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Introduction. Anaesthesia is frequently administered through Monitored Anaesthesia Care (MAC) utilising various combinations of anaesthetic drugs for moderately painful operations like Dilatation and Curettage (D&C), which is preferably done as a daycare procedure. The hunt for improved drug combinations is always ongoing, and the pharmacological properties of the individual drugs are considered. In this regard, anaesthesiologists all over the world are quite fond of the combination of Ketamine and Propofol, which is also known as Ketofol. Recently, especially in situations involving MRI sedation, the combination of ketamine and dexmedetomidine (Dexket) has gained popularity. This study compares the combinations for MAC during D&C surgeries in a daycare setting. Aim. The primary objective was to estimate the recovery times using either combination. Secondarily, we would also compare the duration of analgesia, the haemodynamics, and the side-effect profi les of the two combinations. Material and methods. This study enrolled 60 patients posted for elective D&C. According to standard institutional protocols, they were administered Ketofol(KP group) or Dexket(KD group), depending on the anaesthesia provider's choice. The Ketofol group received Ketamine 1mg/kg and Propofol 1mg/kg with boluses of Ketamine 0.25mg/kg to maintain the depth of anaesthesia using Ramsay sedation score(RSS) >3. KD group received Dexmedetomidine intravenously 1mic/kg over 10 minutes followed by ketamine 1mg/kg boluses of Ketamine 0.25mg/kg to maintain the adequate anaesthetic depth of RSS > 3. Results. The Recovery time in post-operative period was signifi cantly prolonged in the KD group (mean 22.77 minutes) compared to the KP group (mean 17.8 minutes). The total duration of analgesia was also longer in the KD group (250 minutes vs 220 minutes in the KP group). It was seen that the hemodynamic variables (HR, SBP, DBP) were consistently higher in the KD group compared to the KP group. There was a signifi cant difference in SBP, DBP, and MAP in the intraoperative period between the KP and KD groups till 4hr in the postoperative period. Conclusions. We conclude that a combination of Dexmedetomidine and Ketamine has longer recovery times and analgesia duration than a combination of Propofol and Ketamine. Side effects like postoperative nausea and vomiting are not significant. However, since the recovery times are comparatively longer in a daycare setting, dexmedetomidine and Ketamine may not be the preferred agents compared to the combination of Ketamine and Propofol in the context of a daycare setting. [ABSTRACT FROM AUTHOR]

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk–benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed. [ABSTRACT FROM AUTHOR]

Purpose: Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC. Materials and Methods: We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC). Results: We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l1 regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively. Conclusion: We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC. [ABSTRACT FROM AUTHOR]

Introduction: Middle Ear Surgeries (MESs) are generally performed using local anaesthesia under sedation. Butorphanol and nalbuphine both are well-known synthetic opioid with agonist-antagonist characteristics. However, no reports present a direct comparison of the analgesic efficacy of these two drugs. Aim: To evaluate analgesic efficacy of intravenous butorphanol versus intravenous nalbuphine during Monitored Anaesthesia Care (MAC) in patients undergoing tympanoplasty. Materials and Methods: This randomised clinical trial was conducted at the Department of Anaesthesiology, School of Medicine, D.Y. Patil Deemed to be University, Mumbai, Maharashtra India, from March 2018 to March 2021. Total 112 adult patients, undergoing tympanoplasty, were randomly allocated into two groups. Group N received 0.2 mg/kg nalbuphine intravenous (i.v.) and group B received i.v. 0.02 mg/kg butorphanol. The patients were then evaluated for analgesic efficacy, sedation, blood pressure, Mean Arterial Pressure (MAP), Heart Rate (HR), Respiratory Rate (RR), blood oxygen levels (SpO2), Visual Analogue Scale (VAS) Score, need for intraoperative rescue sedation/analgesia, duration of action and side-effects. Results: A significant difference was observed in the patients' responses to needle prick, where only 8 (13.3%) subjects gave a vocal response in group N versus 22 (36.6%) in group B. A significant difference in the mean time of onset of pain amongst both the group was recorded (3.16±1.38 hrs in group N and 2.63±1.19 hrs in group B). A significant difference was also recorded in the mean VAS at 15th (p-value=0.012) and 30th min (p-value= 0.017). Only 7 patients (11.6%) from group N, and 12 patients (20%) from group B required rescue agent (0.5 mcg/kg/ hour dexmedetomidine injection and 75 mg diclofenac sodium injection intravenous). Conclusion: Both 0.2 mg/kg nalbuphine and 0.2 mg/kg Butorphanol provide satisfactory results in terms of analgesic efficacy, sedation, hemodynamic and respiratory parameters, albeit, nalbuphine can be coined to be superior in terms of response to pin prick and duration of action. [ABSTRACT FROM AUTHOR]

