Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology.

PURPOSE: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. MATERIALS AND METHODS: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). RESULTS: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. CONCLUSIONS: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.

Sedation scales and measures--a literature review.

The monitoring and assessment of the degree of conscious sedation experienced by patients is important for both clinical practice and in research. Whereas clinical monitoring remains the gold standard for safety in patient care, numerous measures are available to supplement this and to provide quantitative data on level of sedation. This manuscript provides an overview of existing measures of the degree of sedation. Scales that have been used in published research were identified from a search of Medline and Google Scholar, and for each scale we identified the characteristics of the scale and degree to which the reliability and validity of the scale had been measured.

Sedation of the pediatric patient.

Children's behavior during dental treatment is often unpredictable. Many techniques for behavior management have been developed and include both pharmacologic and nonpharmacologic methods. Pharmacologic management with sedation has been shown to be an important adjunct in treating the fearful, uncooperative or precommunicative patient. This article reviews the definitions, levels, techniques and pharmacology of typical drugs used for sedation. The protocols for safe management of children before, during and after sedation are also discussed.

Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials.

CONTEXT: Long-term sedation with midazolam or propofol in intensive care units (ICUs) has serious adverse effects. Dexmedetomidine, an α(2)-agonist available for ICU sedation, may reduce the duration of mechanical ventilation and enhance patient comfort. OBJECTIVE: To determine the efficacy of dexmedetomidine vs midazolam or propofol (preferred usual care) in maintaining sedation; reducing duration of mechanical ventilation; and improving patients' interaction with nursing care. DESIGN, SETTING, AND PATIENTS: Two phase 3 multicenter, randomized, double-blind trials carried out from 2007 to 2010. The MIDEX trial compared midazolam with dexmedetomidine in ICUs of 44 centers in 9 European countries; the PRODEX trial compared propofol with dexmedetomidine in 31 centers in 6 European countries and 2 centers in Russia. Included were adult ICU patients receiving mechanical ventilation who needed light to moderate sedation for more than 24 hours (midazolam, n = 251, vs dexmedetomidine, n = 249; propofol, n = 247, vs dexmedetomidine, n = 251). INTERVENTIONS: Sedation with dexmedetomidine, midazolam, or propofol; daily sedation stops; and spontaneous breathing trials. MAIN OUTCOME MEASURES: For each trial, we tested whether dexmedetomidine was noninferior to control with respect to proportion of time at target sedation level (measured by Richmond Agitation-Sedation Scale) and superior to control with respect to duration of mechanical ventilation. Secondary end points were patients' ability to communicate pain (measured using a visual analogue scale [VAS]) and length of ICU stay. Time at target sedation was analyzed in per-protocol population (midazolam, n = 233, vs dexmedetomidine, n = 227; propofol, n = 214, vs dexmedetomidine, n = 223). RESULTS: Dexmedetomidine/midazolam ratio in time at target sedation was 1.07 (95% CI, 0.97-1.18) and dexmedetomidine/propofol, 1.00 (95% CI, 0.92-1.08). Median duration of mechanical ventilation appeared shorter with dexmedetomidine (123 hours [IQR, 67-337]) vs midazolam (164 hours [IQR, 92-380]; P = .03) but not with dexmedetomidine (97 hours [IQR, 45-257]) vs propofol (118 hours [IQR, 48-327]; P = .24). Patients' interaction (measured using VAS) was improved with dexmedetomidine (estimated score difference vs midazolam, 19.7 [95% CI, 15.2-24.2]; P < .001; and vs propofol, 11.2 [95% CI, 6.4-15.9]; P < .001). Length of ICU and hospital stay and mortality were similar. Dexmedetomidine vs midazolam patients had more hypotension (51/247 [20.6%] vs 29/250 [11.6%]; P = .007) and bradycardia (35/247 [14.2%] vs 13/250 [5.2%]; P < .001). CONCLUSIONS: Among ICU patients receiving prolonged mechanical ventilation, dexmedetomidine was not inferior to midazolam and propofol in maintaining light to moderate sedation. Dexmedetomidine reduced duration of mechanical ventilation compared with midazolam and improved patients' ability to communicate pain compared with midazolam and propofol. More adverse effects were associated with dexmedetomidine. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT00481312, NCT00479661.

