Place of high-flow nasal oxygen in nonoperating room anesthesia.

PURPOSE OF REVIEW: This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings. RECENT FINDINGS: The number of procedural interventions under deep sedation in NORA is still increasing. Administration of oxygen is recommended to prevent hypoxemia and is usually delivered with standard oxygen through nasal cannula or a face mask. HFNO is a simple alternative with a high warmed humidified flow (ranging from 30 to 70 l/min) with a precise fraction inspired of oxygen (ranging from 21 to 100%). Compared to standard oxygen, HFNO has demonstrated efficacy in reducing the incidence of hypoxemia and the need for airway maneuvers. Research on HFNO has primarily focused on its application in gastrointestinal endoscopy procedures. Yet, it has also shown promising results in various other procedural interventions including bronchoscopy, cardiology, and endovascular procedures. However, the adoption of HFNO prompted considerations regarding cost-effectiveness and environmental impact. SUMMARY: HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.

Deep Sedation for Dental Care Management in Healthy and Special Health Care Needs Children: A Retrospective Study.

BACKGROUND: Very young children, and those with disabilities and extensive oral pathology, who cannot be treated in the dental chair, require deep sedation or general anesthesia for dental treatment. OBJECTIVE: The aim of this study is to describe and compare the oral health status in healthy and SHCN children and the treatments performed under deep sedation on an outpatient basis with a minimal intervention approach, and their impact on quality of life. METHODS: A retrospective study between 2006 and 2018 was made. A total of 230 medical records of healthy and SHCN children were included. The data extracted were age, sex, systemic health status, reason for sedation, oral health status before sedation, treatments administered during sedation, and follow-up. The quality of life after deep sedation of 85 children was studied through parental questionnaires. Descriptive and inferential analyses were made. RESULTS: Of the 230 children, 47.4% were healthy and 52.6% were SHCN. The median age was 7.10 ± 3.40 years (5.04 ± 2.42 in healthy children and 8.95 ± 3.09 in SHCN children). The main reason for sedation was poor handling in the dental chair (99.5%). The most frequent pathologies were caries (90.9%) and pulp pathology (67.8%). Healthy children had more teeth affected by decay and with pulp involvement. Patients aged < 6 years received more pulpectomies and pulpotomies. After treatment, parents stated that children were more rested and less irascible, ate better, increased in weight, and had improved dental aesthetics. CONCLUSIONS: Differences in treatments carried out did not depend on the general health status or the failure rate but on age, with more pulp treatments in healthy children who were younger, and more extractions near to the age of physiological turnover in children with SHCN who were older. Intervention under deep sedation with a minimally invasive treatments approach met the expectations of parents and guardians, as it improved the children's quality of life.

Comparison of effectiveness, cost and safety between moderate sedation and deep sedation under esophagogastroduodenoscopy in Chinese population: a quasi-experimental study.

OBJECTIVE: Most endoscopists routinely perform moderate or deep sedation for esophagogastroduodenoscopy (EGD). Considering that there is no consensus on the optimal sedation depth and it varies from country to country, our study aims to compare the effectiveness, cost and safety of these two sedation methods in the Chinese population. METHODS: This quasi-experimental study included a total of 556 eligible patients from July 2020 to June 2021, and they entered the moderate sedation group or deep sedation group based on their choices. Baseline information, scores of Patient Satisfaction with Sedation Instrument (PSSI) and Clinician Satisfaction with Sedation Instrument (CSSI), examination time, sedation time, recovery time, expenses before medicare reimbursement, hypoxaemia and hypotension were compared between the two groups. Propensity Score Matching (PSM) analysis was conducted to balance the confounding factors. RESULTS: After PSM, 470 patients were involved in the analysis, with 235 for each group. The moderate sedation was clearly superior to the deep sedation group in terms of PSSI score (98.00 ± 0.94 vs. 97.29 ± 1.26), CSSI score (98.00 ± 0.78 vs. 97.67 ± 1.30), sedation time (11.90 ± 2.04 min vs. 13.21 ± 2.75 min), recovery time (25.40 ± 3.77 min vs. 28.0 ± 4.85 min), expenses (433.04 ± 0.00 Yuan vs. 789.85 ± 0.21 Yuan), with all p < .001. Examination time was not significantly different between the two groups (p = .124). In addition, the moderate sedation group had a lower occurrence rate of hypoxaemia (0.36% vs. 3.27%, p = .010) and hypotension (17.44% vs. 44.00%, p < .001) compared to the deep sedation group. CONCLUSIONS: Moderate sedation presented better effectiveness and safety and lower cost, and thereby it should be recommended as a widely used sedation method in clinical practice in China. Trial registration: This trial was registered on http://www.chictr.org.cn/index.aspx (ChiCTR2000038050).

A population pharmacodynamic Markov mixed-effects model for determining remimazolam-induced sedation when co-administered with fentanyl in procedural sedation.