Introduction: Middle Ear Surgeries (MESs) are generally performed using local anaesthesia under sedation. Butorphanol and nalbuphine both are well-known synthetic opioid with agonist-antagonist characteristics. However, no reports present a direct comparison of the analgesic efficacy of these two drugs. Aim: To evaluate analgesic efficacy of intravenous butorphanol versus intravenous nalbuphine during Monitored Anaesthesia Care (MAC) in patients undergoing tympanoplasty. Materials and Methods: This randomised clinical trial was conducted at the Department of Anaesthesiology, School of Medicine, D.Y. Patil Deemed to be University, Mumbai, Maharashtra India, from March 2018 to March 2021. Total 112 adult patients, undergoing tympanoplasty, were randomly allocated into two groups. Group N received 0.2 mg/kg nalbuphine intravenous (i.v.) and group B received i.v. 0.02 mg/kg butorphanol. The patients were then evaluated for analgesic efficacy, sedation, blood pressure, Mean Arterial Pressure (MAP), Heart Rate (HR), Respiratory Rate (RR), blood oxygen levels (SpO2), Visual Analogue Scale (VAS) Score, need for intraoperative rescue sedation/analgesia, duration of action and side-effects. Results: A significant difference was observed in the patients’ responses to needle prick, where only 8 (13.3%) subjects gave a vocal response in group N versus 22 (36.6%) in group B. A significant difference in the mean time of onset of pain amongst both the group was recorded (3.16±1.38 hours in group N and 2.63±1.19 hours in group B). A significant difference was also recorded in the mean VAS at 15th (p-value=0.012) and 30th min (p-value=0.017). Only 7 patients (11.6%) from group N, and 12 patients (20%) from group B required rescue agent (0.5 mcg/kg/hour dexmedetomidine injection and 75 mg diclofenac sodium injection intravenous). Conclusion: Both 0.2 mg/kg nalbuphine and 0.2 mg/kg butorphanolprovide satisfactory results in terms of analgesic efficacy, sedation, haemodynamic and respiratory parameters, albeit, nalbuphine can be coined to be superior in terms of response to pin prick and duration of action.

Introduction: Endoscopic procedures are usually performed under monitored anaesthesia care. Hypoxia could occur due to the sedative effects of drugs used during flexible endoscopic procedures and sharing of airway between endoscopist and anaesthesiologist. Administration of oxygen could reduce the incidence of hypoxia. Aims and Objectives: We aimed to study whether delivery of oxygen through nasal prongs or through a T-piece without an after-burner connected to a nasopharyngeal airway could reduce the incidence of hypoxia during monitored anaesthesia care for flexible endoscopic procedures. While our primary objective was to compare the incidence of hypoxia (oxygen saturation [SpO2] < 90% lasting for at least 15 s), our secondary objectives were to compare the level of sedation and incidence of adverse events. Patients and Methods: Sixty six patients (33 in each group) aged between 18 and 80 years were randomly allocated to one of two groups to receive oxygen through nasal prongs or through a T-piece without an after-burner connected to a nasopharyngeal airway. Drug requirement, SpO2 and adverse events were monitored pre-procedure and every 5 min thereafter till the end of the procedure. Results: There was no statistically significant difference in the mean SpO2 (P > 0.05), but the incidence of hypoxia was less in patients receiving oxygen through nasal prongs as compared to patients receiving oxygen through a T-piece without an after-burner connected to a nasopharyngeal airway (P < 0.05). Adverse events were found to be comparable between two groups. Conclusion: During flexible endoscopy under monitored anaesthesia care, oxygen delivery through nasal prongs results in a lower incidence of hypoxia as compared to oxygen delivery through a T-piece without an after-burner connected to a nasopharyngeal airway. [ABSTRACT FROM AUTHOR]