Pharmacodynamic considerations for moderate and deep sedation.

Moderate and deep sedation can be provided using various classes of drugs, each having unique mechanisms of action. While drugs within a given classification share similar mechanisms and effects, certain classes demonstrate superior efficacy but added concern regarding safety. This continuing education article will highlight essential principles of pharmacodynamics and apply these to drugs commonly used to produce moderate and deep sedation.

The use of sedation in the dental outpatient setting: a web-based survey of dentists.

There were 7276 e-mail requests sent to dentists in the United States and Canada requesting participation in a short web-based survey to update earlier information regarding the use of dental outpatient sedation. Participants were questioned regarding their use of dental outpatient sedation, including the frequency of use, type of sedation used, route ofadministration, medications used, physiologic monitoring employed, and availability qfantagonist medications and an automated external defibrillator In comparison to earlier studies, the use of outpatient dental sedation continues to change. The use of enteral sedation may be increasing, but now is differentiated by minimal and moderate sedation with different training requirements. The use of parenteral sedation by practitioners also appears to be increasing.

Validity and reliability of an intuitive conscious sedation scoring tool: the nursing instrument for the communication of sedation.

OBJECTIVE: To develop a symmetrical 7-level scale (+3, "dangerously agitated" to -3, "deeply sedated") that is both intuitive and easy to use, the Nursing Instrument for the Communication of Sedation (NICS). DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Mixed surgical, medical intensive care unit (ICU) population. INTERVENTIONS: Patient assessment. MEASUREMENTS AND MAIN RESULTS: Criterion, construct, face validity, and interrater reliability of NICS over time and comparison of ease of use and nursing preference between NICS and four common intensive care unit sedation scales. A total of 395 observations were performed in 104 patients (20 intubated [INT], 84 non intubated) by 59 intensive care unit providers. Criterion validity was tested comparing NICS WITH the 8-point level of arousal scale, demonstrating excellent correlation (rs = .96 overall, .95 non intubated, 0.85 intubated, all p < .001). Construct validity was confirmed by comparing NICS with the Richmond Agitation-Sedation Scale, demonstrating excellent correlation (rs = .98, p < .001). Face validity was determined in a blinded survey of 53 intensive care unit nurses evaluating NICS and four other sedation scales. NICS was highly rated as easy to score, intuitive, and a clinically relevant measure of sedation, and agitation and was preferred overall (74% NICS, 17% Richmond Agitation-Sedation Scale, 11% Other, p < .001 NICS vs. Richmond Agitation-Sedation Scale). Interrater reliability was assessed, using the five scales at three timed intervals, during which 37% of patients received sedative medication. The mean NICS score consistently correlated with each of the other scales over time with an rs of >.9. Using the intraclass correlation coefficient as a measure of Interrater reliability, NICS scored as high, or higher than Richmond Agitation-Sedation Scale, Riker Sedation-Agitation Scale, Motor Activity Assessment Scale, or Ramsay over the three time periods. CONCLUSION: NICS is a valid and reliable sedation scale for use in a mixed population of intensive care unit patients. NICS ranked highest in nursing preference and ease of communication and may thus permit more effective and interactive management of sedation.

Effect of epidural neuraxial blockade-dependent sedation on the Ramsay Sedation Scale and the composite auditory evoked potentials index in surgical intensive care patients.

