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Assisted reproductive technique (ART) has emerged as the highest form of treatment for infertile couples. Transvaginal oocyte retrieval is currently performed under conscious sedation in most centers. Since it is a relatively painful procedure, a number of adjuvant therapies have been tried to improve pain relief during the procedure. Music therapy is a nonpharmacological technique that has been successfully used for pain relief in perioperative and chronic pain of malignancy. However, studies evaluating its usefulness in ART-related procedures are limited. We evaluated the effectiveness of music therapy as an adjuvant for pain relief during oocyte retrieval.This was a randomized controlled trial conducted at a tertiary level teaching hospital in South India from September 2020 to March 2021. All women undergoing transvaginal oocyte retrieval were randomized to receive either music therapy along with conscious sedation (Group A) or conscious sedation alone (Group B). The primary outcome was postprocedure pain score assessed by the visual analog scale. Secondary outcomes included anxiety score.A total of 109 women were randomized into Group A (54 women) and Group B (55 women). The postprocedure pain score was comparable between the two study groups (6.0, interquartile range [IQR] 4 to 6 vs. 6.0, IQR 4 to 6; p = 0.69). However, anxiety levels were found to be significantly lower in women who were offered music therapy (3.0, IQR 1 to 5 vs. 4.0, IQR 3 to 6; p = 0.004).The use of music therapy as an adjuvant to conscious sedation was found to have no significant benefit in pain relief during oocyte retrieval.

Pediatric sedation is a clinical activity with potential for serious but rare airway adverse events, particularly laryngospasm. Anticholinergic drugs, atropine and glycopyrrolate, are frequently used with the intention to improve sedation safety by virtue of their antisialagogue effects.The objective of this study is to describe the current practice of anticholinergic use in pediatric sedation and to compare the frequency of serious sedation-related adverse events in patients who received anticholinergics to those who did not.We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Patient characteristics, procedure type, sedation provider, sedatives, location of sedation, anticholinergic administered, adverse events, and airway interventions were reported. Propensity score matching and multivariable logistic regression were used to test whether any association exists between anticholinergic use and serious sedation-related adverse events.Anticholinergics were administered in 7.1% (n = 18 707) of all cases (n = 263 883) reported between November 2011 and October 2017. When anticholinergics were used, atropine was used in 22% (n = 4111) and glycopyrrolate in 78.1% (n = 14 601) of sedations. Use of anticholinergics was more common in patients with well-described risk factors for airway adverse events: active/history of upper respiratory infection, history of reactive airway disease/asthma, and exposure to smoke. However, infants and ASA 3 patients were not associated with higher rate of anticholinergic use. Anticholinergic use was independently associated with an increase in the odds of serious adverse events, OR 1.8 (95% CI 1.6-2.1), especially airway adverse events.In this large Pediatric Sedation Research Consortium study, we found the use of anticholinergic adjuvants independently associated with greater odds of serious adverse events, especially airway adverse events, after adjusting for well-known sedation risk factors using propensity score matching and multivariate analysis.

Moderate sedation using nitrous oxide (NThis study aimed to examine pediatric dental patients' behaviors while undergoing NIn this within-subject observational study, participants received 40% NIn 80 children with a mean age of 7.2 (2.2) years, administration of NIn children sedated with N

Objectives As the population ages and implantation criteria are relaxed, more patients with complex comorbidities are becoming eligible for cochlear implantation (CI). These patients have higher risks associated with general anesthesia. This systematic review assesses outcomes and complications following CI under local anesthetic to examine utility for patients deemed not suitable or at high risk for general anesthesia. Methods A systematic review and meta‐analysis performed according to the 2020 PRISMA guidelines. Databases searched were MEDLINE, PubMed, EMBASE, CINAHL, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. There were no limitations on year of publication or language. Results Then, 132 unique were identified. After screening abstracts and full texts for eligibility criteria a total of 18 articles were included. In the nine studies where audiological data were reported, all patients demonstrated improvement in audiological outcomes following implantation under local anesthetic (LA). Only minor complications of transient vertigo, wound infection, facial nerve paralysis, confusion, and tinnitus were reported but all were transient. Meta‐analysis showed surgical time was significantly shorter under LA. Conclusions CI under LA is safe for patients with comorbidities which preclude them from general anesthesia, with minimal complications and an improved cost‐effectiveness profile. However, larger scale, robust trials are required to assess this further.

