

RESULTS

An increased fall risk (Downton Fall Risk Index ≥ 3) was found in 93% of the study subjects (aged 65-101 years). Baseline data indicated an association between falls that occurred in the previous year and regular use of non-benzodiazepine hypnotics (p = 0.005), but not with the other studied drug classes. During the following 6 months, an association between use of non-benzodiazepine hypnotics and serious falls in the older group (p = 0.017, odds ratio 4.311) was found. No association was found between the other studied drug classes and serious falls.

DISCUSSION

These results indicate an association between falls and the use of non-benzodiazepine hypnotics, compounds that previously have been considered generally well-tolerated in older people.

CONCLUSIONS

Caution is advocated when using non-benzodiazepine hypnotics regularly in older people living in nursing homes.

Non-drug and drug alternatives to benzodiazepines for insomnia in primary care: Study among GPs and pharmacies in a Southwest region of France

OBJECTIVES

Benzodiazepines and related drugs are the most commonly prescribed drugs in the treatment of insomnia, and referral to psychotherapy is rare when recommended as first-line treatment for chronic insomnia. The frequency of referral to psychologists, of use of alternative drugs to benzodiazepines, either prescribed by general practitioners (GPs) or dispensed by community pharmacies, is unknown in France. We aimed to describe the non-pharmacological approaches recommended, such as cognitive behavioral therapies (CBT), and the drugs, including alternatives drugs to benzodiazepines, used by GPs and community pharmacies for patients complaining of insomnia.

METHODS

A cross-sectional study was conducted during 3 months in 2015 on the management of individual GPs' patients and pharmacies' customers consecutively consulting for insomnia in the Midi-Pyrénées region of southwest France. Participating GPs and pharmacists completed a form, for each patient, on their management (drugs, sleeping advices, referral to psychotherapy).

RESULTS

Fifty-five GPs included 263 patients and 43 community pharmacies included 354 customers in the study. Among patients, 193 (73,4%) had already used benzodiazepine. Thirty-eight patients (14.4%) and 2 customers (0.5%) were recommended non-drug therapies (mostly CBT). Benzodiazepines were prescribed 188 times (69.1% of the prescriptions) by GPs. Alternative drugs prescribed were mostly antihistamines (n=26; 9.6%) and antidepressants (n=17; 6.3%). Antihistamines were the most commonly dispensed drugs by pharmacists (n=149; 39.4%).

CONCLUSIONS

While non-pharmacological treatments, such as CBT, are safe and widely recommended, benzodiazepines and antihistamines remain widely used despite the lack of long term benefit and the risk of adverse drug reactions.

Enteral versus intravenous approach for the sedation of critically ill patients: a randomized and controlled trial

Background

ICU patients must be kept conscious, calm, and cooperative even during the critical phases of illness. Enteral administration of sedative drugs might avoid over sedation, and would be as adequate as intravenous administration in patients who are awake, with fewer side effects and lower costs. This study compares two sedation strategies, for early achievement and maintenance of the target light sedation.

Methods

This was a multicenter, single-blind, randomized and controlled trial carried out in 12 Italian ICUs, involving patients with expected mechanical ventilation duration > 72 h at ICU admission and predicted mortality > 12% (Simplified Acute Physiology Score II > 32 points) during the first 24 h on ICU. Patients were randomly assigned to receive intravenous (midazolam, propofol) or enteral (hydroxyzine, lorazepam, and melatonin) sedation. The primary outcome was percentage of work shifts with the patient having an observed Richmond Agitation-Sedation Scale (RASS) = target RASS ±1. Secondary outcomes were feasibility, delirium-free and coma-free days, costs of drugs, length of ICU and hospital stay, and ICU, hospital, and one-year mortality.

