Recently, the need for sedation in gastrointestinal endoscopy has been increasing. However, the National Health Insurance Drug Price list in Japan does not include any drug specifically used for the ...sedation. Although benzodiazepines are the main medication, their use in cases of gastrointestinal endoscopy has not been approved. This has led the Japan Gastrointestinal Endoscopy Society to develop the first set of guidelines for sedation in gastrointestinal endoscopy on the basis of evidence‐based medicine in collaboration with the Japanese Society for Anesthesiologists. The present guidelines comprise 14 statements, five of which were judged to be valid on the highest evidence level and three on the second highest level. The guidelines are not intended to strongly recommend the use of sedation for gastrointestinal endoscopy, but rather to indicate the policy as to the choice of appropriate procedures when such sedation is deemed necessary. In clinical practice, the final decision as to the use of sedation should be made by physicians considering patient willingness and physical condition.
Daily interruption of sedative therapy and limitation of deep sedation have been shown in several randomized trials to reduce the duration of mechanical ventilation and hospital length of stay, and ...to improve the outcome of critically ill patients. However, patients with severe acute brain injury (ABI; including subjects with coma after traumatic brain injury, ischaemic/haemorrhagic stroke, cardiac arrest, status epilepticus) were excluded from these studies. Therefore, whether the new paradigm of minimal sedation can be translated to the neuro-ICU (NICU) is unclear. In patients with ABI, sedation has 'general' indications (control of anxiety, pain, discomfort, agitation, facilitation of mechanical ventilation) and 'neuro-specific' indications (reduction of cerebral metabolic demand, improved brain tolerance to ischaemia). Sedation also is an essential therapeutic component of intracranial pressure therapy, targeted temperature management and seizure control. Given the lack of large trials which have evaluated clinically relevant endpoints, sedative selection depends on the effect of each agent on cerebral and systemic haemodynamics. Titration and withdrawal of sedation in the NICU setting has to be balanced between the risk that interrupting sedation might exacerbate brain injury (e.g. intracranial pressure elevation) and the potential benefits of enhanced neurological function and reduced complications. In this review, we provide a concise summary of cerebral physiologic effects of sedatives and analgesics, the advantages/disadvantages of each agent, the comparative effects of standard sedatives (propofol and midazolam) and the emerging role of alternative drugs (ketamine). We suggest a pragmatic approach for the use of sedation-analgesia in the NICU, focusing on some practical aspects, including optimal titration and management of sedation withdrawal according to ABI severity.
To evaluate the effects of pre- and intraprocedural opioids on adverse events in children undergoing procedural sedation with ketamine in the emergency department (ED).
We conducted a retrospective ...cohort study of all children aged 0-18 years who underwent procedural sedation with intravenous ketamine alone, or in combination with an opioid, at a tertiary-care pediatric ED between June 1, 2018, and August 31, 2020. We explored predictors of serious adverse events (SAEs), desaturation or respiratory intervention, and vomiting.
Of 1164 included children (694 male, 59.6%; median age 5.0 years IQR 2.0-8.0), 80 (6.8%) vomited, 63 (5.4%) had a desaturation or required respiratory interventions, and 6 (0.5%) had SAEs. Pre- and intraprocedural opioids were not independent predictors of sedation-related adverse events. A concurrent respiratory illness (aOR 3.73; 95% CI 1.31-10.60, P = .01), dental procedure (aOR 3.05; 95% CI 1.25-7.21, P = .01), and a greater total ketamine dose (aOR 1.75; 95% CI 1.21-2.54, P = .003) were independent predictors of desaturation or respiratory interventions. A greater total ketamine dose (aOR 1.86; 95% CI 1.16-2.98, P = .01) and older age (aOR 1.15; 95% CI 1.07-1.24, P < .001), were independent predictors of vomiting.
Pre- and intraprocedural opioids do not increase the likelihood of sedation-related adverse events. SAEs are rare during pediatric procedural sedation with ketamine in the ED.
This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency ...department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department,does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) Inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.
