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Concept: Sedation

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Virtual reality (VR) distraction is a nonpharmacological method to prevent acute pain that has not yet been thoroughly explored for anesthesiology. We present our experience using VR distraction to decrease routine intravenous sedation for patients undergoing preoperative perineural catheter insertion.

Concepts: Anesthesia, Opioid, Anatomy, Virtual reality, Sedation

27

When abstinence is an appropriate goal, controlled studies and systematic reviews confirm that rapid, antagonist-precipitated opiate withdrawal procedures are the most effective and cost effective methods of initiating abstinence, and naltrexone (NTX) maintenance. While ‘rapid’ withdrawal, better conceptualised as Rapid Antagonist Induction (RAI), can often be humanely achieved with modest sedation levels, we present three case histories to support our argument that for some patients, general anaesthesia (GA), or techniques of intravenous sedation (IVS) that approach GA, are essential for safety and success. This includes patients with intercurrent disease (e.g. epilepsy or insulin-dependent diabetes) but also those with severe withdrawal phobia after previous distressing experiences. We discuss the history of the procedure. The dangers of RAI under GA or IVS in experienced hands have been exaggerated and the appropriate expertise should be more easily available. Patients and clinicians readily accept risks of major surgery for the excessive intake of food that causes most obesity. Similar risk-acceptance exists in cosmetic surgery and obstetrics. The increasing use and effectiveness of long-acting implants or depot-injections of NTX for relapse-prevention have largely solved compliance problems that undermined the potential of oral NTX. Their ability to prevent opiate overdose in abstinent, non-tolerant patients also strengthens arguments both for offering RAI as a therapeutic option and for reducing psychological, professional and practical barriers to using it.

Concepts: Diabetes mellitus, Hospital, Surgery, Anesthesia, Human sexuality, Logic, Sedation, Etomidate

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BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is widely accepted as the preferred procedure to establish long-term enteral feeding. OBJECTIVE: To learn the long-term outcomes of the patients who have undergone PEG placement, we reviewed our experience with children who underwent this procedure in our institute. METHODS: A total of 83 pediatric patients (42 males and 41 females), who were aged from 3 months to 20 years, underwent PEG insertion in National Taiwan University Hospital from January 2000 to April 2011. The underlying diseases of the patients receiving PEG were neurological dysfunction (n = 67), metabolic disorders (n = 9), gastrointestinal disease (n = 2), and congenital heart disease (n = 1). This procedure was performed under intravenous sedation or under general anesthesia. Prophylactic antibiotics were administered for 1 day. Tube feeding began 24 hours after the PEG placement. The body weight of the patients was recorded 1 day before PEG placement and at least 6 months after PEG placement. RESULTS: The weight-for-age Z-score before and at 6 months after PEG placement were -1.5 ± 2.0 and -0.9 ± 2.1, respectively, which was statistically significant (paired t test, p = 0.006). The catch-up growth was recorded after PEG placement. Complications of PEG in our patients included cellulitis at the gastrostomy wound (n = 14), dislodgement of the tube (n = 17), and persistent gastrocutaneous fistula (n = 3). The PEG tube was removed permanently in seventeen patients because they resumed an adequate oral intake. During the follow-up period, 14 patients died of an underlying disease or infection. CONCLUSION: Our experience confirmed that PEG placement is a good long-term route for nutritional supply with no serious complications in children.

Concepts: Feeding tube, Anesthesia, Sedation, Esophagogastroduodenoscopy, Endoscopy, Percutaneous endoscopic gastrostomy, Gastrostomy, Enteral feeding

27

RATIONALE: Automated weaning has not been compared to a paper-based weaning protocol in North America. OBJECTIVE: We conducted a pilot randomized trial comparing Automated Weaning and Protocolized Weaning in critically ill adults to evaluate clinician compliance and acceptance of the study protocols, recruitment, and impact on outcomes. METHODS: From August 2007 to October 2009, we enrolled critically ill adults requiring > 24 hours of mechanical ventilation and at least partial reversal of the condition precipitating respiratory failure at 9 Canadian intensive care units. We randomized patients who tolerated at least 30 minutes of pressure support and either failed or were not yet ready to undergo a spontaneous breathing trial to Automated or Protocolized Weaning. Both groups utilized pressure support, included spontaneous breathing trials, used a common PEEP/FiO2 chart, sedation protocol and criteria for extubation, reintubation and noninvasive ventilation. RESULTS: We recruited 92 patients (49 Automated, 43 Protocolized) over 26 months. Adherence to assigned weaning protocols and extreme sedation scale scores fell within prespecified thresholds. Combined physician/RT and RN acceptance scores of the study weaning and sedation protocols, respectively, were not significantly different. Automated Weaning patients had significantly shorter median times to first successful breathing trial (1.0 vs. 4.0 d, p<0.0001), extubation (3.0 vs. 4.0 d, p=0.02), successful extubation (4.0 vs. 5.0 d, p=0.01) and underwent fewer tracheostomies and episodes of protracted ventilation. CONCLUSIONS: Compared to a standardized protocol, Automated Weaning was associated with promising outcomes that warrant further investigation. Minor protocol modifications may increase compliance, facilitate recruitment, and enhance feasibility.

Concepts: Epidemiology, Medical terms, Randomized controlled trial, Intensive care medicine, Mechanical ventilation, Failure, Sedation, Spontaneous breathing trial

26

Delirium is frequently missed in older emergency department (ED) patients. Brief (<2 minutes) delirium assessments have been validated for the ED, but some ED health care providers may consider them to be cumbersome. The Richmond Agitation Sedation Scale (RASS) is an observational scale that quantifies level of consciousness and takes less than 10 seconds to perform. The authors sought to explore the diagnostic accuracy of the RASS for delirium in older ED patients.