The clinical effects of remimazolam (an investigational, ultra-short acting benzodiazepine being studied in procedural sedation) were measured using the Modified Observer's Assessment of Awareness/Sedation Scale (MOAA/S). The objective of this analysis was to develop a population pharmacokinetic/pharmacodynamic model to describe remimazolam-induced sedation with fentanyl over time in procedural sedation. MOAA/S from 10 clinical phase I-III trials were pooled for analysis, where data were collected after administration of placebo or remimazolam with or without concomitant fentanyl. A Markov model described transition states for 35,356 MOAA/S-time observations from 1071 subjects. Effect-compartment models of remimazolam and fentanyl linked plasma concentrations to the Markov model, and drug effects were described using a synergistic maximum effect (Emax ) model. Simulations were performed to identify the optimal remimazolam-fentanyl combination doses in procedural sedation. Fentanyl showed synergistic effects with remimazolam in sedation. Increasing age was related to longer recovery from sedation. Patients with body mass index greater than 25 kg/m2 had ~30% higher rates of distribution from plasma to the effect site (keo), indicating a slightly faster onset of sedation. Simulations showed that remimazolam 5 mg was more appropriate than 4 or 6 mg when administered with fentanyl 50 µg. The model and simulations support that a combination of remimazolam 5 mg with fentanyl 50 µg is an appropriate dosing regimen and the dose of remimazolam does not need to be changed in elderly patients, but some elderly patients may have a longer duration of sedation.

Uso de la sedación y anestesia en los pacientes pediátricos sometidos a radioterapia / Use of sedation and anesthesia in the pediatrics patients undergoing radiotherapy

Resumen Justificación: La radioterapia es esencial para el tratamiento del cáncer pediátrico. Al menos la mitad de los niños que requieren radioterapia van a necesitar sedación o anestesia. Es importante conocer las complicaciones potenciales asociadas con el uso repetitivo de medicamentos sedantes o anestésicos. El objetivo del estudio fue describir las características clínicas y epidemiológicas de los pacientes con diagnóstico de cáncer del Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", de la Caja Costarricense de Seguro Social, que recibieron sedación o anestesia durante su tratamiento con radioterapia externa en el período de enero del 2016 a junio del 2019. Métodos: Es un estudio observacional, descriptivo y retrospectivo de una serie de casos. Se incluyeron pacientes pediátricos con diagnóstico de cáncer, sometidos a tratamiento con radioterapia y que requirieron sedación o anestesia durante esa intervención. Las técnicas estadísticas utilizadas para las variables cualitativas fueron tablas de frecuencias simples y de asociación o contingencia; las variables cuantitativas se describen mediante estadígrafos de tendencia central y posición, así como de variabilidad. Resultados: Un total de 61 pacientes con diagnóstico de cáncer y que recibieron radioterapia fueron estudiados. El 57,4% de los pacientes fueron hombres. El 75% de los pacientes tenía 4,0 años o menos. La localización anatómica más frecuente del tumor fue en sistema nervioso central. Una minoría (14,5%) recibió como tratamiento único la radioterapia. El 75% de los pacientes recibió 30 o menos sesiones de tratamiento bajo sedación o anestesia. El propofol se suministró al 100,0% de los pacientes en todas las sesiones de tratamiento. El tiempo promedio de sedación o anestesia fue de 67,9 ± 28,2 minutos. El 34,4% de los pacientes presentaron complicaciones respiratorias, cardiovasculares o ambas, en al menos una sesión de tratamiento. Conclusiones: En los pacientes pediátricos con cáncer quienes reciben tratamiento con radioterapia, fue requerido el uso de la sedación y anestesia principalmente en niños de corta edad; en general, las complicaciones de la radioterapia fueron transitorias y usualmente bien toleradas, sin presentar morbimortalidad. Como monoterapia, el Propofol no mostró complicaciones asociadas; sin embargo, al adicionar otros fármacos sí se observaron complicaciones respiratorias y predominó la desaturación transitoria de oxígeno.

