Safety of geriatric patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration with deep sedation: a retrospective study.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be performed in a wide range, from minimal sedation to general anesthesia. Advanced age increases perioperative risks related to anesthesia and is also associated with many pathological processes that further increase morbidity and mortality. The ideal sedation protocol for EBUS-TBNA has yet to be determined in geriatric patients. Deep sedation (DS) may increase the safety and performance of the procedure. There are limited studies evaluating the effectiveness and safety of EBUS-TBNA under DS in elderly patients. METHODS: 280 patients who underwent EBUS-TBNA under DS were included in this retrospective study. 156 patients aged 65 years and over (Group 1) and 124 patients under 45 (Group 2) were compared. Demographic data, comorbidities, pulmonary function tests (PFTs), hemodynamic measurements, and peripheral oxygen saturation (SpO2) before the procedure were evaluated. In addition, the duration of the EBUS-TBNA procedure, sedation agents and dosages, recovery time, and complications related to the procedure in the 24 h and applied medications and treatments were recorded. RESULTS: There was no difference in body mass index, EBUS-TBNA procedure duration, and recovery time between geriatric and young patients(p > 0.05). The proportion of female patients, pre-anesthesia SpO2, and PFTs were found to be significantly lower in geriatric patients(p < 0.05). ASA classification, frequency of comorbidities, and initial mean arterial pressure were found to be significantly higher in the geriatric group(p < 0.05). The propofol-ketamine combination was the most preferred sedative in both groups. The dose of propofol used in the regimen in which propofol was administered alone was found to be lower in the elderly group (p < 0.05). The increase in the HR was significant in Group 2 in the T4 and T5 periods with respect to T1 when the differences were compared (p < 0.05). As a complication, the frequency of high blood pressure during the procedure was higher in the elderly group (p < 0.05). CONCLUSIONS: The EBUS-TBNA procedure performed under DS was safe in elderly and young patients. Our study showed that the procedure and recovery times were similar in the elderly and young groups. The incidence of temporary high blood pressure during the procedure was higher in the elderly patients. The other complication rates during the procedure were similar in groups. Decreased propofol dose in the regimen using propofol alone has shown us that anesthetists are more sensitive to the administration of sedative agents in geriatric patients, taking into account comorbidities and drug interactions.

Health Status Perception and Psychological Sequelae in Buried Victims: An Observational Study on Survivors of the Earthquake in Amatrice (Italy), Three Years Later.

INTRODUCTION: The extrication from rubble is particularly critical for the survival of the victims of an earthquake. Early repeated infusion of sedative agents (SAs) in the acute trauma phase may interfere with neural processes leading to posttraumatic stress disorder (PTSD). STUDY OBJECTIVE: This study aimed to analyze the psychological status reported by the buried victims of the earthquake in Amatrice (August 24, 2016; Italy) by considering type of the SAs administered during the extrication maneuvers. METHODS: This was an observational study on data from 51 patients directly rescued under the rubble during the earthquake in Amatrice. During extrication maneuvers, a moderate sedation was administered by titrating ketamine (0.3-0.5mg/kg) or morphine (0.1-0.15mg/kg) with respect to the Richmond Agitation and Sedation Scale (RASS; between -2 and -3) in buried victims.Three years following the rescue, the survivors were interviewed on their perceived health status and stress using a questionnaire which consisted of 17 items: the standard four-item set of healthy days core questions (CDC HRQOL-4); the 12-item General Health Questionnaire (GHQ-12); and in addition, survivors were asked if they had a diagnosis for anxiety, depression, or for PTSD. RESULTS: The study analyzed data from the complete clinical documentation of 51 survivors; 30 were males and 21 females, with an average age of 52 years. Twenty-six (26) subjects were treated with ketamine, while 25 were treated with morphine, during the extrication procedures. Concerning the quality-of-life analysis, only 10 survivors out of 51 perceived their health status as good; the others reported psychological disorders. The GHQ-12 scores showed that all survivors had psychological distress with a mean total score of 22.2 (SD = 3.5). Eighteen (18) victims declared to have had a diagnosis of generalized anxiety (35%), while 29 were treated for depression (57%) and PTSD (57%) by a specialist. With regards to the perceived distress level and the anxiety disorder, this analysis showed significant associations with SAs used during extrication, with a better performance for ketamine than for morphine. CONCLUSION: These findings suggest investigating whether early sedation with ketamine directly in the disaster setting may promote the prophylaxis and reduce the risk of developing trauma-related disorders (TRDs) on the buried victims of major natural disasters in future studies.

Comparative Effectiveness of Midazolam, Propofol, and Dexmedetomidine in Patients With or at Risk for Acute Respiratory Distress Syndrome: A Propensity Score-Matched Cohort Study.