Endovascular therapy (EVT) is now standard of care for eligible patients with acute ischaemic stroke caused by large vessel occlusion in the anterior circulation. EVT can be performed with general anaesthesia (GA) or with monitored anaesthesia care, involving local anaesthesia with or without conscious sedation (LA/CS). Controversies remain regarding the optimal choice of anaesthetic strategy and observational studies suggested poorer functional outcome and higher mortality in patients treated under GA, essentially because of its haemodynamic consequences and the delay to put patients under GA. However, these studies are limited by selection bias, the most severe patients being more likely to receive GA and recent randomised trials and meta-analysis showed that protocol-based GA compared with LA/CS is significantly associated with less disability at 3 months. Unlike for intravenous thrombolysis, few data exist to guide management of blood pressure (BP) before and during EVT, but arterial hypotension should be avoided as long as the occlusion persists. BP targets following EVT should probably be adapted to the degree of recanalisation and the extent of ischaemia. Lower BP levels may be warranted to prevent reperfusion injuries even if prospective haemodynamic management evaluations after EVT are lacking. [ABSTRACT FROM AUTHOR]

Background: Deep brain stimulation (DBS) is an increasingly utilized technique to treat symptoms of neurological movement disorders, most commonly, Parkinson’s Disease. Patients and surgeons alike appreciate the minimally invasive nature of this procedure, as well as its reversibility. As these surgeries are being performed more often, it is becoming increasingly important to optimize our anesthetic management during these cases. Methods: We conducted a retrospective review of the DBS procedures that have been performed at our institution utilizing monitored anaesthesia care (MAC) via dexmedetomidine infusion to report on the frequency and type of perioperative complications as well as to assess the effectiveness of this technique. Results: A total of 150 patients and 174 lead placements were included in this study. Dexmedetomidine was the sole anaesthetic used in 85.6% of cases. The remaining cases used a combination of dexmedetomidine and adjuvant agents. A total of one perioperative complication was found in our series, resulting in a total complication rate percentage per patient of 0.6%.Conclusions: We found very few perioperative complications associated with the use of dexmedetomidine during these challenging cases. With its anxiolytic, sedative, and analgesic properties coupled with preservation of respiration and a short half-life, dexmedetomidine has ideal properties for DBS procedures.

Background: Tympanoplasty is routinely done under local anaesthesia with sedation due to various advantages. Systemic analgesics and sedatives are generally given to improve the patient comfort. Aim & Objectives: To determine the effectiveness of combination of midazolam and butorphanol for sedation and to assess the sedation technique using midazolam and butorphanol for tympanoplasty under monitored anaesthesia care. Material and Methods: One hundred patients scheduled for tympanoplasty under local anaesthesia were given bolus doses of intravenous midazolam 0.03 mg/kg and butorphanol 0.03 mg/kg followed by midazolam infusion at 0.01 mg/kg/hr. If required, additional bolus doses of 0.01 mg/kg of both midazolam and butorphanol were given to achieve desired sedation and analgesia. The total dosage of midazolam and butorphanol, vital parameters, sedation score using Ramsay sedation score, pain score and surgeon satisfaction score using Numeric rating scale were recorded. Results: Ninety nine patients underwent tympanoplasty satisfactorily with sedation technique. Only one patient needed conversion to general anaesthesia. The mean duration of surgery was 92.7±8.16 minutes. The total midazolam and butorphanol dosages were 2.45±0.233 mg and 1.65±0.179 mg respectively. The desired Ramsay Sedation Score (RSS) of 3 and pain score Numerical Rating Scale (NRS) = 2.82±0.72) were achieved within 4-8 minutes. No side effects of excessive sedation were observed. Conclusion: Combined use of midazolam and butorphanol in low doses produces adequate sedation for tympanoplasty under local anaesthesia without serious adverse effects.