Abstract Background: Radiation therapy is essential for the treatment of pediatric cancer. At least half of the children who require radiation therapy will need sedation or anesthesia. It is important to know the potential complications associated with repetitive use of sedative or anesthetic medications. The objective of the study was to describe the clinical and epidemiological characteristics of patients diagnosed with cancer at the National Children's Hospital "Dr. Carlos Sáenz Herrera" of the Costa Rican Social Security Fund, who received sedation or anesthesia during their treatment with external radiotherapy in the period from January 2016 to June 2019. Methods: It is an observational, descriptive and retrospective study of a series of cases. Pediatric patients diagnosed with cancer, who underwent radiotherapy treatment and who required sedation or anesthesia during that intervention were included. The statistical techniques used for the qualitative variables were simple frequency tables and association or contingency tables; quantitative variables are described using central tendency and position statistics, as well as variability. Results: A total of 61 patients diagnosed with cancer and receiving radiotherapy were studied. 57.4% of the patients were men. 75% of patients were 4.0 years or younger. The most frequent anatomic location of the tumor was in the central nervous system. A minority (14.5%) received radiotherapy as the only treatment. 75% of patients received 30 or fewer treatment sessions under sedation or anesthesia. Propofol was administered to 100.0% of patients in all treatment sessions. The average sedation or anesthesia time was 67.9 ± 28.2 minutes. 34.4% of the patients presented respiratory or cardiovascular complications, or both, in at least onetreatment session. Conclusions: In pediatric patients diagnosed with cancer, the use of sedation and anesthesia during radiotherapy treatment was required mainly in young children and in moderate frequency, the complications of the radiation therapy were temporary and usually well tolerated, without presenting morbidity and mortality. Propofol as monotherapy turned out to have no associated complications, however, when other drugs were added, adverse effects were observed in respiratory system, the most frequent being transient oxygen desaturation.

COVID-19 et aide médicale à mourir: Constitution des trousses lors d'une pénurie de propofol / COVID-19 and medical assistance in dying: Creation of kits during a shortage of propofol

CONTEXTE: Le présent document ainsi que les constats qu'il énonce ont été rédigés en réponse à une interpellation du ministère de la Santé et des Services sociaux dans le contexte de l'urgence sanitaire liée à la maladie à coronavirus (COVID-19) au Québec. L'objectif est de réaliser une recension sommaire de données dans la documentation publiée et la littérature grise pour informer les décideurs publics et les professionnels de la santé. Vu la nature rapide de cette recension, les constats qui en découlent ne reposent pas sur une recherche exhaustive de la littérature et une évaluation des études avec une méthode systématique. Dans les circonstances d'une telle urgence de santé publique, l'INESSS reste à l'affût de toutes nouvelles données susceptibles de lui faire modifier sa position. PRÉSENTATION SOMMAIRE DE LA DEMANDE: Le propofol fait partie de médicaments administrés dans le cadre de l'aide médicale à mourir (AMM) au Québec. Après l'usage d'un anxiolytique, le propofol instaure un coma artificiel profond et est suivi de l'administration d'un bloqueur neuromusculaire. Ce médicament est aussi largement utilisé comme sédatif aux soins intensifs. Le contexte actuel de pandémie et l'anticipation d'un nombre croissant d'admissions aux soins intensifs laissent présager à brève échéance une difficulté d'approvisionnement de ce médicament notamment. Dans ce contexte, le MSSS a demandé à l'INESSS d'identifier des médicaments alternatifs au propofol actuellement utilisé dans la constitution des trousses d'AMM tout en tenant compte des ruptures de stock actuelles et anticipées des médicaments de remplacement. MÉTHODOLOGIE Questions d'évaluation: Quelles sont les alternatives à l'instauration d'un coma profond par le propofol pour l'administration d'une aide médicale à mourir? Critères de sélection: Population: Personnes de 18 ans ou plus ayant recours à l'AMM Intervention: Médicament pouvant instaurer un coma artificiel profond Résultat d'intérêt: Efficacité, innocuité, modalités d'utilisation Types de documents retenus: Tout document contenant des informations pertinentes, que ce soit de la littérature scientifique ou de la littérature grise. CONSTATS DE L'INESSS: L'importance d'atteindre un niveau de coma profond avant l'administration de bloqueur neuromusculaire est primordiale; Pour l'instant, l'option intraveineuse (IV) de rechange au propofol recommandée dans la littérature consultée et dont l'utilisation serait envisageable au Québec est le phénobarbital IV. En revanche, ce produit est également à risque de rupture; Parmi les options parentérales pouvant être considérées, l'étomidate, bien que plus difficile d'accès (Programme d'Accès spécial à Santé Canada pour autres indications), possède un mécanisme d'action semblable au propofol et permet l'instauration d'un coma profond sans activité cérébrale persistante, ce que la kétamine et les benzodiazépines, quant à elles, ne permettraient pas. Pour ces trois produits, les doses à utiliser pour l'induction du coma seraient des hautes doses, mais celles-ci ne sont pas connues pour l'instant; En raison d'incertitudes liées à la variabilité du délai d'action, des effets indésirables incommodants et à la complexité de la prise, la voie orale n'est pas à privilégier; Les autres voies d'administration (intramusculaire, sous-cutanée, rectale et intraosseuse) ne sont pas recommandées dans la littérature consultée. Dans le contexte de la pandémie, certains médicaments en pénurie utilisés dans le contexte de l'AMM sont aussi des médicaments très utilisés dans un contexte de soins palliatifs. Tous les efforts doivent être consentis afin de préserver ces médicaments, afin d'assurer un contrôle optimal de la douleur ainsi que des autres symptômes.