Background: Sedatives are commonly used in patients with or at risk for acute respiratory distress syndrome (ARDS) during mechanical ventilation. To systematically compare the outcomes of sedation with midazolam, propofol, and dexmedetomidine in patients with or at risk for ARDS. Methods: We developed a dataset of real-world data to enable the comparison of the effectiveness and safety of sedatives and the associated outcomes from the MIMIC-III database and the eICU Collaborative Research database. We performed a systematic study with six cohorts to estimate the relative risks of outcomes among patients administered different sedatives. Propensity score matching was performed to generate a balanced 1:1 matched cohort and to identify potential prognostic factors. The outcomes included hospital mortality, duration of mechanical ventilation, length of intensive care unit stay, length of hospitalization, and likelihood of being discharged home. Results: We performed 60 calibrated analyses among all groups and outcomes with 17,410 eligible patients. Sedation with dexmedetomidine was associated with a lower in-hospital mortality rate than sedation with midazolam and propofol or sedation without dexmedetomidine (p < 0.001). When compared with no sedation, the use of midazolam, propofol or dexmedetomidine was associated with a longer ICU stay and longer hospitalization duration (p < 0.01). Patients treated with midazolam were relatively less likely to be discharged home (p < 0.05). Conclusion: Patients treated with dexmedetomidine had a reduced risk of mortality. These data suggest that dexmedetomidine may be the preferred sedative in patients with or at risk for ARDS.

Comparison of sedation with dexmedetomidine vs propofol during hysteroscopic surgery: Single-centre randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: The most appropriate sedative agent for conscious sedation in minor hysteroscopic surgeries is still unclear. Dexmedetomidine a sedative and analgesic agent, may be appropriate for outpatient procedures. The aim of our study was to compare the sedative, analgesic and hemodynamic effects of dexmedetomidine vs propofol in combination with fentanyl and midazolam in patients undergoing minor hysteroscopy surgery. METHODS: Sixty patients undergoing minor hysteroscopic surgery were randomized to receive either dexmedetomidine (n = 30) or propofol (n = 30) groups. Dexmedetomidine was infused at 1 µg/kg for 10 minutes followed by a 0.7 µg/kg/h maintenance infusion. Propofol was infused a bolus of 1.5 mg/kg followed by a 2.5 mg/kg/h maintenance infusion. Fentanyl 1.5 mcg/kg and midazolam 0.03 mg/kg were performed to all patients as premedication therapy before the hysteroscopic surgery. Post-operative pain score was assessed with visual analogue scale (VAS). Hemodynamic variables and Riker Sedation-Agitation Scale (SAS) scores were recorded for all patients. RESULTS: Mean arterial pressure and heart rate in the dexmedetomidine group were significantly lower than in propofol group, whereas SpO2 was similar between two groups. In addition, post-operative Riker SAS and VAS scores were significantly lower in dexmedetomidine group than in the propofol group. Bradycardia, hypotension and serious adverse events did not occur in any patients. WHAT IS NEW AND CONCLUSION: Dexmedetomidine was associated with better analgesia and lower post-operative pain score than propofol in patients undergoing hysteroscopic surgery. However, arterial pressure and heart rate should be more closely monitored in patients received dexmedetomidine.

Using animal models to evaluate the functional consequences of anesthesia during early neurodevelopment.

Fifteen years ago Olney and colleagues began using animal models to evaluate the effects of anesthetic and sedative agents (ASAs) on neurodevelopment. The results from ongoing studies indicate that, under certain conditions, exposure to these drugs during development induces an acute elevated apoptotic neurodegenerative response in the brain and long-term functional impairments. These animal models have played a significant role in bringing attention to the possible adverse effects of exposing the developing brain to ASAs when few concerns had been raised previously in the medical community. The apoptotic degenerative response resulting from neonatal exposure to ASAs has been replicated in many studies in both rodents and non-human primates, suggesting that a similar effect may occur in humans. In both rodents and non-human primates, significantly increased levels of apoptotic degeneration are often associated with functional impairments later in life. However, behavioral deficits following developmental ASA exposure have not been consistently reported even when significantly elevated levels of apoptotic degeneration have been documented in animal models. In the present work, we review this literature and propose a rodent model for assessing potential functional deficits following neonatal ASA exposure with special reference to experimental design and procedural issues. Our intent is to improve test sensitivity and replicability for detecting subtle behavioral effects, and thus enhance the translational significance of ASA models.

Propofol for gastrointestinal endoscopy.

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.

The Effect of Psychological Preparation on the Level of Anxiety before Upper Gastrointestinal Endoscopy.