Background and objectives Propofol-based sedation is one of the most commonly used methods for endoscopic retrograde cholangiopancreatography (ERCP). The commonest complications during ERCP are in the form of adverse cardiopulmonary events as a result of sedation. Etomidate has a more stable cardiovascular and respiratory profile than propofol and has been used for sedation in simple gastrointestinal endoscopy but has not been studied for procedural sedation in ERCP. The objective of the present study was to compare the safety and feasibility of etomidate and propofol for sedation during ERCP procedures. Methods This single-center, randomized trial included 100 American Society of Anesthesiologists (ASA) physical status class I to II patients who were scheduled for ERCP. All patients received midazolam 0.02 mg/kg, lignocaine (2%) 1 mg/kg, and fentanyl 1 µg/kg intravenously, followed by etomidate or propofol according to the group allocation. The primary outcome was to compare the mean arterial pressure (MAP) at various timepoints between the two groups and secondary outcomes were to compare oxygen saturation, induction and recovery times, and adverse events. Transient hypotension was defined as any decrease in MAP below 60 mmHg or 20% below the baseline. Transient hypoxia was defined as desaturation (saturation of peripheral oxygen (SpO2) <92%) lasting for more than 10 seconds requiring airway intervention. Results Fifty patients were enrolled in each group (Group E: etomidate and Group P: propofol). Transient hypotension occurred in eight (16%) patients in Group P, and two (4%) patients in Group E (P= 0.045). Baseline MAP was comparable between the two groups but was significantly lower in Group P at three timepoints during the study. Nine (18 %) patients in Group P had a transient hypoxic episode, compared to none in Group E (p= 0.006). The induction and recovery times were similar in the two groups. Conclusions Etomidate offers better hemodynamic and respiratory stability than propofol and can be recommended for use during ERCP in ASA I/II patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Dhingra et al.)

Even though, the incidence of Mitral Stenosis (MS) has reduced grossly, it still remains a health problem in developing countries and is the most common rheumatic valvular lesion encountered in pregnant patients. The already compromised cardiac status of a pregnant female deteriorates further by the presence of MS. So, pregnancy is a common situation during which untreated and frequently poorly tolerated MS are first diagnosed. Percutaneous Balloon Mitral Valvuloplasty (BMV) may be life saving in such a setting and a multidisciplinary approach in the management reduces the mortality and morbidity during the procedure. Anaesthetic management of such a procedure has hardly ever been reported. We report a case of a 23-year-old woman presenting at 28 weeks gestation with severe MS and severe pulmonary hypertension (52 mmHg) who underwent successful percutaneous BMV under monitored anaesthesia Care. The anaesthetic considerations in such situations are being discussed.

Background and Aims: Monitored anaesthesia care (MAC) is meant for procedures under local anaesthesia. Various drugs have been used for this purpose. The recently introduced alpha2 agonist, dexmedetomidine provides "conscious sedation" with adequate analgesia and minimal respiratory depression. Hence, the safety and efficacy of two doses of dexmedetomidine for sedation and analgesia were evaluated. Methods: A total of 90 patients were distributed in three groups of 30 each: Dexmedetomidine 0.5 μg/kg (DL), dexmedetomidine 1.0 μg/kg (DH) and normal saline (C). The initial loading dose was followed by maintenance infusion of 0.2-0.7 μg/kg/h of dexmedetomidine or equivalent volume of saline. Study drug was started at least 15 min before placement of local anaesthesia. Drugs were titrated to a target level of sedation (=3 on Ramsay sedation scale [RSS]). Midazolam 0.02 mg/kg for RSS < 3 and fentanyl 0.5 μg/kg were supplemented as required. The statistical analysis was performed using Chi-square test and mean and anova analysis. Results: In groups DL and DH fewer patients required supplemental midazolam, 56.7% (17/30) and 40% (12/30), compared with control, where 86.7% (26/30)needed midazolam supplements. P = 0.000. Both groups DL and DH required significantly less fentanyl (84.8 and 83.9 μg) versus control (144.2 μg). There was significantly increased ease of achieving and maintaining targeted sedation and analgesia in both dexmedetomidine groups when compared with placebo (P = 0.001). Adverse events observed with dexmedetomidine were bradycardia and hypotension. Conclusions: Dexmedetomidine in the doses studied was considered safe and effective sedative and analgesic for patients undergoing procedures under MAC.