Utilisation de la sédation et de l'anesthésie générale pour les soins dentaires en pédiatrie / Use of sedation and general anesthesia in pediatric dental care

MISE EN CONTEXTE: La prestation de soins dentaires en pédiatrie peut, dans certaines situations, nécessiter l'utilisation de techniques de gestion du comportement pour maintenir ou établir une voie de communication avec l'enfant, atténuer son anxiété, favoriser sa coopération et ainsi pouvoir dispenser les soins bucco-dentaires requis de manière efficace et sécuritaire. Ces techniques peuvent être regroupées en techniques non pharmacologiques (p. ex. le renforcement positif, la distraction) et en techniques pharmacologiques (p. ex. la sédation au protoxyde d'azote). Dans la plupart des cas, l'utilisation de techniques non pharmacologiques de base (p. ex. la technique du « dire-montrer-faire ¼) ou encore de la sédation au protoxyde d'azote sera suffisante pour assurer la gestion du comportement. Dans d'autres situations, des techniques de gestion comportementale plus avancées telles l'immobilisation protectrice ou l'anesthésie générale seront requises. Le choix des techniques appropriées est fait en fonction des besoins de l'enfant à la suite de l'évaluation effectuée par le dentiste, mais aussi de l'expertise et des compétences de ce dernier. En dentisterie pédiatrique, la sédation dite minimale, principalement par inhalation de protoxyde d'azote, et l'anesthésie générale sont généralement administrées dans le cadre de traitements pour la carie. La sédation minimale permet une diminution de l'état d'anxiété sans toutefois altérer de façon significative l'état de conscience, alors que l'anesthésie générale induit un état d'inconscience. Au Québec, les traitements dentaires sous sédation minimale sont généralement offerts par des dentistes généralistes et les dentistes pédiatriques en cabinet dentaire privé, mais la sédation n'est toutefois pas couverte par le régime public. L'anesthésie générale, qui requiert la présence d'un médecin anesthésiologiste, est offerte en milieu hospitalier de même qu'en milieu ambulatoire (clinique privée d'anesthésie), et elle est généralement prise en charge par le régime public pour les enfants de moins de 10 ans (si le soin dentaire l'est aussi). Au cours des dernières années, certains acteurs du réseau de la santé québécois ont évoqué la possibilité d'une augmentation du recours à l'anesthésie générale en milieu hospitalier pour des interventions comme des soins dentaires dispensés à la clientèle pédiatrique. Préoccupé par cette question, le ministère de la Santé et des Services sociaux (MSSS) a confié à l'Institut national d'excellence en santé et en services sociaux (INESSS) le mandat de synthétiser les connaissances scientifiques et les balises qui encadrent l'utilisation de la sédation et de l'anesthésie générale dans le domaine de la dentisterie pédiatrique. En complément à ce volet, le MSSS a demandé à l'INESSS d'interroger les bases de données médico-administratives pour tracer un portrait sommaire et vérifier des questions ayant été soulevées concernant l'utilisation de l'anesthésie générale en contexte de soins dentaires pédiatriques. MÉTHODES: Une revue de la littérature scientifique des dix dernières années a été réalisée pour alimenter les aspects suivants : les indications/contre-indications, l'efficacité et les risques associés à la sédation (particulièrement minimale) et à l'anesthésie générale, ainsi que les effets de ces dernières sur la qualité de vie et l'expérience de soins des patients et de leurs parents. Une synthèse des recommandations et directives sur les exigences relatives à l'utilisation sécuritaire de la sédation et de l'anesthésie générale en dentisterie pédiatrique a été effectuée à partir des guides et lignes directrices repérés sur les sites Web pertinents. Une consultation avec des experts du domaine a permis de mieux comprendre le cadre réglementaire et le contexte de pratique dans lequel s'inscrit l'utilisation des différentes techniques de gestion comportementale en dentisterie pédiatrique. Un portrait sommaire de l'utilisation de l'anesthésie générale pour les soins dentaires pédiatriques a été élaboré à partir des données extraites des bases de données clinicoadministratives pour la période 2010-2018 ainsi qu'à partir de l'information recueillie auprès des établissements du réseau. RÉSULTATs: Peu de lignes directrices et de guides s'attardent aux indications et à l'efficacité des diverses modalités de sédation ou de l'anesthésie générale dans le domaine dentaire. Littérature et experts consultés s'entendent sur le fait qu'il importe de privilégier la technique de gestion comportementale la moins effractive permettant de dispenser les soins dentaires requis, selon les besoins et le profil de l'enfant traité, et guidé par le jugement clinique et l'expertise du dentiste. Ainsi, lorsqu'une sédation minimale est indiquée et que l'enfant présente la coopération requise, la sédation au protoxyde d'azote sera privilégiée. L'anesthésie générale ne sera considérée que lorsque les besoins s'avèrent plus complexes, si une coopération suffisante du patient ne peut être obtenue et si les autres modalités de gestion comportementale ne peuvent être retenues. Les risques associés à la sédation, tout comme à l'anesthésie générale, sont rapportés de façon variable dans la littérature, mais ils doivent être évalués par les professionnels de la santé en fonction de l'ampleur de l'effet recherché. La littérature ne permet pas de se positionner clairement à propos d'une association entre l'anesthésie générale et des effets indésirables significatifs (atteinte neurodéveloppementale, mortalité). L'ensemble des risques potentiels peut être géré adéquatement par un encadrement approprié de la pratique qui assurera des conditions d'utilisation sécuritaire des différentes modalités du continuum de sédation-anesthésie générale. Outre l'évaluation complète du patient, ces conditions, étroitement liées, sont les suivantes: une formation à jour, pour le dentiste, adaptée à la technique utilisée; une formation à jour en réanimation cardiorespiratoire pour le dentiste et son équipe; une surveillance du patient appropriée à la technique utilisée durant et à la suite de l'intervention; la mise en application de protocoles cliniques clairs, notamment pour la gestion des complications et les situations d'urgence; la présence d'une équipe dûment formée, mais tout particulièrement apte à la pratique collaborative en interdisciplinarité; la création d'un mécanisme de signalement et d'un registre des événements indésirables qui se sont produits lors de l'utilisation des différentes modalités de la sédation ou de l'anesthésie générale; la mise en application de modalités d'amélioration continue de la qualité. Au Québec, l'utilisation de la sédation et de l'anesthésie générale est notamment encadrée par des lois et divers règlements. En ce qui a trait à la qualité de vie et à l'expérience de soins dentaires sous sédation ou anesthésie générale, il ressort de la littérature que le protoxyde d'azote ou l'anesthésie générale, lorsque requis, peuvent être relativement bien acceptés et satisfaisants pour les parents et leurs enfants pourvu qu'un soutien adapté soit disponible. Enfin, l'analyse des données clinico-administratives provinciales n'a pas permis de relever une tendance à la hausse marquée de l'utilisation de l'anesthésie générale en milieu hospitalier pour les soins dentaires pédiatriques. Bien que plusieurs hôpitaux québécois permettent un accès, quoique limité, aux blocs opératoires aux dentistes, de nombreux enfants de moins de 10 ans (dont l'état n'est généralement pas médicalement compromis) sont traités dans les quelques cliniques privées d'anesthésie générale qui offrent ce service en milieu ambulatoire. CONCLUSION: Les lignes directrices et guides de pratique canadiens et internationaux recensés portent en grande partie sur les conditions qui permettent une utilisation pertinente et sécuritaire de la sédation et de l'anesthésie générale. Au Québec, l'Ordre des dentistes a actuellement en cours plusieurs chantiers au regard de l'encadrement de l'utilisation des modalités de sédation par ses membres, y compris une réflexion sur la formation continue et la création d'un registre des événements indésirables.