ABSTRACT BACKGROUND: Bowel preparation with mannitol is a well-established method in Brazil. However, factors that interfere with the gastric emptying time period are yet to be known. Knowing these ...factors may favor the examination scheduling logistics and the individualized orientation for each patient. OBJECTIVE: Know the factors that can contribute to the gastric emptying time after intestinal preparation with express mannitol. METHODS: This is a prospective observational study to know factors that may contribute on the gastric emptying timing: predominant type of diet, comorbidities, medication usage, previous surgeries, number of evacuation per week, bearer of bowel obstipation, fecal type, diet type, number of evacuations after the home usage of bisacodyl before the ingestion of mannitol and number of evacuations after the ingestion of mannitol until reaching a proper bowel preparation. Before starting the colonoscopy exam, an upper digestive endoscopy exam was made to aspirate the gastric content. RESULTS: Sample was composed of 103 patients, 55 (53.4%) women, medium age 61 (±12.1) years, medium weight 75.3 (±14.1) kg, medium height 1.7 (±10) m and medium BMI of 26.6 (±3.9) kg/m2. Average gastric residual volume was 120.9 (0-900) mL. Gastric residual volume (GRV) below 100 mL (GRV ≤100 mL) occurred in 45 (43.6%) patients, 24 (53.3%) women, medium age of 61.0 years and medium BMI of 26.7 kg/m2. Gastric residual volume above 100 mL (GRV >100 mL) occurred on 58 (56.3%) patients, 29 (50%) women, medium age of 61.0 years and medium BMI of 26.2 kg/m2. Comparing both groups, average fasting time period after the ingestion of mannitol was significantly higher on the group with GRV ≤100 mL than group with GRV >100 mL, 123.1 (60-246) vs 95.3 (55-195) minutes, respectively. There was also statistical significance concerning the usage of ezetimibe 6 (13.7%) in the group with GRV ≤100 mL and statistical significance in the group with GRV >100 mL concerning the usage of paroxetine 3 (6.7%) and tadalafil 3 (6.7%) and surgical history of prostatectomy 3 (6.7%) and bridle withdrawal 3 (6.7%). CONCLUSION: We may conclude in this study that the usage of ezetimibe and fasting above 2 hours after the ingestion of mannitol decrease significantly the incidence of a GRV >100 mL. The usage of paroxetine, tadalafil and surgical history of prostatectomy or bridle withdrawal may contribute to increase de incidence of a GRV >100 mL.
RESUMO CONTEXTO: O preparo intestinal com manitol é um método bem estabelecido no Brasil. No entanto, os fatores que interferem no tempo de esvaziamento gástrico ainda não são conhecidos. O conhecimento desses fatores pode favorecer a logística de agendamento do exame e a orientação individualizada para cada paciente. OBJETIVO: Estudar os fatores que podem contribuir para o tempo de esvaziamento gástrico após o preparo intestinal com manitol expresso. MÉTODOS: Trata-se de um estudo observacional prospectivo com o objetivo de conhecer os seguintes fatores que podem contribuir no tempo de esvaziamento gástrico: tipo de dieta predominante, comorbidades, uso de medicamentos, cirurgias anteriores, número de evacuações por semana, portador de obstipação intestinal, tipo fecal, tipo de dieta, número de evacuações após o uso domiciliar de bisacodil antes da ingestão de manitol e número de evacuações após a ingestão de manitol até atingir o preparo intestinal adequado. Antes de iniciar o preparo intestinal, os pacientes responderam a um questionário clínico. O endoscópio foi introduzido para aspirar o conteúdo gástrico, antes de iniciar a colonoscopia. RESULTADOS: A amostra foi composta por 103 pacientes, sendo 55 mulheres, com média de idade de 61 anos, peso médio de 75,3 kg, altura média de 1,7 m e IMC médio de 26,6 kg/m2. O volume residual gástrico médio medido foi 120,9 (0-900) mL. Volume residual gástrico inferior a 100 mL (VRG ≤100 mL) foi encontrado em 45 (43,6%) pacientes, sendo 24 (53,3%) mulheres, com média de idade de 61,0 anos e IMC médio de 26,7 kg/m2. Volume residual gástrico acima de 100 mL (VRG >100 mL) ocorreu em 58 (56,3%) pacientes, sendo 29 (50%) mulheres, com idade média de 61,0 anos e IMC médio de 26,2 kg/m2. Comparando os dois grupos, notou-se que o tempo médio de jejum após a ingestão de manitol foi significativamente maior no grupo com VRG ≤100 mL do que no grupo com VRG> 100 mL, 123,1 (60-246) vs 95,3 (55-195) minutos, respectivamente. Também houve significância estatística em relação ao uso de ezetimiba 6 (13,7%), sendo maior no grupo com VRG ≤100 mL. Além disso, houve significância estatística no grupo com VRG >100 mL quanto ao uso de paroxetina 3 (6,7%) e tadalafil 3 (6,7%) e história cirúrgica de prostatectomia 3 (6,7%) e retirada de bridas 3 (6,7%). CONCLUSÃO: Podemos concluir neste estudo que o uso de ezetimiba e o jejum acima de 2 horas após a ingestão de manitol diminuem significativamente a incidência de um VRG> 100 mL. O uso de paroxetina, tadalafil e história cirúrgica de prostatectomia ou retirada de bridas podem contribuir para o aumento da incidência de um VRG >100 mL.