Despite being a standard of care for children undergoing stressful procedures, little data exist on parental perception of pediatric sedation.This study aimed to investigate recovery characteristics and parental satisfaction for pediatric sedations performed with four widely used sedative regimens.A prospective observational study was conducted at the Institute for Maternal and Child Health of Trieste, Italy, enrolling children undergoing procedural sedation with one of the following pharmacological regimens: propofol, propofol + midazolam, ketamine + propofol, and dexmedetomidine + midazolam. A questionnaire was used to assess the occurrence of symptoms upon recovery from sedation and the following day, and the caregivers' satisfaction for both the recovery pattern and the overall sedation experience, according to a numerical rating scale (0-10). Answers were collected through a telephone survey. The primary outcome was the difference in the quality of the recovery as perceived by caregivers; the secondary and tertiary outcomes were the perceived quality of the overall sedation experience and the frequency of sedation-related adverse events, respectively.Data from 655 patients, 149 receiving propofol, 245 propofol + midazolam, 134 ketamine + propofol, and 127 dexmedetomidine + midazolam, were analyzed. The level of parents' satisfaction for both the recovery and the sedation experience was overall high and increased with the patients' age in all the pharmacological groups (Spearman's rank correlation, ρ .083, p = .033, and ρ .087, p = .026, respectively), with no statistically significant differences between groups when adjusting for age. The occurrence of irritability, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress at any moment negatively affected parental satisfaction.In this study, caregivers' satisfaction with pediatric sedation was high, regardless of the regimen used. Lower parental satisfaction was associated with younger age, irritability after sedation, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress.

BACKGROUND The Ramsay scale is the most widely used scale during pediatric procedures although it has not been formally validated. OBJECTIVE To validate the Ramsay scale during invasive procedures under sedation in pediatrics. METHODS A prospective analytic study was conducted in two hospitals. All patients ≥6 months that were undergoing invasive procedures under sedation were enrolled. All were recorded, and these videos were edited and randomized. 150 videos were scored by four observers (a pediatrician, a pediatric intensive care unit nurse, an anesthetist, and an operating room nurse). All videos were scored with the Ramsay scale and University of Michigan Sedation Scale. Observers were blinded to drug administration. Construct validity was measured through Wilcoxon test paired samples after administration of sedatives. Criterion validity, intra-observer reliability, and interobserver correlation were evaluated by comparing the scores of the scales using Spearman's correlation coefficient. Interobserver agreement was measured using the intraclass correlation coefficient. To assess test-retest reliability, 50 videos were randomly selected and reevaluated. RESULTS Sixty-five patients were included. Construct validity was demonstrated through changes in the Ramsay scale scoring after administration of sedatives (p

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Paediatric procedures requiring sedation are increasingly being performed off site, but there are no national guidelines for paediatric procedural sedation in Finland or studies on it. Therefore, the aim of this survey was to assess national practices for paediatric procedural sedation outside operation rooms and intensive care units in terms of indications, sedative medication, treatment facilities, patient safety and training of the personnel. An online survey including single- and multiple-choice questions and open-ended questions was sent to Finnish paediatricians, paediatric surgeons and paediatric anaesthesiologists via the electronic mailing lists of national societies in December 2019. A total of 71 responses were received. Lumbar puncture (41%), intra-articular injections (38%) and MRI (17%) were the most common procedures that required routine sedation. Benzodiazepines were the most frequently used sedatives during both painful procedures (80%) and imaging (61%). Pulse oximetry monitoring was reported by 75% of the respondents, but other physiological parameters were rarely monitored (ECG 28%; blood pressure 39%; respiratory rate 34%). The level of sedation was not objectively assessed. Adrenaline (72%) and equipment for managing adverse respiratory outcomes (supplemental oxygen 98%; ventilation equipment 92%) were available in most facilities in which sedation was performed. Only one-third of the respondents had undergone training for paediatric procedural sedation, and only 39% of the hospital units compiled statistical data on sedation-related adverse events. The paediatric procedural sedation practices vary across hospitals. National guidelines for patient monitoring and training of personnel could improve treatment quality and patient safety.

OBJECTIVE To report on the feasibility, indications, and diagnostic yield of cone beam computed tomography (CBCT) of horses' extremities performed under standing sedation. STUDY DESIGN Retrospective clinical case series. SAMPLE POPULATION Fifty-nine CBCT examinations in 58 horses. METHODS Examinations were categorized for indications for CBCT dependent on a suspicion, presence, or absence of a diagnosis prior to CBCT. The number of acquisitions per examination, total time for the examination, diagnostic score of each acquisition (diagnostic, diagnostic-compromised, nondiagnostic), and additional diagnostic information regarding preexisting diagnostic information were recorded. RESULTS Three (median) acquisitions were performed per examination in a median study time of 14 minutes. In 24 of 33 cases with a suspected diagnosis, this diagnosis was confirmed or definitively refuted; in seven of 33 cases, the suspected diagnosis was refuted without a new diagnosis; and, in two of 33 cases, the suspected diagnosis could not be confirmed nor could a new diagnosis be made. In five of nine cases without a preexisting diagnosis, a diagnosis was established. In 16 cases with a diagnosis prior to CBCT, additional information was recorded, or a surgical plan was prepared. In 14 of 18 cases in which additional contrast techniques were used, additional information was gained. CONCLUSION Standing CBCT of the horses' extremities is feasible and can produce diagnostic information in a timely fashion. CLINICAL SIGNIFICANCE The results provide evidence of the practicality and diagnostic potential of standing CBCT of horses' extremities.