Results

There were 348 patients enrolled. There were no differences in the primary outcome: enteral 89.8% (74.1–100), intravenous 94.4% (78–100), p = 0.20. Enteral-treated patients had more protocol violations: n = 81 (46.6%) vs 7 (4.2%), p < 0.01; more self-extubations: n = 14 (8.1%) vs 4 (2.4%), p = 0.03; a lighter sedative target (RASS = 0): 93% (71–100) vs 83% (61–100), p < 0.01; and lower total drug costs: 2.39 (0.75–9.78) vs 4.15 (1.20–20.19) €/day with mechanical ventilation (p = 0.01).

Conclusions

Although enteral sedation of critically ill patients is cheaper and permits a lighter sedation target, it is not superior to intravenous sedation for reaching the RASS target.

Trial registration

ClinicalTrials.gov, NCT01360346. Registered on 25 March 2011.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2280-x) contains supplementary material, which is available to authorized users.

Analysis of fall-related adverse events among older adults using the Japanese Adverse Drug Event Report (JADER) database

Background

Falls are a common but serious problem in older adults, and may lead to fractures and bleeding. As many factors, such as medication, aging, and comorbid diseases may simultaneously affect fall-related adverse events (AEs) in older adults, we evaluated the association between fall-related AEs and the use of medication, aging, and comorbid diseases using the Japanese Adverse Drug Event Report (JADER) database.

Methods

We analyzed reports of fall-related AEs associated with α-blockers, diuretics, calcium channel blockers, central nervous system (CNS)-active drugs (opioids, benzodiazepines, hypnotics and sedatives, non-selective monoamine reuptake inhibitors, and selective serotonin reuptake inhibitors (SSRI)) in the JADER database using the reporting odds ratio (ROR). For the definition of falls, we used the Preferred Terms of The Medical Dictionary for Regulatory Activities (MedDRA). We used the association rule mining technique to discover undetected associations, such as potential risk factors.

Results

The JADER database comprised 430,587 reports between April 2004 and November 2016. The RORs (95% CI) of α-blockers, diuretics, calcium channel blockers, opioids, benzodiazepines, hypnotics and sedatives, non-selective monoamine reuptake inhibitors, and SSRIs were 1.63 (1.27–2.09), 0.74 (0.63–0.86), 1.26 (1.15–1.38), 0.93 (0.80–1.07), 1.83 (1.68–2.01), 1.55 (1.12–2.14), 2.31 (1.82–2.95), and 2.86 (2.49–3.29), respectively. From the lift value in the association rule mining, the number of administered CNS-active drugs and patient age were associated with fall-related AEs. Furthermore, the scores of lift for patients with herpes zoster administered calcium channel blockers or benzodiazepines and patients with dementia administered benzodiazepines were high.

Conclusion

Our results suggest that the number of administered CNS-active drugs and patient age are both associated with fall-related AEs. We recommend that patients with herpes zoster treated with calcium channel blockers and benzodiazepines be closely monitored for fall-related AEs.

Effectiveness of preanesthetic administration of gabapentin on sedative action during intravenous sedation with propofol

PURPOSE

There are no sufficient evidences for the sedative effect of gabapentin during anesthesia, especially intravenous sedation (IVS). The purpose of this study was to evaluate the sedative effect of gabapentin as preanesthetic medication during the IVS with propofol.

METHODS

10 volunteer subjects joined this study. They underwent propofol IVS three times on separate days. On the first day, the IVS without gabapentin was performed as a control. On the second and the third day, gabapentin 200 mg and 400 mg were administered before the IVS, respectively. The target blood concentration (C_T) of propofol was gradually increased, and the bispectral index (BIS) value and Ramsay sedation score (RSS) were evaluated at each propofol C_T. Postanesthetic complications and influences on vital signs were also evaluated.

RESULTS

Compared to the control group, the propofol C_Ts in the gabapentin 400 mg group significantly reduced at the BIS values of 60 and 70 (p = 0.031 and p = 0.043, respectively), and at RSS 3, 4, 5 and 6 (p = 0.040, p = 0.004, p = 0.001 and p = 0.004, respectively). There was no significant difference in propofol C_Ts between the control group and the gabapentin 200 mg group. There were no abnormality and no deterioration in circulation and respiration in all groups. There were no significant increases in complications with the administration of gabapentin.