BACKGROUND: In certain situations, providing pediatric dental care may require the use of behaviour management techniques to maintain or establish communication with the child, reduce his or her anxiety and promote his or her cooperation, and thus enable the dentist to provide the required oral and dental care in a safe and effective manner. These techniques can be grouped into two categories: nonpharmacological techniques (e.g., positive reinforcement and distraction) and pharmacological techniques (e.g., nitrous oxide sedation). In most cases, the use of basic nonpharmacological techniques (e.g., the "tell-show-do" technique) or nitrous oxide for sedation will be sufficient for achieving behaviour management. In other situations, more advanced behaviour management techniques, such as protective stabilization or general anesthesia, will be required. The appropriate techniques are chosen according to the child's needs after an assessment by the dentist, but also according to the dentist's expertise and skills. In pediatric dentistry, minimal sedation, mainly by nitrous oxide inhalation, and general anesthesia are usually administered during caries treatment. Minimal sedation reduces the patient's anxiety without significantly altering his or her state of consciousness, while general anesthesia induces a state of unconsciousness. In Québec, dental treatment under minimal sedation is usually administered by general dentists and pediatric dentists in private practice, but sedation is not covered by the public plan. General anesthesia, which requires the presence of an anesthesiologist, is available in hospitals and in outpatient settings (private anesthesia clinics) and is generally covered by the public plan for children under 10 years of age (if the dental care is covered as well). In recent years, some in Québec's health-care system have raised the possibility of an increased in-hospital use of general anesthesia for procedures such as pediatric dental care. Concerned about this issue, the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d'excellence en santé et en services sociaux (INESSS) to provide a synthesis of the scientific knowledge and guidelines concerning the use of sedation and general anesthesia in pediatric dentistry. The MSSS also asked the INESSS to search medico-administrative databases in order to provide a brief description and verify certain issues that have been raised regarding the use of general anesthesia in pediatric dental care. METHODS: INESSS conducted a review of the scientific literature over the past 10 years regarding the indications/contraindications, the efficacy and risks associated with sedation (particularly minimal) and general anesthesia, and the impact of sedation and general anesthesia on the quality of life and the care experience of patients and their parents. A synthesis of recommendations and guidelines on the requirements for the safe use of sedation and general anesthesia in pediatric dentistry was produced, based on practice guides found on relevant websites. Consultation with experts in this field provided a better understanding of the regulatory framework and practice context in which the use of the various behavioural management techniques in pediatric dentistry takes place. A brief description of the use of general anesthesia in pediatric dental care was prepared from data extracted from clinical and administrative databases for the period from 2010 to 2018 and from information gathered from institutions in Québec's health-care system. RESULTS: Few guidelines or other practice guides focus on the indications for and the efficacy of the various sedation modalities or general anesthesia in dentistry. The literature and the experts consulted agree that it is important to opt for the least invasive behavioural management technique for providing the required dental care, based on the needs and profile of the child being treated and guided by the dentist's clinical judgment and expertise. Therefore, when minimal sedation is indicated and the child shows the necessary cooperation, the dentist will choose nitrous oxide sedation. General anesthesia will only be considered when the needs are more complex, if sufficient patient cooperation cannot be obtained and if the other behavioural management modalities are not an option. The risks associated with sedation, like those associated with general anesthesia, are variably reported in the literature, but they should be assessed by health professionals according to the magnitude of the desired effect. The literature does not permit a clear position to be taken regarding an association between general anesthesia and significant adverse effects (neurodevelopmental damage and death). All the potential risks can be adequately managed with appropriate supervision of the practice to ensure safe conditions for the use of the different modalities in the sedation-general anesthesia continuum. Apart from a complete patient assessment, these conditions, which are closely related, are as follows: up-to-date training for the dentist that is tailored to the technique used; up-to-date cardiopulmonary resuscitation training for the dentist and his or her team; patient monitoring appropriate for the technique used during and after the procedure; the implementation of clear clinical protocols, including for the management of complications and emergency situations; the presence of a well-trained team that is specifically capable of interdisciplinary collaborative practice; the creation of a reporting mechanism and a registry of adverse events that occured during the use of the different sedation and general anesthesia modalities; the implementation of continuous quality improvement procedures. In Québec, the use of sedation and general anesthesia is governed by statutes and various regulations. As regards quality of life and the dental care experience under sedation or general anesthesia, the literature indicates that nitrous oxide or general anesthesia, when required, can be relatively well accepted and satisfactory to parents and their children, provided the appropriate support is available. Lastly, the analysis of the provincial clinico-administrative data did not show a marked upward trend in the in-hospital use of general anesthesia for pediatric dental care. Although a number of Québec hospitals provide access, albeit limited, to operating rooms for dentists, many children under 10 years of age (whose health is generally not medically compromised) are treated in the few private general anesthesia clinics that offer this service on an outpatient basis. CONCLUSION: The Canadian and international practice guidelines and other practice guides identified focus to a large extent on the conditions for an appropriate and safe use of sedation and general anesthesia. The Ordre des dentistes du Québec is currently working on several projects concerning the regulation of the use of sedation modalities by its members, including a discussion on continuing education and the creation of an adverse effects registry.