Concepts: Health care, Health care provider, Healthcare, Hospital, Illness, Psychometrics, Performance, Sedation

21

To compare the prevalence and characteristics of facility laws governing abortion provision specifically (targeted regulation of abortion providers [TRAP] laws); office-based surgeries, procedures, sedation or anesthesia (office interventions) generally (OBS laws); and other procedures specifically.

Concepts: Law, Human rights, Anesthesia, Regulation, Sedation, Law of the United States, Administrative law

13

Daily interruption of sedative therapy and limitation of deep sedation have been shown in several randomized trials to reduce the duration of mechanical ventilation and hospital length of stay, and to improve the outcome of critically ill patients. However, patients with severe acute brain injury (ABI; including subjects with coma after traumatic brain injury, ischaemic/haemorrhagic stroke, cardiac arrest, status epilepticus) were excluded from these studies. Therefore, whether the new paradigm of minimal sedation can be translated to the neuro-ICU (NICU) is unclear. In patients with ABI, sedation has ‘general’ indications (control of anxiety, pain, discomfort, agitation, facilitation of mechanical ventilation) and ‘neuro-specific’ indications (reduction of cerebral metabolic demand, improved brain tolerance to ischaemia). Sedation also is an essential therapeutic component of intracranial pressure therapy, targeted temperature management and seizure control. Given the lack of large trials which have evaluated clinically relevant endpoints, sedative selection depends on the effect of each agent on cerebral and systemic haemodynamics. Titration and withdrawal of sedation in the NICU setting has to be balanced between the risk that interrupting sedation might exacerbate brain injury (e.g. intracranial pressure elevation) and the potential benefits of enhanced neurological function and reduced complications. In this review, we provide a concise summary of cerebral physiologic effects of sedatives and analgesics, the advantages/disadvantages of each agent, the comparative effects of standard sedatives (propofol and midazolam) and the emerging role of alternative drugs (ketamine). We suggest a pragmatic approach for the use of sedation-analgesia in the NICU, focusing on some practical aspects, including optimal titration and management of sedation withdrawal according to ABI severity.

Concepts: Stroke, Traumatic brain injury, Intracranial pressure, Neurology, Midazolam, Benzodiazepine, Sedation, Sedative

7

BACKGROUND: Traditionally, the use of ketamine for patients with traumatic brain injuries is contraindicated due to the concern of increasing intracranial pressure (ICP). These concerns, however, originated from early studies and case reports that were inadequately controlled and designed. Recently, the concern of using ketamine in these patients has been challenged by a number of published studies demonstrating that the use of ketamine was safe in these patients. AIMS: The purpose of this article was to review the current literature in regards to using ketamine in patients with traumatic brain injuries in different clinical settings associated with anesthesia, as well as review the potential mechanisms underlying the neuroprotective effects of ketamine. RESULTS: Studies examining the use of ketamine for induction, maintenance, and sedation in patients with TBI have had promising results. The use of ketamine in a controlled ventilation setting and in combination with other sedative agents has demonstrated no increase in ICP. CONCLUSIONS: The role of ketamine as a neuroprotective agent in humans remains inconclusive and adequately powered; randomized controlled trials performed in patients undergoing surgery for traumatic brain injury are necessary.

Concepts: Randomized controlled trial, Traumatic brain injury, Surgery, Intracranial pressure, Cerebrospinal fluid, Sedation, Brain herniation, Sedative

6

PURPOSE: To ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality. METHODS: We conducted a multicentre prospective longitudinal cohort study in 11 Malaysian hospitals including medical/surgical patients (n = 259) who were sedated and ventilated ≥24 h. Patients were followed from ICU admission up to 28 days in ICU with 4-hourly sedation and daily delirium assessments and 180-day mortality. Deep sedation was defined as Richmond Agitation Sedation Score (RASS) ≤-3. RESULTS: The cohort had a mean (SD) age of 53.1 (15.9) years and APACHE II score of 21.3 (8.2) with hospital and 180-day mortality of 82 (31.7 %) and 110/237 (46.4 %). Patients were followed for 2,657 ICU days and underwent 13,836 RASS assessments. Midazolam prescription was predominant compared to propofol, given to 241 (93 %) versus 72 (28 %) patients (P < 0.0001) for 966 (39.6 %) versus 183 (7.5 %) study days respectively. Deep sedation occurred in (182/257) 71 % patients at first assessment and in 159 (61 %) patients and 1,658 (59 %) of all RASS assessments at 48 h. Multivariable Cox proportional hazard regression analysis adjusting for a priori assigned covariates including sedative agents, diagnosis, age, APACHE II score, operative, elective, vasopressors and dialysis showed that early deep sedation was independently associated with longer time to extubation [hazard ratio (HR) 0.93, 95 % confidence interval (CI) 0.89-0.97, P = 0.003], hospital death (HR 1.11, 95 % CI 1.05-1.18, P < 0.001) and 180-day mortality (HR 1.09, 95 % CI 1.04-1.15, P = 0.002), but not time to delirium (HR 0.98, P = 0.23). Delirium occurred in 114 (44 %) of patients. CONCLUSION: Irrespective of sedative choice, early deep sedation was independently associated with delayed extubation and higher mortality, and thus was a potentially modifiable risk in interventional trials.

Concepts: Cohort study, Longitudinal study, Epidemiology, Hospital, Relative risk, Midazolam, Sedation, Sedative

5

In the absence of a universal definition of light or deep sedation, the level of sedation that conveys favorable outcomes is unknown. We quantified the relationship between escalating intensity of sedation in the first 48 hours of mechanical ventilation and 180-day survival, time to extubation, and delirium.

Concepts: Cohort study, Longitudinal study, Epidemiology, Light, Mechanical ventilation, The First 48, Sedation, A&E Network