There is disagreement regarding the benefits of goal-directed therapy in moderate-risk abdominal surgery. Therefore, we tested the hypothesis that the addition of non-invasive cardiac index and pulse pressure variation monitoring to mean arterial pressure-based goal-directed therapy would reduce the incidence of postoperative complications in patients having moderate-risk abdominal surgery. In this pragmatic multicentre randomised controlled trial, we randomly allocated 244 patients by envelope drawing in a 1:1 fashion, stratified per centre. All patients had mean arterial pressure, cardiac index and pulse pressure variation measured continuously. In one group, healthcare professionals were blinded to cardiac index and pulse pressure variation values and were asked to guide haemodynamic therapy only based on mean arterial pressure (control group). In the second group, cardiac index and pulse pressure variation values were displayed and kept within target ranges following a pre-defined algorithm (CI-PPV group). The primary endpoint was the incidence of postoperative complications within 30 days. One hundred and seventy-five patients were eligible for final analysis. Overall complication rates were similar (42/94 (44.7%) vs. 38/81 (46.9%) in the control and CI-PPV groups, respectively; p = 0.95). The CI-PPV group had lower mean (SD) pulse pressure variation values (9.5 (2.0)% vs. 11.9 (4.6)%; p = 0.003) and higher mean (SD) cardiac indices (2.76 (0.62) l min-1 .m-2 vs. 2.53 (0.66) l min-1 .m-2 ; p = 0.004) than the control group. In moderate-risk abdominal surgery, we observed no additional value of cardiac index and pulse pressure variation-guided haemodynamic therapy to mean arterial pressure-guided volume therapy with regard to postoperative complications. [ABSTRACT FROM AUTHOR]

Introduction: Tympanoplasty for the surgical correction of chronic suppurative otitis media is one of the most comman ENT surgical procedures. This surgery can be done both under general anaesthesia and local anaesthesia with sedation. Dexmedetomidine is said to have both analgesic and sedative properties. The aim of this study is to compare the results of monitored local anaesthesia with dexmedetomidine with general anaesthesia in patients undergoing tympanoplasty to find out the better efficacious anaesthesia for this surgery. Methods: 100 patients were planned for tympanoplasty were taken up for this study. 50 patients were operated under general anaesthesia and remaining 50 patients were operated under monitored local anaesthesia with dexmedetomidine. The results were evaluated intraoperatively and postoperatively for duration of surgery, hemodynamic stability and complications. Patient's and surgeon's satisfaction was also evaluated. Results: The results showed that there was lesser operating time, lesser complications and more hemodynamic stability in patients operated under monitored anaesthetic care with dexmedetomidine than under general anaesthesia. There was better surgeon and patient satisfaction in dexmedetomidine group and there was no requirement of general anaesthesia afterward. Conclusion: It can be concluded that dexmedetomidine is a safe and effective sedative for tympanoplasty done under monitored local anaesthesia and can be preferred method of choice over general anaesthesia. [ABSTRACT FROM AUTHOR]

Purpose: Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC., Materials and Methods: We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC)., Results: We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l 1 regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively., Conclusion: We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2023.)

Hyperemesis gravidarum (HG) is one of the common unique liver diseases that occurs during pregnancy. Mild cases can be spontaneously resolved in time but severe cases usually require supportive medical treatment to relieve symptoms. Moreover, differential diagnosis may be required in severe cases that manifest with persistent nausea-vomiting, dehydration and weight loss refractory to treatment. Thus, to rule out any gastrointestinal pathology, this case was referred to the outpatient anaesthesia clinic after the first unsuccessful awake endoscopy attempt without sedation. Therefore, anaesthetic support for endoscopy of a pregnant woman with severe HG was presented in this case report. [ABSTRACT FROM AUTHOR]

Background and Aims: Monitored anaesthesia care (MAC) is meant for procedures under local anaesthesia. Various drugs have been used for this purpose. The recently introduced alpha2 agonist, dexmedetomidine provides "conscious sedation" with adequate analgesia and minimal respiratory depression. Hence, the safety and efficacy of two doses of dexmedetomidine for sedation and analgesia were evaluated. Methods: A total of 90 patients were distributed in three groups of 30 each: Dexmedetomidine 0.5 μg/kg (DL), dexmedetomidine 1.0 μg/kg (DH) and normal saline (C). The initial loading dose was followed by maintenance infusion of 0.2-0.7 μg/kg/h of dexmedetomidine or equivalent volume of saline. Study drug was started at least 15 min before placement of local anaesthesia. Drugs were titrated to a target level of sedation (=3 on Ramsay sedation scale [RSS]). Midazolam 0.02 mg/kg for RSS < 3 and fentanyl 0.5 μg/kg were supplemented as required. The statistical analysis was performed using Chi-square test and mean and anova analysis. Results: In groups DL and DH fewer patients required supplemental midazolam, 56.7% (17/30) and 40% (12/30), compared with control, where 86.7% (26/30)needed midazolam supplements. P = 0.000. Both groups DL and DH required significantly less fentanyl (84.8 and 83.9 μg) versus control (144.2 μg). There was significantly increased ease of achieving and maintaining targeted sedation and analgesia in both dexmedetomidine groups when compared with placebo (P = 0.001). Adverse events observed with dexmedetomidine were bradycardia and hypotension. Conclusions: Dexmedetomidine in the doses studied was considered safe and effective sedative and analgesic for patients undergoing procedures under MAC. [ABSTRACT FROM AUTHOR]