Appropriate selection of echocardiographic guidance for transcatheter atrial septal defect closure.

Transesophageal echocardiography (TEE) under general anesthesia (GA) or intracardiac echocardiography (ICE) under sedation is usually used for echocardiographic guidance during transcatheter atrial septal defect (ASD) closure. However, appropriate selection of guidance has not been fully established. Our study aimed to evaluate whether selection of guidance depending on anatomic ASD features and TEE tolerability under sedation contributes to procedure success. On the basis of anatomic ASD characteristics and TEE tolerability under sedation during the pre-procedural TEE, we selected either TEE, ICE, or combined TEE and ICE under moderate-to-deep sedation or TEE under GA for guidance. Anatomic characteristics of the defect, medical costs, complications, and primary outcomes for these four different types of guidance were analyzed. A total of 154 patients were classified into four guidance groups depending on the results of diagnostic TEE under sedation; 11 patients were scheduled for the procedure under GA in advance. Procedures were successfully completed in all but two patients in whom closure guided by TEE under sedation was attempted for an extremely large defect or extensive superior rim deficiency. Two patients who underwent TEE or combined TEE and ICE guidance under sedation were converted to ICE-only guidance due to desaturation or excessive body movement. Device dislodgement was not observed during the procedure or during median follow-up of 1188 days [interquartile range 577-1831]. Appropriate selection of guidance might contribute to successful transcatheter ASD closure.

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil.

OBJECTIVE: To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. METHODS: A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. RESULTS: Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. CONCLUSION: This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study.

Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. / Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD.

AIMS: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil / Práticas relacionadas à avaliação de sedação, analgesia e delirium entre pediatras intensivistas no Brasil

ABSTRACT Objective To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. Methods A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. Results Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. Conclusion This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

RESUMO Objetivo Compreender o uso de ferramentas, protocolos e medidas de conforto relacionadas à sedação/analgesia, além de rastrear a presença de delirium em unidades de terapia intensiva pediátricas. Métodos Um inquérito com 14 questões foi distribuído, por meio de correio eletrônico, para médicos pediatras intensivistas brasileiros. Oito questões eram sobre os dados demográficos dos médicos e dos hospitais, e seis questões eram sobre as práticas na avaliação da sedação, analgesia e delirium em unidades de terapia intensiva pediátrica. Resultados Responderam ao inquérito 61 médicos dos 373 e-mails enviados (taxa de resposta de 16,3%). A maioria dos médicos era da Região Sudeste (57,2%) e 46,5% trabalhavam em hospitais públicos, sendo 28,6% sob administração direta do Estado. Dos respondedores, 57,1% utilizavam protocolos formais de sedação e analgesia, sendo a escala de Ramsay a mais utilizada (52,5%). Não utilizavam escores de rastreamento de delirium 48,2% dos médicos, e o Cornell Asssessment of Pediatric Delirium (23,2%) foi o mais utilizado. A maioria (85,7%) dos médicos não utilizou a prática da interrupção diária da sedação, e apenas 23,2% utilizavam medidas não farmacológicas para o conforto do paciente com frequência, com a participação heterogênea dos pais nesse processo. Conclusão Este estudo destaca a heterogeneidade nas práticas de avaliação da sedação/analgesia e insuficiência de rastreamento de delirium entre os intensivistas pediátricos brasileiros.

Sedation AND Weaning In Children (SANDWICH): protocol for a cluster randomised stepped wedge trial.

INTRODUCTION: Weaning from ventilation is a complex process involving several stages that include recognition of patient readiness to begin the weaning process, steps to reduce ventilation while optimising sedation in order not to induce distress and removing the endotracheal tube. Delay at any stage can prolong the duration of mechanical ventilation. We developed a multicomponent intervention targeted at helping clinicians to safely expedite this process and minimise the harms associated with unnecessary mechanical ventilation. METHODS AND ANALYSIS: This is a 20-month cluster randomised stepped wedge clinical and cost-effectiveness trial with an internal pilot and a process evaluation. It is being conducted in 18 paediatric intensive care units in the UK to evaluate a protocol-based intervention for reducing the duration of invasive mechanical ventilation. Following an initial 8-week baseline data collection period in all sites, one site will be randomly chosen to transition to the intervention every 4 weeks and will start an 8-week training period after which it will continue the intervention for the remaining duration of the study. We aim to recruit approximately 10 000 patients. The primary analysis will compare data from before the training (control) with that from after the training (intervention) in each site. Full details of the analyses will be in the statistical analysis plan. ETHICS AND DISSEMINATION: This protocol was reviewed and approved by NRES Committee East Midlands-Nottingham 1 Research Ethics Committee (reference: 17/EM/0301). All sites started patient recruitment on 5 February 2018 before randomisation in April 2018. Results will be disseminated in 2020. The results will be presented at national and international conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: ISRCTN16998143.

Innovation in sedation and analgesia training.

PURPOSE OF REVIEW: We reviewed evidence of recent innovations in sedation education and discuss experiences with sedation training in Taiwan. RECENT FINDINGS: Current Status of Sedation Training: Didactic training and supervised clinical mentoring are common methods of sedation training. Although training course designed by professional societies to meet individual hospital credentialing requirements, the course content and training expectations vary and are likely inadequate to non-anesthesiologist sedation practitioners. Less Common Forms of Sedation Training: These include screen-based simulation, high-fidelity manikin-based simulation. Screen-based simulation sedation training is popular, convenient, and relatively inexpensive. Although there are numerous courses available, course content has not been standardized. High-fidelity simulation has been accepted to improve knowledge, self-confidence, awareness of emergency, crisis resource management, and teamwork, but it is costly, time intensive, and requires expertise in using simulation equipment. Although screen-based training is attractive and convenient, there is no evidence to suggest that it can replace high-fidelity simulation. Another recently developed education modality is virtual reality simulation. It has gained recent popularity as an immersive approach to medical training, but minimal content has been developed for sedation training. Beyond training, several other potential innovations may improve sedation effectiveness and patient safety. These include adherence to practice guidelines established by professional organizations, utilization of a pre-procedure sedation checklist, interpreting capnography, and implementation of real-time bedside drug displays that provide predictions of concentrations and their associated effects. SUMMARY: Effective sedation education and training, especially for nonanesthesiologists, is essential to improve patient safety for procedural sedation. Several innovative approaches have been proposed and are relatively early in their development and implementation. Further studies designed to assess the impact of these new training modalities on patient safety and outcomes are warranted.