CONCLUSION

The oral administration of 400 mg dose of gabapentin reduced the propofol C_Ts for achieving an adequate sedation level on IVS.

[Etomidate for intravenous induction of anaesthesia]

The pharmacological and historical knowledge about the currently available intravenous induction hypnotics form the basis for the daily work of anesthetists. Side effects of using hypnotic induction agents must be anticipated and adequately treated. Decades of experience with using intravenous induction hypnotics have led to theoretical requirements for an ideal narcotic agent with a best possible side effect profile. In the absence of this optimal hypnotic induction agent, a careful selection of one or a combination of narcotic drugs is necessary to meet the needs of the respective risk constellation of the patient. While propofol enjoyed increasing frequency of use over the last three decades and is currently regarded as the gold standard in numerous clinics, thiopental is a noteworthy alternative apart from its elimination kinetics. Furthermore, substances with favorable hemodynamic profiles are available with etomidate and ketamine. Midazolam as a short-acting benzodiazepine rounds off the spectrum.

Psychotropic medication in children and adolescents in the United States in the year 2004 vs 2014

BACKGROUND

There is a global perception that psychotropic utilization in children and adolescents is increasing in the US.

METHODS

We present prevalent estimates for all psychotropics prescribed in the US (using commercial claims from Medicare and Medicaid) to children and adolescents in 2004 (total population N = 6,808,453) and in 2014 (total population N = 11,082.260). Further we evaluated if there has been a statistically significant change in prevalence during this time period. Analyses were stratified for the 6 major drug classes, all individuals' psychotropics (87 drugs), age and sex.

RESULTS

The prevalence of psychotropic drug prescription was 8.55% in 2004 and 9.00% in 2014 (age stratified in 2004 and 2014 toddlers: 3.08 and 2.63%, children: 8.74 and 8.73%, adolescents: 10.89% and 12.11). The prevalence for each drug class in 2004 and 2014 was: stimulants/other ADHD drugs 5.0 and 5.8%; antidepressants 2.8 and 2.7%; anxiolytic-hypnotic-sedative 2.2 and 2.3%; mood stabilizers 0.1 and 0.1%; antipsychotics 1.3 and 1.1%; and for drugs treating drug dependence 0.02 and 0.02%.

CONCLUSIONS

The perception that psychotropic utilization in children and adolescents is increasing in the US, derived from the 2 to 3 fold increase seen from the mid 80's to the mid 90's is not valid anymore. There has been a slowdown in the increase of prescribing psychotropics. In the last 10 years, in toddlers there was a decrease in the prescription; in children there was no change; and in adolescents there was a slight increase. The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall. Graphical abstract In the last 10 years there has been a slowdown in the increase of prescribing psychotropics. In toddlers there was a decrease in the prescription (3.08 and 2.63%); in children (8.74 and 8.73%) there was no change; and in adolescents there was a slight increase (10.89% and 12.11). The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall.

[Palliative sedation : Development and consensus of a German language documentation template]

BACKGROUND

Palliative sedation (PS) serves as a therapeutic option in cases of otherwise intractable suffering. As the use of sedative and hypnotic medication in many diverse situations is a core competency of anesthesiology, anesthesiologists are confronted with questions of sedative therapy at the end of life in institutions for specialized palliative care, in intensive care units and intermediate care wards. In recent years a number of guidelines have been published internationally but so far no official guidelines exist in Germany. The most recognized document is the European Association for Palliative Care (EAPC) framework on PS. This project aims to develop a German language template for the preparation, application, documentation and evaluation of PS according to the current frameworks, especially the EAPC framework on PS.

METHODS

A first draft of the template was generated by the project team using the EAPC framework and individual templates of various institutions, which had been collected during a previous project. Professionals (n = 136) from inpatient and outpatient specialist palliative and hospice care were invited to assess all items of the draft regarding "relevance", "wording" and "feasibility" in an online Delphi survey (Unipark®, Questback, Cologne, Germany). After the second Delphi round an expert panel was asked to reflect the results and generate a final draft. Approval was granted if acceptance exceeded 75% of participants.