The aims of this study were to examine variation in the use of conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) across hospitals and over time and to evaluate outcomes of CS ...compared with general anesthesia (GA) using instrumental variable analysis, a quasi-experimental method to control for unmeasured confounding.
Despite increasing use of CS for TAVR, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding.
Among 120,080 patients in the TVT (Transcatheter Valve Therapy) Registry who underwent transfemoral TAVR between January 2016 and March 2019, the relationship between anesthesia choice and TAVR outcomes was evaluated using hospital proportional use of CS as an instrumental variable.
Over the study period, the proportion of TAVR performed using CS increased from 33% to 64%, and CS was used in a median of 0% and 91% of cases in the lowest and highest quartiles of hospital CS use, respectively. On the basis of instrumental variable analysis, CS was associated with decreases in in-hospital mortality (adjusted risk difference: 0.2%; p = 0.010) and 30-day mortality (adjusted risk difference: 0.5%; p < 0.001), shorter length of hospital stay (adjusted difference: 0.8 days; p < 0.001), and more frequent discharge to home (adjusted risk difference: 2.8%; p < 0.001) compared with GA. The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach, however.
In contemporary U.S. practice, the use of CS for TAVR continues to increase, although there remains wide variation across hospitals. The use of CS for TAVR is associated with improved outcomes (including reduced mortality) compared with GA, although the magnitude of benefit appears to be less than in previous studies.
In this article we will give a comprehensive literature review on sedation/general anaesthesia (S/GA) and discuss the international variations in practice and options available for S/GA for imaging ...children.
The key articles were obtained primarily from PubMed, MEDLINE, ERIC, NHS Evidence and The Cochrane Library.
Recently, paediatric radiology has seen a surge of diagnostic and therapeutic procedures, some of which require children to be still and compliant for up to 1 h. It is difficult and sometimes even impossible to obtain quick and high-quality images without employing sedating techniques in certain children. As with any medical procedure, S/GA in radiological practice is not without risks and can have potentially disastrous consequences if mismanaged. In order to reduce any complications and practice safety in radiological units, it is imperative to carry out pre-sedation assessments of children, obtain parental/guardian consent, monitor them closely before, during and after the procedure and have adequate equipment, a safe environment and a well-trained personnel.
Although the S/GA techniques, sedative drugs and personnel involved vary from country to country, the ultimate goal of S/GA in radiology remains the same; namely, to provide safety and comfort for the patients. Advances in knowledge Imaging children under general anaesthesia is becoming routine and preferred by operators because it ensures patient conformity and provides a more controlled environment.
Purpose
Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.
Methods
Medical records of patients ...who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.
Results
A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16–85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22,
p
= 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%,
p
= 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%,
p
< 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.
Conclusions
The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.
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