Presently technologically advanced endoscopes offer more and more diagnostic and operative opportunities. Deciding for sedation and general anaesthesia one should consider patient's characteristic (risk profile, any comorbidities, preferences), and nature of endoscopic intervention (reason, duration, invasiveness and complexity). The guidelines of the Polish Society of Anaesthesiology and Intensive Therapy determining the principles, conditions and administrative aspects of anaesthesiology and intensive therapy services to ensure the safety of patients restrict provision of health care services in anaesthesia, intensive therapy, resuscitation, management of pain irrespective of its cause, and sedation to a physician: a specialist in anaesthesiology and intensive care, an anaesthesiologist and a resident in training (a physician specializing in anaesthesiology and intensive therapy)if directly supervised by a specialist in anaesthesiology and intensive therapy. All patients undergoing planned degree of sedation that affects or eliminates life-preserving reflexes and planned general anaesthesia with loss of consciousness and protective reflexes outside operating theatre should be left to anaesthetists, who are responsible for adequacy of anaesthetic equipment, patient's preparation and monitoring according to generally approved standards. This publication does not discuss sedation provided by non-anaesthetists. [ABSTRACT FROM AUTHOR]

Background: Monitored anaesthesia care (MAC) typically involves administration of local anaesthesia in combination with IV sedatives, anxiolytic and/or analgesic drugs which is a common practice during various ENT surgical procedures. Aims: To compare the effectiveness and safety profile of clonidine against midazolam as an intravenously administered agent for MAC. Settings and design: Randomized, double blind, prospective study. Methodology: Sixty patients undergoing ENT surgery under MAC were divided into two groups of 30 patients each. The patients in Group C received clonidine 2 mcg/kg IV and in Group M received midazolam 20 mcg/kg IV over 10 min. Ramsay sedation score, requirement of intraoperative rescue sedation (propofol) and analgesic (diclofenac infusion), postoperative visual analogue score & analgesic requirement (tramadol), adverse effects, recovery profile (Aldrete Score) and satisfaction scores of patients and surgeon were recorded. Data were analysed by chi-square, student t test and analysis of variance using Epi info 6 with p value <0.05 as significant. Results: Mean Ramsay sedation score (RSS) was significantly more in Group M (2.50 ± 0.73) as compared to Group C (1.80 ± 0.85), p = 0.001. Intraoperative rescue sedation with propofol infusion (if RSS<3) was required by significantly higher number of patients in Group C (n=19, 63.4%) than in Group M (n=6, 20%), P=0.001. Intraoperative rescue analgesic requirement was significantly more in Group M (n =21, 70%) as compared to Group C (n=11, 36.6%), p=0.009. Intraoperative bleeding score was significantly less in Group C (1.93±0.80) than in group M (2.43±0.73), P=0.014. Postoperative VAS score was also significantly less in Group C than in Group M (2.28±1.9 vs. 3.28±1.81, P=0.041). Both patients and surgeon were more satisfied in Group C than in Group M (p=0.010 & 0.019 respectively). All patients had Aldrete score of 10 at the end of surgery in both groups. Conclusion: We conclude that clonidine along with rescue sedation using propofol infusion can be a better alternative to midazolam in MAC since it provides a calm patient with better intraoperative & postoperative analgesia, and a bloodless surgical field leading to increased satisfaction of both patient and surgeon. [ABSTRACT FROM AUTHOR]