Children admitted to the pediatric intensive care unit (PICU) often require multiple medications to achieve comfort and sedation. Although starting doses are available, these medications are typically titrated to the desired effect. Both oversedation and undersedation are associated with adverse events. The aim of this retrospective study was to evaluate cumulative medication burden necessary to achieve comfort in patients in the PICU and determine relevant predictors of medication needs. In order to account for all of the sedative medications, z-scores were used to assess the population average dose of each medication and compare each patient day to this population average. Sedation regimens for 130 patients in the PICU were evaluated. Mean overall infusion rates of fentanyl, morphine, and hydromorphone were 1.67 ± 0.81 µg/kg/hour, 0.12 ± 0.08 mg/kg/hour, and 17.84 ± 13.4 µg/kg/hour, respectively. The mean infusion rate of dexmedetomidine was 0.59 ± 0.28 µg/kg/hour, and midazolam was 0.14 ± 0.1 mg/kg/hour. Summation z-sores were used to rank the amount of sedation medication needed to achieve comfort for each individual patient for his/her PICU stay in relation to the entire sample. Patient age, weight, and length of mechanical ventilation were all significant predictors of sedation requirement. This study will provide data necessary to develop a model of cumulative medication burden needed to achieve appropriate sedation in this population. This descriptive model in appropriately ranking patients based on sedative needs is the first step in exploring potential genetic factors that may provide an insight into homing in on the appropriate sedation regimen.

Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8-14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1-0.2 mg.kg-1 for all patients undergoing surgery associated with significant postoperative pain.

Background Central airway obstruction and fistula are treated with a tracheobronchial Y stent. In the currently used self‐expandable metal Y stents, the delivery system is 8 mm in diameter and requires either a 9 mm tracheal tube or rigid bronchoscope to enable airway control during insertion. In this study we present a novel technique of laryngeal mask airway (LMA) assisted Y stent insertion, enabling airway control during deployment of the Y stent. Methods All procedures using LMA in assisting Y stent insertions between 2014–2020 were reviewed. Data collected included demographics, clinical diagnosis and disease characteristics, indication, procedural success rates, clinical outcome and survival. Results A total of 10 patients with a median age of 61.5 years (range 37–73) underwent LMA assisted Y stent insertion. Indications for stent insertion were malignant disease with central airway obstruction or fistula. In all cases airway patency was achieved leading to improvement of symptoms and performance status. No procedural complications were reported. The median survival was 4.5 weeks (range: 2–26). Conclusions LMA assisted Y stent insertion enables airway control during the procedure. In comparison to silicone Y stent insertion, the procedure is less cumbersome, shorter in duration and does not require the use of general anesthesia or rigid bronchoscopy. Key points Significant findings of the study LMA assisted Y stent insertion enables airway control during the implantation of metallic self‐expanding Y stent. The procedure does not require the use of general anesthesia or rigid bronchoscopy. What this study adds In this study we present the technique and outcomes of LMA assisted Y stent insertion. This method of Y stent insertion provides an additional treatment option for patients with central airway obstruction and fistula., LMA assisted Y stent insertion enables airway control during the implantation of metallic self‐expanding Y stent. The procedure does not require the use of general anaesthesia or rigid bronchoscopy.

Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Anxiety is an adaptive emotional response to potentially threatening or dangerous situations; moderated by the sympathetic nervous system. Dental anxiety is common and presents before, during or after dental treatment. The physiological response includes an increase in heart rate, blood pressure, respiratory rate, and cardiac output. Consequently, extensive distress leads to avoidance of dental treatment and multiple failed appointments, impacting both oral and general health. Dental anxiety can generate a variety of negative consequences for both the dentist and the patient. Evidence-based strategies are essential for mitigating and relieving anxiety in the dental clinic. Psychotherapeutic behavioural strategies can modify the patient's experience through a minimally invasive approach with nil or negligible side effects, depending on patient characteristics, anxiety level and clinical situations. These therapies involve muscle relaxation, guided imagery, physiological monitoring, utilizing biofeedback, hypnosis, acupuncture, distraction and desensitization. Pharmacological intervention utilizes either relative analgesia (nitrous oxide), conscious intravenous sedation or oral sedation, which can have undesirable side effects, risks and contraindications. These modalities increase the cost and availability of dental treatment.