BACKGROUND/PURPOSE: Peripheral deafferentation induced by neuraxial anesthesia reduces the degree of cortical arousal. This study investigated whether epidural analgesia blockade decreased sedation, as measured by the rapidly extracted auditory evoked potentials index, A-line autoregressive index (AAI) and Ramsay Sedation Scale (RSS) in sedated surgical intensive care patients, and looked at whether this was a concentration-dependent effect of lidocaine. METHODS: Forty patients underwent major lower abdominal surgery and received epidural analgesia in the surgical intensive care unit. Patients were continuously sedated with propofol to achieve an RSS value of 3, randomly divided into two groups, and received epidural analgesia with 10 mL of 0.5% or 1% lidocaine. Sedation was evaluated using the RSS and AAI, and analgesia was evaluated using a visual analog scale (VAS). RSS, AAI, electromyography (EMG) activity of AAI and VAS values were recorded at 5 minutes before and 30, 60 and 90 minutes after epidural lidocaine administration. RESULTS: Epidural 0.5% lidocaine produced a reduction of AAI, EMG and VAS at 30, 60 and 90 minutes after administration. For 1% epidural lidocaine administration, AAI, EMG and VAS were also reduced at 30, 60 and 90 minutes after epidural lidocaine administration. However, there was no difference in the AAI between the two concentrations; moreover, no significant change was observed in the RSS. CONCLUSION: Epidural lidocaine analgesia could potentiate sedation in patients evaluated by the AAI, but had no effect on the RSS. The present study suggests that the AAI could provide an objective and more precise index than the RSS in evaluation of sedation level in patients who are undergoing epidural pain management in the intensive care unit.

Is higher ASA class associated with an increased incidence of adverse events during procedural sedation in a pediatric emergency department?

OBJECTIVE: To prospectively investigate whether American Society of Anesthesiologists (ASA) class, as assigned by nonanesthesiologists, is associated with adverse events during procedural sedation in a pediatric emergency department. METHODS: A prospectively collected database of children aged 0 to 21 years undergoing procedural sedation in the emergency department of an urban, tertiary care, children's hospital was retrospectively reviewed. This database included clinical and demographic characteristics, including assigned ASA class. It also included information relative to the procedure, the sedation, and any complications related to the sedation. Complications were defined a priori as persistent oxygen desaturation to less than 93% on pulse oximetry requiring supplemental oxygen, bronchospasm, dizziness, apnea, seizure, hiccoughs, laryngospasm, stridor, arrhythmia, hypotension, rash, vomiting, aspiration, or a disinhibition/agitation/dysphoria emergence reaction. Main outcome measure was the incidence of complications relative to ASA class. RESULTS: Procedural sedation was performed in the emergency department 1232 times during the study period; 30 sedations did not have either ASA class or occurrence of a complication recorded. Thus, 1202 sedations were included in the study. Nine hundred eighty-eight patients were classified as ASA class 1, whereas 214 were classified as ASA class 2 or greater. There were a total of 215 adverse events in the study population. Most of these were hypoxia (185 total) and were more likely to occur in patients with an ASA class 2 or greater (P = 0.021). CONCLUSIONS: Adverse events during procedural sedation are more common in patients with higher ASA class.

Evaluation of the compliance between EEG monitoring (Bispectral IndexTM) and Ramsey Sedation Scale to measure the depth of sedation in the patients who underwent procedural sedation and analgesia in the emergency department.

BACKGROUND: This study aimed to investigate the compliance between electroencephalogram monitoring (Bispectral Index, BIS) and Ramsay Sedation Scale (RSS) to measure the depth of sedation in patients who underwent procedural sedation and analgesia (PSA) in an emergency department. This study also aimed to investigate the usefulness of this compliance for early diagnosis of complications. METHODS: A total of 54 consecutive patients during PSA in the emergency department were included in this study. The BIS and RSS scores at regular intervals and also all complications and interventions of these patients were evaluated. The compliance between the BIS and the RSS score was evaluated. The BIS scores of cases with complication and without complication were compared. RESULTS: The BIS and RSS scores exhibited a high correlation was detected between the average BIS and RSS scores at each time interval (r=-0.989, p<0.001). The BIS scores of the complicated and uncomplicated cases were different at 15 min after the procedure (p=0.019). The cases were divided into two groups according to the BIS scores <70 and ≥70; complication rates were higher in the BIS score <70 group during the procedure (p=0.037). CONCLUSION: In our study, a high correlation was detected between BIS monitoring and RSS scores. BIS monitoring for PSA can be used as a full-time, objective, and an alternative technique for person-dependent clinical scales and also as an indicator for early diagnosis of complications.

A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial.