RESULTS

The 3 rounds of the Delphi process were completed by 64, 46 and 41 participants, respectively. The Delphi process as well as the expert panel led to significant changes of the template. The indications for PS had to be clarified. The significance of documentation of vital parameters, such as oxygen saturation, blood pressure or respiratory rate during PS was intensively discussed. In many teams, predominantly hospice or outpatient palliative care teams, it seems to be difficult to measure these parameters or it is regarded as inappropriate in a palliative care setting. In contrast, the EAPC framework recommends monitoring of vital parameters in cases of intermittent or respite sedation. Finally, a solution was found to support documentation of additional data without the explicit mentioning of specific parameters. After the third Delphi round, all 16 items of the documentation template reached consensus with respect to relevance (82.9-100%), clarity of wording (80.5-100%), and feasibility in practice (78-100%).

CONCLUSION

This article provides an empirically based, multiprofessional consented documentation template for PS. Core elements of the documentation of PS are the indications and the decision process towards PS. During the treatment, at least the level of sedation and the symptom burden have to be recorded. The documentation of vital signs during PS remains a highly disputed topic. The presented data suggest that especially in outpatient settings and in hospices measuring and documentation of vital parameters is uncommon and therefore is often regarded as not feasible. This template can help to support the medically and ethically sound use of PS and facilitate research. The template can be accessed at http://www.palliativmedizin.uk-erlangen.de/forschung/downloads/ .

Hypnotics use in children 0-18 months: moderate agreement between mother-reported survey data and prescription registry data

BACKGROUND

Different methods in pharmacoepidemiology can be used to study hypnotic use in children. But neither questionnaire-based data nor prescription records can be considered a "gold standard". This study aimed to investigate the agreement between mother-reported questionnaire-based data and prescription record data for hypnotic drugs in children aged 0-18 months. The agreement was compared to the agreement for a group of antiepileptic drugs.

METHODS

Prescription record data were collected from the Norwegian prescription database for 47,413 children also surveyed in the Norwegian mother and child cohort between 2005 and 2009. Agreement between in the two data sources was calculated using Cohens Kappa. Multinomial logistic regression was used to calculate the effect of sociodemographic variables on discrepancies in data sources.

RESULTS

The agreement between mother-reported and dispensed hypnotics was less than 50% for all hypnotics. Sensitivity of reporting increased with number of filled prescriptions. The agreement of antiepileptic drugs was 92.9% in the same population. Of several sociodemographic factors only paternal educational level and maternal work situation was significantly related to agreement between prescription record and survey data.

CONCLUSION

There was a moderate agreement between reported use and dispensed hypnotic drugs for infants and toddlers. Results indicate that sociodemographic factors play only a minor role in explaining discrepancy.

Consistent association between hypnotics/sedatives and non-traffic injuries. Results from a national household survey

AIM

To quantify the relationship between patterns of psychostimulants, hypnotics/sedatives and alcohol consumption and the frequency of unintentional non-traffic injuries (UNTIs) requiring medical assistant in Spain.

METHODS

We carried out a cross sectional study using a randomized pooled sample from two household surveys on psychoactive drugs use (n=51,649 subjects aged 15-64 years). We estimated the magnitude of the association between the use of psychostimulants and hypnotics/sedatives in the last 12 months as well as alcohol consumption in the last 30days with the occurrence of UNTIs in the last 12 months (falls, knocks/bumps and cuts) by building several logistic regression models, which took into account the effect of sociodemographic characteristics and the use of other psychoactive drugs (including cannabis). The presence of interactions between age or gender with drug use was also assessed.