Background Pediatric procedural sedation (PPS) has been established worldwide as standard practice for several decades. However, there are no comprehensive guidelines or multi-facility databases of PPS in Japan, and the current status of PPS and PPS-related adverse events is unclear. The objectives of this study were to investigate the status of PPS in Japan and clarify the adverse events and risk factors. Methods This study was a single-facility, database survey performed at Oita University Hospital from September 2016 to March 2019. Children under 18 years of age who had been kept sedated for medical procedures with intravenous sedatives were enrolled in this study. Adverse events were recorded and defined according to the Quebec Guideline. Results During the study period, PPS was performed for 1,436 consecutive cases. The majority (94%) of the sedatives used were thiamylal alone or thiamylal combined with ketamine. There were a total of 253 adverse events in 233 cases (16.2%), including oxygen desaturation, airway hypersensitivity, and vomiting. Patients recovered from respiratory-related adverse events immediately with simple intervention. No patient required endotracheal intubation and no severe adverse event occurred. Four risk factors (a higher American Society of Anesthesiologists classification, longer procedure time, non-compliance of nil per os status, and no Pediatric Advanced Life Support certification for sedation personnel) were associated with the occurrence of adverse events. Conclusions Adverse events occurred in 16.2% of all PPS cases. Further studies are needed to analyze the serious adverse events and risk factors for PPS in Japan.

Objective Rapidly and safely managing severe acute behavioural disturbance (ABD) in the prehospital setting is important for the welfare of both patient and prehospital clinician alike. We investigated the safety and effectiveness of ketamine as rescue sedation in patients with severe ABD. Methods This prospective observational study investigated ketamine use by a state ambulance service as rescue sedation for patients with severe ABD who remained agitated following droperidol administration. The primary outcome was the proportion of adverse events (vomiting, hypersalivation, emergence, over-sedation, airway obstruction, laryngospasm, hypoxia, bradypnoea and intubation). Secondary outcomes included time to sedation, requirement for additional sedation and rate of successful sedation. Results There were 105 presentations (males 69/102 [69%]; median age 31 years (16-83 years). The commonest causes of ABD were illicit drug (39%) and alcohol (33%) intoxication. The median total dose of intramuscular ketamine was 200 mg (interquartile range [IQR] 150-200 mg). There were 64 adverse events in 40 (38%) patients. Four had vomiting, two had hypersalivation, two had emergence, 15 were oversedated, four had hypoxia, three had bradypnoea and 16 were intubated. Sedation was achieved in 103 (98%) patients at a median time post-ketamine of 8 min (IQR 5-13 min). Additional sedation was administered to 41 patients (nine prehospital and 37 within 1 h of arriving to hospital). In 44 (42%) patients, ketamine successfully sedated the patient with no adverse effects and no ongoing sedation requirement. Conclusion The use of ketamine as rescue sedation in prehospital patients with severe ABD is effective. Adverse events are common but can be managed supportively.

Background Left atrial appendage occlusion (LAAO) using Watchman device has become a world-wide, well-established therapeutic alternative to chronic systemic oral anticoagulation in patient who are at high-risk of bleeding with paroxysmal (PAF) or chronic atrial fibrillation (Afib). Currently, LAAO procedures are performed under general anesthesia (GA) and patients stay overnight post procedure in the United States. We aimed to present the effectiveness and safety of same day discharge following LAAO under moderate conscious sedation (MCS) in patients without procedural complications. Methods A total of 112 patients between August 2019 and May 2020 with elevated CHA2 DS2 VASc (median score of 3) underwent transesophageal echocardiography (TEE)-guided LAAO with FDA approved Watchman (Boston Scientific, MN) under MCS and discharged home on the same day 6 hr following their post procedural transthoracic echocardiogram (TTE) evaluations. All patients had next day TTE and follow up at the cardiology clinic. We prospectively evaluated clinical and procedural outcomes using medical records of these patients. Results Among all the patients, the mean age was 83.5 ± 8.5 years, 45 (40%) were women. Procedural duration, device implant time and fluoroscopic times were 45 ± 8.6, 14.5 ± 7.8 and 10.2 ± 1.2 min, respectively. The median required dosage of propofol was 105 ± 2.8 mg. No complications arose from MCS. There was no need for conversion to GA in any of the patients during the procedure. All patients were able to be discharged 6 hr following their TTE evaluation post procedure. There were no procedural complications. Conclusions Same day discharge following LAAO closure seems to be safe and effective in patients without procedural complications. LAAO can also be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the LAAO procedure, reduce procedural time, procedural costs and hospital stay while increasing overall patient satisfaction.