INTRODUCTION: Anxiety is one of the problems in patients undergoing invasive procedures. One way to control anxiety is through psychological preparation. AIM: This study was aimed to evaluate the effect of psychological preparation on anxiety level in patients undergoing upper gastrointestinal endoscopy. MATERIALS AND METHODS: The present study consisted of 98 patients which were referred to Ahvaz Golestan Hospital for upper gastrointestinal endoscopy. They were randomly (table of random numbers) divided into a control group and an experimental group. All of the participants filled out Spielberg State-Trait Anxiety Inventory (STAI). The experimental group was psychologically prepared for endoscopy (given information about endoscopy and behavioural intervention), and then both groups were asked to complete STAI again an hour before endoscopy. The collected data were analysed through Mann-Whitney, Kruskal-Wallis, and Chi-square tests using SPSS 17.0. RESULTS: Before the intervention was carried out, there was no significant difference between the two groups in terms of the rate of state and trait anxiety (p>0.05). After the intervention, the rate of state and trait anxiety decreased significantly (p<0.05) in experimental group. CONCLUSION: In patients subjected to endoscopy, psychological preparation was effective in reducing their anxiety and thus this can be considered as an efficient method in decreasing anxiety.

Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis.

BACKGROUND & AIMS: Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non-gastroenterologist-directed sedation on the outcomes. METHODS: A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons. RESULTS: Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63-1.07), and for developing hypotension was 0.92 (95% CI, 0.64-1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38-0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56-1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists. CONCLUSIONS: Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.

Comparison of dexmedetomidine with on-demand midazolam versus midazolam alone for procedural sedation during endoscopic submucosal dissection of gastric tumor.

OBJECTIVE: Endoscopic submucosal dissection (ESD) is commonly performed as a treatment for gastric neoplasms. However, sedation with midazolam (MDZ) often does not reach satisfactory sedation levels during the procedure and the drug may suppress respiration and blood pressure. This study aimed to investigate the safety and efficacy of dexmedetomidine (DEX) with on-demand MDZ (the DEX group) in comparison with MDZ alone (the MDZ group) as a sedative during ESD of gastric neoplasms. METHODS: Eighty patients undergoing ESD for gastric tumor were randomly assigned to one of two treatment regimens (40 patients in each). We investigated the depth of sedation by using a Modified Observers Assessment Alertness/Sedation score, the number of patients' reactions interfering with the procedure, sedation related-adverse events and the degree of satisfaction of patients and doctors. RESULTS: There was no statistically significant difference between the two groups regarding their age, gender, body mass index, American Society of Anesthesiologists physical status classification and the characteristics of the tumor. Appropriate sedation rate and the degree of satisfaction of the doctors were significantly higher in the DEX group than in the MDZ group. Patients' reactions interfering with the procedure were more numerous in the MDZ group than in the DEX group. There was no significant difference in adverse events between the two groups. CONCLUSIONS: DEX with on-demand MDZ for sedation during gastric ESD is as safe as MDZ alone and the sedation effect of DEX with MDZ is superior to that of MDZ alone.

Propofol vs traditional sedative agents for endoscopic retrograde cholangiopancreatography: a meta-analysis.

AIM: To investigate the efficacy and safety of propofol sedation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Databases including PubMed, Embase, and the Cochrane Central Register of Controlled Trials updated as of October 2010 were searched. Main outcome measures were ERCP procedure duration, recovery time, incidence of hypotension and hypoxia. RESULTS: Six trials with a total of 663 patients were included. The pooled mean difference in ERCP procedure duration between the propofol and traditional sedative agents was -8.05 (95% CI: -16.74 to 0.63), with no significant difference between the groups. The pooled mean difference in the recovery time was -18.69 (95% CI: -25.44 to -11.93), which showed a significant reduction with use of propofol sedation. Compared with traditional sedative agents, the pooled OR with propofol sedation for ERCP causing hypotension or hypoxia was 1.69 (95% CI: 0.82-3.50) and 0.90 (95% CI: 0.55-1.49), respectively, which indicated no significant difference between the groups. CONCLUSION: Propofol sedation during ERCP leads to shorter recovery time without an increase of cardiopulmonary side effects. Propofol sedation can provide adequate sedation during ERCP.

Analysis of Anesthetic Sedative Agents Used in Our Hospital during the Period of 2001～2003 / 中国药房

OBJECTIVE:To evaluate the application situation of anesthetic sedative agents in our hospital.METHODS:11945prescriptions of anesthetic sedative agents in inpatient department of our hospital during the period of2001～2003were statistically analyzed.RESULTS:There were5kinds of commonly used anesthetic sedative agents in3dosage types alto-gether;the anesthetic sedatives agents were mainly used in patients ranging from40～50years old;the drug use index(DUI)of all the kinds were all less than1,with the DUI of the majority at no more than0.5.CONCLUSION:Anesthetic sedative dosage for the treatment of cancer of late stage is lower than one needed,which suggests that sufficient dosage should be given to the cancer suffering patients by the physician.