Introduction: This study investigates the effects of the monitored anaesthesia care associated with subarachnoid anesthesia in children and estabilishment of an optimal method, by comparing two techniques of intravenous supplementation: sedation with Midazolam versus analgosedation with Ketamine and Propofol. Patients and methods: This study included 200 patients with ages between one and 17 years old, who have undergone spinal anaesthesia before a surgical intervention on the inferior abdomen, between January and December 2009. Half of the patients have been given Midazolam either in premedication and during surgery (group A) and the others have been premedicated with Ketamine and continuously sedated with Propofol, intraoperatively (group B). Results and discussions: During the lumbar puncture, children who have undergone premedication with Ketamine were asleep and didn't oppose the manipulation of the lumbar spine (group A) and the others, premedicated with Midazolam have presented either a thorax retraction or a contraction of the paravertebral muscles (group B). While operating, in both groups the following have been registered: the same grade of sedation, minimal modifications of the blood pressure and of the pulse; there haven't been any significant fluctuations of the respiratory rate or undesirable side effects. The introduction of monitored anesthesia care with analgosedation in association with subarachnoid anesthesia proved to be better comparatively to sedation offering a supperior grade of comfort, either to the child, due to provided analgesia and to the anesthetist, due to thorax immobility for a successfully maneuver. Conclusions: The monitored anaesthesia care with Ketamine and Propofol intensifi es subarachnoid anaesthesia in children and might be considered the optimal method for undergoing underumbilical surgery. [ABSTRACT FROM AUTHOR]

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Objective: Chronic subdural haematoma (CSDH) is a common neurosurgical problem, and treatment includes evacuation of the haematoma by burr hole drainage. Commonly, these procedures are performed under local anaesthesia, general anaesthesia or, recently, with monitored anaesthesia care (MAC). We compared dexmedetomidine- and propofol-based sedation along with scalp nerve block for burr hole evacuation of CSDH., Methods: In this prospective randomised study, 62 patients were divided into the following two groups of 31 patients each: Group D and Group P. Group D received dexmedetomidine 1 μg kg -1 over 10 minutes as a loading dose, followed by 0.2-0.7 μg kg -1 hr -1 . Group P received propofol 1 mg kg -1 over 10 minutes as a loading dose, followed by 1-3 mg kg -1 hr -1 . The heart rate (HR) and blood pressure were measured at different intervals. The recovery parameter and satisfaction score were also recorded., Results: There were no significant differences noted in the demographic profile. A significant decrease in HR compared to preoperative value was seen in Group D compared to Group P. Blood pressure values were statistically significantly lower in both study groups, compared to preoperative values during the whole procedure and after surgery (p<0.05). Time to achieve modified Aldrete score of 9-10 was not significantly different between the groups (p=0.354). Surgeon satisfaction was significantly better in Group D compared to Group P (p<0.05), but patient satisfaction was similar between the groups (p=0.364)., Conclusion: Dexmedetomidine-based sedation compared to propofol, along with scalp block for MAC in patients undergoing burr hole evacuation of CSDH is associated with haemodynamic stability and greater surgeon satisfaction., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Background: This study aimed to compare remifentanil and ketamine-propofol in terms of hemodynamic response, duration of recovery and patient satisfaction in operative hysteroscopy cases who underwent monitored anaesthesia care in combination with paracervical block., Methods: Monitored anaesthesia care was used in 60 ASA I-II female patients. The patients were divided into two groups as remifentanil (Group R) and ketamine-propofol (Group K-P). The hemodynamic effects of remifentanil and ketamine-propofol, and duration of recovery were recorded and compared. The patient satisfaction was also recorded and the two groups were compared., Results: Age, body mass, ASA status, duration of anaesthesia and type of surgery were found to be similar between groups. The time of the Aldrete score reaching ≥ 9 was found to be shorter in Group R when compared with Group KP (Group R: 4.1 ± 1.9 min, Group K-P: 6.1 ± 2.6 min) (P< 0.05). The incidence of postoperative nausea and vomiting was found to be significantly higher in the remifentanil group (P ≤ 0.05). When the groups were compared in terms of patient satisfaction, in both groups this was found to be similar., Conclusion: Sedation with remifentanil combined with a paracervical block during monitored anaesthesia care provides early recovery with effective sedation and analgesia in hysteroscopy procedures.