Introduction Serial muscle biopsies within clinical trials for Duchenne muscular dystrophy (DMD) are critical to document therapeutic responses. Less invasive means of sampling muscle are needed. Methods We analyzed a retrospective consecutive case-series cohort of vacuum-assisted core needle muscle biopsy procedures performed on healthy and dystrophic individuals at a single institution assessing for safety and reliability of obtaining sufficient high quality biopsy tissue for histologic assessment in adult and pediatric subjects. Results Of 471 muscle cores from 128 biopsy procedures, 377-550mg of total muscle tissue was obtained per procedure with mean core weight of 129mg (SD 25.1mg). All Biopsies were adequate for histological assessment. There were no significant adverse events. Discussion This core needle biopsy approach, when combined with improved sample processing, provides a safe means to consistently obtain muscle samples for diagnostic and clinical trial applications. This article is protected by copyright. All rights reserved.

Background and aim Endoscopist directed nurse administered propofol sedation (EDNAPS) is widely considered to be safe and efficient, but there are limited data from the Australian health-care setting, and Australian sedation guidelines do not support the practice. Thus, we report data from a prospective audit of EDNAPS over a 6.5-year period in an Australian referral hospital. Methods Consecutive endoscopic procedures performed between January 2013 and June 2019. Sedation protocol was an initial dose of midazolam 1-3 mg intravenously (i.v.) and propofol 10-50 mg i.v.. Further aliquots of propofol 10-30 mg i.v. were given as required. ProvationMD® endoscopic reporting system was used to prospectively record patient demographics, medication and dose, American Society of Anesthesiologist's (ASA) class, and sedation-related complications. Results During the 78-month period, 28 051 eligible procedures were performed; 3093 procedures performed with anesthetic support or without EDNAPS were excluded. In total, 24 958 procedures with EDNAPS were analyzed including 7563 gastroscopies, 12 941 colonoscopies, 2932 gastroscopy and colonoscopy, 1440 flexible sigmoidoscopies, and 82 combined gastroscopy and flexible sigmoidoscopy. Of these, 9539 were ASA 1 (38.2%), 13 680 were ASA 2 (54.8%), 1733 were ASA 3 (6.9%), and 4 were ASA 4 (0.02%). Sedation-related complications occurred in 66 patients (0.26%), predominantly transient hypoxic episodes. No patient required intubation for an airway emergency, and there was no sedation-related mortality. Sedation-related complications increased with ASA class and were significantly more common with gastroscopy. Conclusions Endoscopist directed nurse administered propofol sedation is a safe way of performing endoscopic sedation in low-risk patients in the hospital setting.

To evaluate the effect of sedation or general anesthesia (GA) on elbow goniometry and thoracic limb circumference (TLC) measurements in dogs with elbow osteoarthritis (OA).Prospective study.Twenty-four client-owned dogs with radiographically confirmed elbow OA.Elbow goniometry and TLC measurements were made before and after either sedation or GA by using a hand-held goniometer and spring tension measuring tape, respectively. Observers were not allowed to review their pre-sedation or pre-GA measurements at the time of obtaining measurements on dogs under sedation or GA. Mixed analysis of variance models were used to compare elbow goniometry and TLC measurements before and after sedation or GA.Eleven and thirteen dogs were included in the sedation and GA groups, respectively. Mean elbow flexion decreased by 5° and 3° and mean elbow extension increased by 6° and 2° under sedation and GA, respectively. Total range of motion increased by 11° under sedation and by 5° under GA. Each of these changes was statistically significant (P .05) except elbow extension under GA (P = .129). Sedation and GA did not influence TLC measurements (P .05).Sedation or GA led to slight and similar increase in elbow flexion and extension but did not influence TLC measurements in dogs with elbow OA.Sedation or GA can cause slight alterations to goniometric measurements in canine elbows with OA. The protocols used in this study for sedation and GA seem interchangeably acceptable for goniometry and TLC measurements in dogs with elbow OA.

BACKGROUND In the monitored anesthesia care (MAC) setting for awake craniotomy (AC), maintaining airway patency in sedated patients remains challenging. This randomized controlled trial aimed to compare the validity of the below-epiglottis transnasal tube insertion (the tip of the tube placed between the epiglottis and vocal cords) and the nasopharyngeal airway (simulated by the above-epiglottis transnasal tube with the tip of the tube placed between the epiglottis and the free edge of the soft palate) with respect to maintaining upper airway patency for moderately sedated patients undergoing AC. METHODS Sixty patients scheduled for elective AC were randomized to receive below-epiglottis (n = 30) or above-epiglottis (n = 30) transnasal tube insertion before surgery. Moderate sedation was maintained in the pre- and post-awake phases. The primary outcome was the upper airway obstruction (UAO) remission rate (relieved obstructions after tube insertion/the total number of obstructions before tube insertion). RESULTS The UAO remission rate was higher in the below-epiglottis group [100% (12/12) vs 45% (5/11); P = .005]. The tidal volume values monitored through the tube were greater in the below-epiglottis group during the pre-awake phase (P