OBJECTIVE: Protocolized sedation (PS) and daily sedative interruption (DI) in critically ill patients have both been shown to shorten the durations of mechanical ventilation (MV) and intensive care unit (ICU) stay. Our objective was to determine the safety and feasibility of a randomized trial to determine whether adults managed with both PS + DI have a shorter duration of MV than patients managed with PS alone. DESIGN: Prospective randomized, concealed, unblinded, multicenter, pilot trial. SETTING: Three university-affiliated medical-surgical ICUs. PATIENTS: Sixty-five adults anticipated to require MV >48 hrs and receiving sedative/analgesic infusions. INTERVENTIONS: Patients were randomized to PS alone, or PS + DI. PS was implemented by bedside nurses; sedatives/analgesics were titrated to achieve Sedation Agitation Score (SAS) 3-4. The PS + DI group also had infusions interrupted daily until the patients awoke. MEASUREMENTS AND MAIN RESULTS: Diagnosis, age [mean +/- SD] (53 +/- 18.3 vs. 62.1 +/- 16.7 yrs) and Acute Physiology and Chronic Health Evaluation II (27.7 +/- 8.4 vs. 26.6 +/- 8.4) were similar in the PS and PS + DI groups, respectively. The median duration of MV in the PS and PS + DI groups was 8.0 vs. 10.5 days, and ICU stay was 10.0 vs. 13.0 days, respectively. The SAS was within target range (3-4) in 59% of 9,611 measurements, and within an acceptable range (2-5) in 86% of measurements. Self-assessed nursing and respiratory therapist workload was low in the majority of the cohort. Adverse events were similar in both groups. Patient recruitment was slower than projected (1.5 patients/mo). CONCLUSION: This pilot trial comparing PS vs. PS + DI confirmed the safety and acceptability of the sedation protocol and DI, and guided important modifications to the protocol, thus enhancing the feasibility of a future multicenter trial. This trial was not designed to detect small but significant differences in clinically important outcomes.

Effect of a nursing-implemented sedation protocol on weaning outcome.

OBJECTIVE: To evaluate the effect of the implementation of a nursing-driven protocol of sedation on duration of intubation. DESIGN: Before-and-after prospective study. SETTING: 18-bed medical-surgical intensive care unit. PATIENTS: Patients receiving mechanical ventilation longer than 48 hrs who were ready to wean. INTERVENTIONS: During the observational period, sedatives and analgesics were adjusted according to physicians' orders. During the intervention period, sedatives and analgesics were adjusted by nurses according to an algorithm-based sedation guideline, including a sedation scale. MEASUREMENTS AND MAIN RESULTS: A total of 356 patients were included in the study (176 patients in the observational period and 189 patients in the intervention period). There were no significant differences in the duration of intubation between the two periods (median, 7 [interquartile range, 5-13] days vs. 7 [interquartile range, 5-9] days). In a Kaplan-Meier analysis, the probability of successful extubation was higher during the intervention period than during the observational period (log-rank = 0.02). During the intervention period, patients were more awake without a significant increment in the nurse workload; however, there was no significant decrease in the total doses of sedatives and analgesics administered. CONCLUSIONS: The implementation of a nursing-driven protocol of sedation may improve the probability of successful extubation in a heterogeneous population of mechanically ventilated patients.

Moderate sedation for chest physicians.

Specialists in pulmonary and critical care medicine frequently perform invasive procedures that may require sedation or anesthesia for patient comfort. The number and complexities of interventional pulmonary procedures that can be performed in the bronchoscopy suite or critical care unit continues to expand. Procedures that formerly were done only in the operating room on inpatients are now done routinely in the office, ambulatory surgery center, or hospital outpatient department. No matter the setting, the key to successfully performing these procedures is a safe, pain-free environment for the patient. Anesthesia care and procedural sedation services share the goals of providing the patient comfort during a painful procedure and the operating physician an acceptable working environment. Historically, anesthesiologists have applied the expertise gained in managing anesthesia for major surgeries to sedation care for minor procedures. While the supply of anesthesiologists and anesthetists has shown only a modest increase, the growth in minimally invasive procedures has been explosive in recent years. To meet demand, a service, originally known as conscious sedation and now referred to as moderate sedation, has become common, in which the operating physician supervises a specially trained sedation nurse. This article will provide a clinical definition of moderate sedation and then focus on ways to properly code and bill for pulmonary procedures performed with moderate sedation.