RESULTS

Psychostimulants use was associated with a higher frequency of UNTIs (aOR=1.24; 95%CI:1.03-1.49). The strongest association was found with cuts (aOR=1.64; 95%CI:1.10-2.43). An association between hypnotics/sedatives and UNTIs was also found in each type of injury and was higher with regular use (>=30days) than with non-regular use (<30days). The age modified the association between hypnotic/sedatives and knocks/bumps, being higher in the 35-64 years group (aOR=2.34; 95%CI:1.78-3.06) than in the 15-34 years group (aOR=1.59; 95%CI:1.14-2.21). Regarding alcohol, an increased risk of UNTIs was also observed in all types of UNTIs, even with moderate use, being the association higher for cuts in heavy drinkers (aOR=2.41; 95%CI:1.63-3.57).

CONCLUSIONS

Our results reveal a consistent relationship between hypnotics/sedatives and UNTIs, especially in regular users. Additional research should apply longitudinal designs to establish causal relationships and to gain an in-depth knowledge in this area in order to specific public health interventions.

Differences between men and women in substance use: the role of educational level and employment status

OBJECTIVE

To determine differences between men and women in hazardous drinking, heavy cannabis use and hypnosedative use according to educational level and employment status in the economically active population in Spain.

METHOD

Cross-sectional study with data from 2013 Spanish Household Survey on Alcohol and Drugs on individuals aged 25-64 [n=14,113 (women=6,171; men=7,942)]. Dependent variables were hazardous drinking, heavy cannabis use and hypnosedative consumption; the main independent variables were educational level and employment situation. Associations between dependent and independent variables were calculated with Poisson regression models with robust variance. All analyses were stratified by sex.

RESULTS

Hazardous drinking and heavy cannabis use were higher in men, while women consumed more hypnosedatives. The lower the educational level, the greater the gender differences in the prevalence of this substances owing to different consumption patterns in men and women. While men with a lower educational level were higher hazardous drinkers [RII=2.57 (95%CI: 1.75-3.78)] and heavy cannabis users [RII=3.03 (95%CI: 1.88-4.89)] compared to higher educational level, in women the prevalence was the same. Women with a lower education level and men with a higher education level had higher hypnosedative consumption. Unemployment was associated with increased heavy cannabis use and hypnosedative use in both women and men and with lower hazardous drinking only in women.

CONCLUSIONS

There are differences between men and women in the use of psychoactive substances that can be explained by the unequal distribution of substance use in them according to educational level. Unemployment was associated with substance use in both men and women.

Drug Burden Index and change in cognition over time in community-dwelling older men: the CHAMP study

OBJECTIVE

Anticholinergic and sedative medications are associated with acute cognitive impairment, but the long-term impact on change in cognition is unclear. This study investigated the effect of anticholinergic and sedative medications, quantified using the Drug Burden Index (DBI), on change in cognition over time in community-dwelling older men.

METHODS

This was a prospective cohort study of men aged ≥70 years in Sydney, Australia. DBI was assessed at baseline, 2, and 5 years. Cognitive performance was assessed using the Mini-Mental State Exam (MMSE) at each wave. Logistic quantile mixed-effects modelling was used to assess the adjusted effect of DBI on the median MMSE-time profile. Analyses were restricted to men with English-speaking backgrounds (n = 1059, 862, and 611 at baseline, 2, and 5 years).

RESULTS

Overall, 292 (27.7%), 258 (29.9%), and 189 (31.3%) men used anticholinergic or sedative medications at baseline, 2, and 5 years. There was a concave relationship between MMSE and time, where higher DBI corresponded to lower MMSE scores (coefficient: -0.161; 95% CI: -0.250 to -0.071) but not acceleration of declining MMSE over time.

CONCLUSIONS

Exposure to anticholinergic and sedative medications is associated with a small impairment in cognitive performance but not decline in cognition over time. KEY MESSAGES Exposure to anticholinergic and sedative medications, quantified using the Drug Burden Index, is associated with small cross-sectional impairments in cognitive performance. There was no evidence that exposure to anticholinergic and sedative medications is associated with accelerating decline in cognitive performance over a 5-year follow-up. Older people taking anticholinergic and sedative medications may derive immediate but small benefits in cognitive performance from clinical medication reviews to minimize or cease prescribing of these medications.