BACKGROUND The standard approach to subcutaneous defibrillator (S-ICD) implantation often requires general anesthesia or anesthesiologist-delivered deep sedation. Ultrasound-guided serratus anterior plane block (SAPB) combined with parasternal block (PSB) has been proposed in order to provide anesthesia/analgesia and to reduce the need for sedation during S-ICD implantation. In this pilot study, we compared the double-block approach (SAPB + PSB) with the single-block approach (SAPB only) and with the standard approach involving local anesthesia and sedation. METHODS We prospectively enrolled 22 patients undergoing S-ICD implantation: in 10, the single-block approach was adopted; in 12, the double-block approach. As a control group, we retrospectively enrolled 14 consecutive patients who had undergone S-ICD implantation under standard local anesthesia and sedation in the previous 6 months. Intra- and postprocedural data, including patient-reported pain intensity, were collected and compared in the three study groups. RESULTS The double-block approach was associated with a shorter procedure duration than the single-block and standard approaches (63.3 ± 7.9 vs 70.1 ± 6.8 vs 76.9 ± 7.8 min; P

Background High-quality evidence of analgesia and sedation management in pediatric intensive care units (PICUs) is lacking. Methods An online survey concerning the institutional management of pain, sedation, delirium, and withdrawal syndrome, as well as non-pharmacological interventions to reduce pain and / or to provide comfort, was conducted with the medical directors of 31 PICUs in Japan. The survey was conducted from September to November 2016. Results The response rate was 77% (24/31). Pain was routinely assessed in nine (38%) PICUs. Self-report pain scales were used in 14 (58%) PICUs. Observational pain scales for children who were unable to self-report were used in only one PICU. Physician-driven analgesia protocols were used in two (8%) PICUs. Although sedation scales for intubated patients were used in 15 (63%) PICUs, they were used for the goal-directed sedation management in nine (38%). Nurse-driven sedation protocols were used in two (8%) PICUs. Five (21%) PICUs used delirium assessment tools, and delirium screening was not routinely done in any PICU. Five (21%) PICUs regularly used withdrawal assessment tools for a high-risk group of patients with withdrawal syndrome. Non-pharmacological interventions for analgesia and comfort were frequently practiced for mechanically ventilated patients. Conclusions This study is the first survey conducted by physicians regarding pain and agitation management in PICUs in Japan, and the results revealed great diversity in practice. The implementation strategies to assess pain, delirium, and withdrawal syndrome, as well as to set goals regarding sedation level, are lacking. Protocols for analgesia and sedation management are uncommon.

Objective: Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. Methods: This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation

OBJECTIVES To investigate whether second-look endoscopy (SLE)-guided therapy could be used to prevent post-endoscopic variceal ligation (EVL) early bleeding. METHODS Consecutive cirrhotic patients with large esophageal varices (EV) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into a SLE group and a non-SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions as well as proton pump inhibitors and octreotide administration were applied based on the SLE findings. The post-EVL early rebleeding and mortality rates were compared between the two groups. RESULTS A total of 252 patients were included in the final analysis. Post-EVL early rebleeding (13.5% vs 4.8%, P = 0.016) and bleeding-caused mortality (4.8% vs 0%, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, post-EVL early rebleeding and mortality rates were reduced by SLE in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child-Pugh classification B to C at randomization (hazard ratio [HR] 8.77, P = 0.034), AVB at index EVL (HR 3.62, P = 0.003), discontinuation of non-selective β-blocker after randomization (HR 4.68, P = 0.001) and non-SLE (HR 2.63, P = 0.046) were more likely to have post-EVL early rebleeding. No serious adverse events occurred during SLE. CONCLUSION SLE-guided therapy reduces post-EVL early rebleeding and mortality rates in cirrhotic patients with large EV receiving EVL for AVB.

Objectives: As the population ages and implantation criteria are relaxed, more patients with complex comorbidities are becoming eligible for cochlear implantation (CI). These patients have higher risks associated with general anesthesia. This systematic review assesses outcomes and complications following CI under local anesthetic to examine utility for patients deemed not suitable or at high risk for general anesthesia. Methods: A systematic review and meta-analysis performed according to the 2020 PRISMA guidelines. Databases searched were MEDLINE, PubMed, EMBASE, CINAHL, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. There were no limitations on year of publication or language. Results: Then, 132 unique were identified. After screening abstracts and full texts for eligibility criteria a total of 18 articles were included. In the nine studies where audiological data were reported, all patients demonstrated improvement in audiological outcomes following implantation under local anesthetic (LA). Only minor complications of transient vertigo, wound infection, facial nerve paralysis, confusion, and tinnitus were reported but all were transient. Meta-analysis showed surgical time was significantly shorter under LA. Conclusions: CI under LA is safe for patients with comorbidities which preclude them from general anesthesia, with minimal complications and an improved cost-effectiveness profile. However, larger scale, robust trials are required to assess this further.