Assessing sedation in critically ill children by bispectral index, auditory-evoked potentials and clinical scales.

OBJECTIVE: To evaluate the correlation and agreement between the bispectral index (BIS), middle latency auditory-evoked potential index (AEP index), Ramsay scale (RS) and COMFORT scale (CS) for evaluation of the level of sedation in critically ill children. DESIGN: Prospective observational study. SETTING: Pediatric critical care unit. PATIENTS: Seventy-seven critically ill children receiving sedation and mechanical ventilation. MEASUREMENTS AND RESULTS: Simultaneous recording of BIS, AEP index, RS and CS were performed once a day, for a maximum of 5 days. Two levels of sedation were categorized: light-moderate versus deep-very deep. Correlations between methods were determined using Spearman rank correlation test and the agreement using Cohen's Kappa test. The correlation and agreement between the four methods was moderate-to-good. Correlation was not found in paralyzed children. There was no correlation between the four methods and the heart rate or blood pressure, or with the type or dose of sedative medication. Receiver-operating characteristic (ROC) analysis revealed best discrimination between light-moderate and deep-very deep sedation at BIS and AEP index values of 63.5 and 33.5 when the level of sedation was classified by the RS, and at BIS and AEP index values of 67 and 37.5, respectively, when the level of sedation was classified by the CS. CONCLUSION: There is a moderate-to-good correlation and agreement of BIS and AEP index with the clinical scales in critically ill children without neuromuscular blockade. BIS and AEP index could be useful to evaluate the level of sedation in critically ill children with and without neuromuscular blockade.

Sedation practice: is it time to wake up and embrace change?

Recommendations for sedation regimes in the intensive care unit (ICU) have evolved over the last decade based on findings that relate the clinical approach to improved patient outcomes. Martin and co-workers conducted two surveys into German sedation practice covering the time period during which these changes occurred and as such provide an insight into how these recommendations are being incorporated into everyday clinical practice.

Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain.

OBJECTIVE: To establish beginning evidence of clinical validity and reliability of the Neonatal Pain, Agitation and Sedation Scale (N-PASS) in neonates with prolonged pain postoperatively and during mechanical ventilation. STUDY DESIGN: Prospective psychometric evaluation. Two nurses administered the N-PASS simultaneously and independently before and after pharmacologic interventions for pain or sedation. One nurse also administered the premature infant pain profile (PIPP) concurrently with the N-PASS. The setting consisted of 50-bed level III neonatal intensive care unit. Convenience sample of 72 observations of 46 ventilated and/or postoperative infants, 0 to 100 days of age, gestational age 23 to 40 weeks was used. Outcome measures comprised convergent and construct validity, interrater reliability and internal consistency. RESULT: Interrater reliability measured by intraclass coefficients of 0.85 to 0.95 was high (P<0.001 to 0.0001). Convergent validity was demonstrated by correlation with the PIPP scores (Spearman's rank correlation coefficient of 0.83 at high pain scores, 0.61 at low pain scores). Internal consistency, measured by Cronbach's alpha, was evident with pain scores (0.82), and with sedation scores (0.87). Construct validity was established via the Wilcoxon signed-rank test, comparing the distribution of N-PASS scores before and after pharmacologic intervention showing pain scores of 4.86 (3.38) and 1.81 (1.53) (mean (s.d.), P<0.0001) and sedation scores of 0.85 (1.66) and -2.78 (2.81) (P<0.0001) for pre- and postintervention assessments, respectively. CONCLUSIONS: This research provides beginning evidence that the N-PASS is a valid and reliable tool for assessing pain/agitation and sedation in ventilated and/or postoperative infants 0 to 100 days of age, and 23 weeks gestation and above.

Atomized intranasal midazolam use for minor procedures in the pediatric emergency department.