The rise, fall, and future direction of computer-assisted personalized sedation.

PURPOSE OF REVIEW: The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. RECENT FINDINGS: CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. SUMMARY: Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model.

Impact of Moderate Sedation versus Monitored Anesthesia Care on Outcomes and Cost of Endobronchial Ultrasound Transbronchial Needle Aspiration.

BACKGROUND AND OBJECTIVES: The ideal type of sedation for endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is not known. Two previous studies comparing the diagnostic yield between moderate sedation (MS) and deep sedation/general anesthesia (DS/GA) had provided conflicting results with one study clearly favoring the latter. No study had addressed cost. This is concerning for pulmonologists without routine access to anesthesia services. Our objective was to assess the impact of MS and Monitored Anesthesia Care (sedation administered and monitored by an anesthesiologist) on the outcomes and cost of EBUS-TBNA. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected data on consecutive EBUS-TBNA performed under two different types of sedation in a single academic center. A diagnostic TBNA was defined as an aspirate yielding any specific diagnosis or if subsequent surgery or follow-up of nondiagnostic/normal aspirates showed no pathology. Current Medicare time-based allowances were used for professional charges calculation. RESULTS: There was no difference observed between MS and MAC in regards of the diagnostic yield (92.9% versus 91.9%), procedure duration, number, location, and size of lymph node (LN) sampled, but there were more passes per LN with MAC. The average charges were 74.30 USD for MS and 319.91 for MAC. There were more hypotensive and desaturations episodes with MAC but none required escalation of care. CONCLUSIONS: When performed under MS, EBUS-TBNA has similar diagnostic yield as under MAC but may be associated with less side effects. The difference in sedation cost is modest; however, an additional 245$ for each EBUS done under MAC would have significant cost implications on the health system. These findings are of critical importance for bronchoscopists without routine access to anesthesia services and for optimization of healthcare cost and resource utilization.

Upper Airway Video Endoscopy: Assessment of the response to positive pressure ventilation and mechanical in-exsufflation.

Upper airways (UA) include the nasal cavities, pharynx, and larynx, and its main function is to warm and filter the inspired air. UA dysfunction is in the pathogenesis of various disorders, such as obstructive sleep apnea syndrome (OSAS) and vocal cord dysfunction. In addition, in some neurodegenerative diseases (e.g. Amyotrophic Lateral Sclerosis - ALS), UA dysfunction may also compromise the effective use of ventilatory support (VS). In this context, the endoscopic evaluation of UA may be useful in understanding the OSAS mechanisms, in determining the causes for treatment-induced airway obstruction and even in helping to titrate noninvasive ventilation (NIV) in ALS patients with bulbar or pseudo-bulbar (spastic) dysfunction. Specifically, in OSAS patients, when residual obstructive events persist, although an optimal ventilatory mode has been apparently achieved, along with interface and equipment, the endoscopic evaluation of UA seems to be a valuable tool in understanding its mechanisms, even assisting adjustments to NIV parameters. In addition, it has also been described as being useful in laryngeal response to mechanical in-exsufflation (MI-E) and Exercise-Induced Laryngeal Obstruction (EILO). However, no protocol has yet been published or validated for this. For this reason, a literature review was conducted on UA function and its response to positive pressure and MI-E. Special emphasis has also been given to the current indication for video endoscopy in chronically ventilated patients.

Should we include monitors to improve assessment of awareness and pain in unconscious palliatively sedated patients? A case report.

BACKGROUND: Awareness and pain during palliative sedation is typically assessed by observational scales, but the use of such scales has been put into question. CASE PRESENTATION: A woman in her mid-80s was admitted to a palliative care unit, presenting with chronic lymphatic leukemia, depression, and a cerebrovascular accident, with right-sided hemiplegia and aphasia. The patient was unable to eat and was suffering from nausea and vomiting. Before admission, the patient had expressed her desire to discontinue treatment on several occasions. CASE MANAGEMENT: The decision was made to initiate palliative sedation. The patient consented to take part in a study to assess level of comfort and pain using two monitoring devices (NeuroSense monitor and Analgesia Nociception Index monitor). CASE OUTCOME: The patient died 90 h after initiation of palliative sedation. Titration of the medication was challenging and sedation was not deep enough during the first 2 days. Thirteen assessments made with the Ramsay Sedation Scale showed that the patient was considered to be in a deep sleep, while in fact the NeuroSense monitor indicated otherwise. CONCLUSION: This case demonstrates the feasibility and potential advantages of using monitoring devices to objectify assessments of pain and discomfort in palliatively sedated patients.

Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial.

BACKGROUND: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. METHODS: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. RESULTS: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04]. CONCLUSIONS: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00590707.