OBJECTIVE Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN Review of prospectively collected data. METHODS Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2849-E2856, 2021.

Introduction Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large‐vessel occlusion in the anterior circulation, but there is a debate on the optimal anesthetic approach during this therapy. Meta‐analyses of observational studies suggest that general anesthesia increases disability and death compared with conscious sedation However, their results are conflicting. This meta‐analysis study was performed to assess the relationship between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke. Methods Through a systematic literature search up to August 2020, 18 studies included 4,802 subjects at baseline with endovascular therapy for acute ischemic stroke and reported a total of 1,711 subjects using general anesthesia and 1,961 subjects using conscious sedation were found. They recorded relationships between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke. Odds ratio (OR) or Mean differences (MD) with 95% confidence intervals (CIs) were calculated between the effect of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke using the dichotomous or contentious methods with a random or fixed‐effect model. Results No significant difference were found between general anesthesia and conscious sedation during the endovascular therapy for acute ischemic stroke in functional independence at 90 days (OR, 0.78; 95% CI, 0.44–1.40, p = 40); successful recanalization at 24 hr (OR, 1.23; 95% CI, 0.62–2.41, p = 55); mortality at 90 days (OR, 1.36; 95% CI, 0.83–2.24, p = .22); interventional complication (OR, 1.24; 95% CI, 0.76–2.02, p = .40); symptomatic intracranial hemorrhage (OR, 0.64; 95% CI, 0.41–0.99, p = .05); aspiration pneumonia (OR, 0.96; 95% CI, 0.58–1.58, p = .87); and National Institute of Health Stroke Scale score after 24 hr (MD, 0.38; 95% CI, −1.15–1.91, p = .62); with relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage. Conclusions General anesthesia has no independent relationship compared to conscious sedation during the endovascular therapy for acute ischemic stroke with a relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage. This relationship encouraged us to recommend either anesthetic strategy during the endovascular therapy for acute ischemic stroke with no possible fear of higher complication., What's already known about this topic?Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large‐vessel occlusion in the anterior circulation, but there is a debate on the optimal anesthetic approach during this therapy. Meta‐analyses of observational studies suggest that general anesthesia increases disability and death compared with conscious sedation However, their results are conflicting. This meta‐analysis study was performed to assess the relationship between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke.What does this article add?General anesthesia has no independent relationship compared to conscious sedation during the endovascular therapy for acute ischemic stroke with a relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage.This relationship encouraged us to recommend either anesthetic strategy during the endovascular therapy for acute ischemic stroke with no possible fear of higher complication.

Cataract surgery is usually of short duration and is associated with minimal pain when employing topical or regional anaesthesia. Patient education regarding the peri-operative process may help alleviate anxiety and avoid the need for sedation. However, sedation may be required, and we discuss the various options. Many consider that pre-operative fasting is necessary due to the risk of aspiration but fasting may not be required if minimal sedation is administered. If the use of sedatives, hypnotics or analgesics is required, then their associated adverse events should be considered.

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.

INTRODUCTION: Patients undergoing minimally invasive procedures under a light conscious sedation perceive pain and anxiety. Hypnosis used together with analgesics has been investigated in numerous studies.AIMS AND METHODS: To assess the effectiveness of hypnotic analgesia in management of pain, anxiety, analgesic consumption, procedure length and adverse events in adults undergoing minimally invasive procedures. Clinical controlled trials in which hypnosis was used together with pharmacological analgesia compared to pharmacological analgesia alone during invasive procedures were included. Seven databases were searched. The methodological quality of the studies was assessed by two reviewers using a standardised instrument for critical appraisal from Joanna Briggs Institute, 'Meta-Analysis of statistics assessment and review Instrument'. Meta-analyses using the review manager version 5.3 software were conducted on procedure length and adverse events. Results for pain, anxiety and analgesics were synthesised in narrative summaries. Conduction of the review adheres to the PRISMA checklist.RESULTS: Ten studies comprising 1,365 participants were included. A reduction in the consumption of pain medication was found between 21%-86% without aggravating pain intensity and anxiety. In few studies, significant reduction in pain intensity and anxiety was found. Meta-analysis including seven studies revealed a small beneficial effect on reducing procedure length. A meta-analysis on adverse events showed no significant reduction. Statistical heterogeneity was found among the studies included.CONCLUSION: For patients undergoing invasive procedures, hypnotic analgesia was effective in reducing consumption of analgesics. Only a slight effect was, however, found on experienced anxiety and pain intensity. It did not prolong the procedure and was safe to provide.RELEVANCE TO CLINICAL PRACTICE: Hypnosis is recommended as pain management for adults during invasive procedures. A reduced consumption of pain medication potentially has a major impact on monitoring and observation of patients following the procedure, thus improving patient safety and reducing resource consumption.