BACKGROUND: Procedural sedation is increasingly more common in pediatric emergency departments. We report our experience with intranasal midazolam (INM) using a unique atomization delivery device, specifically the efficacy and safety of this method of sedation. METHODS: We performed a retrospective chart review of children who received INM sedation in the emergency department from April 1, 2005, through June 30, 2005. All children aged 1 to 60 months who received INM as the initial means of sedation were eligible for the study. Patients were excluded if they were older than 60 months. RESULTS: There were 205 patients who received INM for sedation and who met the study criteria. The mean age was 31.3 +/- 13.2 months (range, 1.5-60 months). The mean and median initial INM dose was 0.4 mg/kg (range, 0.3-0.8 mg/kg). Laceration repair was the most common procedure necessitating sedation (89%). The median degree-of-sedation score achieved was 2.0 (anxiolysis). Eleven patients (5.4%; 95% CI, 3%-9%) required an additional sedative to complete the procedure. Ten of the 11 patients received ketamine as the adjunctive sedative, and 1 patient required additional INM. The average time of last oral intake to start of sedation was 3.5 hours (range, 0.5-10.0 hours). Thirty six patients (18%) were NPO for 2 hours or less. There was 1 adverse event (0.5%; 95% CI, 0%-3%). This was a minor desaturation episode following ketamine administration requiring brief blow by oxygen. There were no adverse events (0%; 95% CI, 0%-2%) in patients who received INM alone. CONCLUSION: We conclude that atomized INM is effective in providing anxiolysis to children undergoing minor procedures in the pediatric emergency department. We are encouraged that no adverse events occurred with the use of INM alone despite relatively short fasting times.

Relative potency of ketamine and S(+)-ketamine in dogs.

The aim of this study was to determine the relative potency of racemic ketamine and S(+)-ketamine for the hypnotic effect and to evaluate the clinical anesthesia produced by equianesthetic doses of these two substances in dogs. One hundred and eight dogs were allocated in groups R2, R2.5, R3, R6, R9, R12, S2, S2.5, S3, S6, S9, and S12, to receive by intravenous route 2, 2.5, 3, 6, 9, and 12 mg/kg of ketamine or S(+)-ketamine, respectively. A dose-effect curve was drawn with the dose logarithm and the percentage of dogs that presented hypnosis in each group. The curve was used to obtain a linear regression, to determine the effective doses 100 and the potency relationship. In another experimental phase, eight groups of five dogs received 3, 6, 9 and 12 mg/kg of ketamine or S(+)-ketamine to evaluate the periods of latency, hypnosis, and total recovery. The times in which the dogs reached the sternal position, attempted to stand up for the first time, recovered the standing position, and started to walk were also recorded. The hypnotic dose for ketamine was 9.82 +/- 3.02 (6.86-16.5) mg/kg and for S(+)-ketamine was 7.76 +/- 2.17 (5.86-11.5) mg/kg. The time of hypnosis was longer in R3 and the first attempt to stand up occurred early in R6 when compared with S3 and S6 respectively. When R9 (100% of hypnosis with ketamine) and S6 [100% of hypnosis with S(+)-ketamine] were compared (1:1.5 ratio), the time to sternal position (12 +/- 2.5 and 20.2 +/- 5.6 min respectively) and the total recovery time (45 +/- 5.5 and 60.2 +/- 5.2 min respectively) were significantly shorter with S(+)-ketamine. It was concluded that the potency ratio between ketamine and S(+)-ketamine in dogs is smaller than the one reported in other species, and that the dose obtained after a reduction of 50%, as usually performed in humans, would not be enough to obtain equianesthetic effects in dogs.

Procedural sedation and analgesia in children.

Procedural sedation and analgesia for children--the use of sedative, analgesic, or dissociative drugs to relieve anxiety and pain associated with diagnostic and therapeutic procedures--is now widely practised by a diverse group of specialists outside the operating theatre. We review the principles underlying safe and effective procedural sedation and analgesia and the spectrum of procedures for which it is currently done. We discuss the decision-making process used to determine appropriate drug selection, dosing, and sedation endpoint. We detail the pharmacopoeia for procedural sedation and analgesia, reviewing the pharmacology and adverse effects of these drugs. International differences in practice are described along with current areas of controversy and future directions.