Background and aim A number of studies were able to show a reduction of hypoxemia episodes during procedural sedation through the use of capnography (CA). The present study investigates the number of episodes of hypoxemia during percutaneous endoscopic gastrostomy (PEG) placement with propofol sedation comparing standard monitoring (SM) versus SM with additional CA surveillance. Methods In this single center randomized controlled trial, 150 patients were prospectively randomized 1:1 in either the SM group or the CA group after stratification for ASA class, PEG method (push or pull method), presence of head and neck tumor, and tracheostomy. CA analysis was performed for all patients but was blinded for the endoscopic team in the SM group. Results In the SM group, 57% episodes of hypoxemia (SpO2 15 s) and 41% episodes of severe hypoxemia (SpO2 15 s) were observed in comparison with 28% and 20% in the CA group, respectively. Odds ratios for hypoxemia and severe hypoxemia were 0.29 (confidence interval 0.15-0.57; P = 0.0005) and 0.35 (confidence interval 0.17-0.73; P = 0.008) in favor of the CA group. On average, CA was able to detect imminent mild and severe hypoxemia 83 and 99 s before standard monitoring. Standard monitoring represented an independent risk factor for hypoxemia and severe hypoxemia. Conclusions Respiratory complications of sedation during PEG placement are frequent events. CA is able to detect imminent hypoxemia at an early time point. This allows an early intervention and consecutively the avoidance of mild and severe hypoxemia. Therefore, CA monitoring can be recommended particularly during PEG insertion procedures.

Nurses play a key role in administering sedation to mechanically ventilated children, which impacts children's psychological, physiological and cognitive changes in the paediatric intensive care unit. This study aimed to survey the sedation practices of paediatric intensive care unit nurses on mechanically ventilated children in China and explored the influencing factors. A cross-sectional survey was conducted based on electronic questionnaires comprised of the Nurse Sedation Practices Scale (Chinese version) in 14 different types of paediatric intensive care units of 11 academic hospitals in China from 15 February to 15 April 2017. A convenience sample of 495 nurses [73·4% response rate, (674)] completed the survey. Seven units applied Ramsay Sedation Scale as a sedative assessment tool. The majority of the nurses used observed behaviours and physiological changes of the ventilated children as indicators to assess the sedation level, and they had a positive attitude and intention, which may influence practice positively, whereas high clinical workload and the lack of communication between the nurses and families might hinder practice. The practice of sedation varied greatly in different regions, and the respondents of the northwest region scored lower. Paediatric nurses in China rarely used a validated paediatric instrument to assess sedation, and most nurses relied on physiological and behavioural cues. The quality of sedation training, nursing workload and regional economic disparity affected the sedation practice. The restricted visiting policy and lack of clearly defined nursing responsibilities around sedation may hinder effective sedation assessment and management. This study found that there was no paediatric-validated tool popularized in paediatric intensive care units in China and explored influencing factors. We suggest that a validated tool, high-quality training and hospital's policy, such as visiting regulation, should be promoted to improve the sedation practice.

Phase lag entropy, an electro-encephalography-based hypnotic depth indicator, calculates diversity in temporal patterns of phase relationship. We compared the performance of phase lag entropy with the bispectral index™ in 30 patients scheduled for elective surgery. We initiated a target-controlled infusion of propofol using the Schnider model, and assessed sedation levels using the Modified Observer's Assessment of Alertness/Sedation scale every 30 s with each stepwise increase in the effect-site propofol concentration. Phase lag entropy and bispectral index values were recorded. The correlation coefficient and prediction probability between phase lag entropy or bispectral index and the sedation level or effect-site propofol concentration were analysed. We calculated baseline variabilities of phase lag entropy and bispectral index. In addition, we applied a non-linear mixed-effects model to obtain the pharmacodynamic relationships among the effect-site propofol concentration, phase lag entropy or bispectral index and sedation level. As sedation increased, phase lag entropy and bispectral index both decreased. The prediction probability values of phase lag entropy and bispectral index for sedation levels were 0.697 and 0.700 (p = 0.261) and for the effect-site concentration of propofol were 0.646 and 0.630 (p = 0.091), respectively. Baseline variability in phase lag entropy and bispectral index was 3.3 and 5.7, respectively. The predicted propofol concentrations, using the Schnider pharmacokinetic model, producing a 50% probability of moderate and deep sedation were 1.96 and 3.01 μg.ml-1 , respectively. Phase lag entropy was found to be useful as a hypnotic depth indicator in patients receiving propofol sedation.