Sedação consciente com óxido nitroso em clínica odontológica: principais indicações e segurança / Concious sedation with nitrous oxide in dental clinics: main indications and safety

A ansiedade desempenha um papel significativo na experiência de tratamentos odontológicos e pode resultar em evasão por parte dos pacientes. Isso é especialmente relevante para grupos como pacientes pediátricos e aqueles com necessidades especiais, que muitas vezes requerem técnicas de controle de comportamento ou sedação devido à ansiedade. No entanto, a ansiedade não deve ser negligenciada mesmo em pacientes sem odontofobia grave, pois está relacionada à percepção da dor durante os procedimentos odontológicos. A sedação consciente com óxido nitroso surge como uma alternativa valiosa para reduzir a ansiedade e melhorar o conforto do paciente. Ao contrário dos benzodiazepínicos e da anestesia geral, o óxido nitroso atua no sistema nervoso de uma forma que deprime levemente o córtex cerebral, sem afetar o centro respiratório. Isso permite o uso de concentrações subanestésicas do gás, administradas com oxigênio por meio de uma máscara nasal. O óxido nitroso é de rápida ação, pouco solúvel e tem um período de recuperação breve, permitindo que os pacientes retornem rapidamente às atividades normais. Este estudo, uma revisão de literatura, explora o mecanismo de ação do óxido nitroso, suas indicações na prática odontológica e examina possíveis riscos e contraindicações associados ao seu uso. Em resumo, a sedação consciente com óxido nitroso se mostra como uma opção promissora para aliviar a ansiedade e melhorar a experiência de tratamentos odontológicos, beneficiando uma ampla gama de pacientes, não apenas aqueles com fobias graves.

Anxiety, in an outpatient dental environment, plays a fundamental role in pain and discomfort expectation, resulting in increase of treatment evasion. The groups that present greater difficulty in cooperation are children and special needs patients, with behavioral control and sedation being often necessary. Nevertheless, literature emphasizes that anxiety must be evaluated as a critical stage and its management done not only in patients with elevated anxiety levels, but being crucial on pain control of every dental patient, since higher grades of restlessness equals higher pain perception. It is known that the use of nitrous oxide in conscious sedation proves to be an useful tool on reducing anxiety and enabling comfortable interventions, indicating that it is an alternative to the use of benzodiazepines and general anesthesia. The drug acts on the nervous system, promoting a slight depression of the cerebral cortex and, unlike benzodiazepines, which act at the medulla level, it does not depress the respiratory center. The technique uses sub-anesthetic concentrations of nitrous oxide delivered with oxygen through a nasal mask. Nitrous oxide is poorly soluble and has a rapid onset of action, being therefore associated with a rapid recovery period. The duration of sedation is controlled and the patient can quickly return to normal activities. This paper is a narrative review with the objective of exploring the mechanism of action of this gas, evaluating its indications for use in dental clinic and verifying possible risks and contraindications.

Anesthetic Considerations in Endovascular Stroke Treatment: A Clinical Case Study.

Acute embolic sequential bilateral occlusion is an extremely rare event and can be difficult to detect during mechanical thrombectomy (MT) under general anesthesia (GA). We describe a male with vascular risk factors who was admitted two hours after the sudden onset of aphasia, right-sided central facial palsy, homonymous hemianopsia, and ipsilateral hemiplegia/hypoesthesia. Thrombolytic intravenous treatment was started, and the patient had an allergic reaction and required intubation. MT was performed under GA, and after the first recanalization, a new contralateral occlusion was detected during the angiographic evaluation, which was also recanalized. Furthermore, we systematically review the literature to identify the prevalence of cases with sequential occlusions described so far and to understand the role of GA in these challenging cases. This allows interventional neuroradiologists to detect such subtle signs, since prompt detection of "de novo" contralateral occlusions with subsequent immediate recanalization is the only way to prevent clinical deterioration in these cases.

Designing a Perioperative Mind-Body Intervention for Peripheral Vascular Interventions.

Background: Peripheral vascular interventions (PVIs) performed under procedural sedation and analgesia (PSA) can be associated with anxiety and poor compliance with patient instructions during surgery. Mind-body interventions (MBIs) such as meditation have demonstrated the potential to decrease perioperative anxiety, though this area is understudied, and no tailored interventions have been developed for the vascular surgical patient population. Objectives: We aimed to design a perioperative MBI that specifically targeted vascular surgical patients undergoing PVIs under PSA. We sought to perform this in a scientifically rigorous, multi-disciplinary collaborative manner. Methods: Following the Obesity-Related Behavioral Intervention Trials (ORBIT) model, we designed (Phase 1a) and then refined (Phase 1b) a MBI for patients undergoing PVIs under PSA to decrease perioperative anxiety and sedation and facilitate patient intraoperative compliance. Phase 1a involved a literature review, informal information gathering and synthesis, and drafting a preliminary protocol for a perioperative MBI. Phase 1b involved assembling a multi-disciplinary expert panel of perioperative and mind-body clinicians and researchers to improve the MBI using an iterative, modified Delphi approach. Results: The modified Delphi process was completed, and a consensus was reached after three iterations. The resulting MBI consisted of two seven-minute preoperative guided meditations on the day of surgery, including diaphragmatic breathing, body scans, and guided imagery emphasizing awareness of the ipsilateral leg where the vascular surgery was performed. A document delineating the integration of the MBI into the operating room workflow was produced, including details regarding the intervention's timing, duration, and modality. Conclusion: Using a multi-specialty expert panel, we designed a novel MBI in the form of a guided meditation with elements of mindfulness and guided imagery to decrease anxiety and increase intraoperative compliance for patients undergoing PVIs under PSA. A prospective pilot study is being planned to test the program's feasibility.

Addressing the critical gap: conscious sedation for pediatric oncology patients in LMICs.

Most newly diagnosed pediatric cancer patients reside in LMICs. These countries face challenges in providing quality treatment, particularly with procedures requiring stillness or causing pain. Conscious sedation (CS) is underutilized in LMICs due, causing treatment delays and adverse outcomes. Advocacy for CS teams, training, and policy support is essential to improve outcomes.

Association between parental factors and child's behaviors during moderate sedation in pediatric dental care.

Background/Aim: Managing young children with negative behaviors can be challenging in dental settings. Moderate sedation (MS) is often used as a treatment option for such children. However, children's behavior during MS may vary depending on several variables. These variables include parental factors, such as parental anxiety, coping strategies, and pain catastrophizing. However, this area, particularly in Saudi Arabia, remains underexplored. Therefore, this study aimed to assess the association among parental anxiety, coping style, pain catastrophizing, and children's behavior during MS among Saudi children. Methods: Based on sample size calculation, this cross-sectional observational study included 85 children aged 3-5 years undergoing dental treatment under MS at King Saud University, Riyadh, Saudi Arabia. Parental anxiety, coping styles, and pain catastrophizing were assessed using the Modified Dental Anxiety Scale, Brief Coping Orientation to Problems Experienced Scale, and Pain Catastrophizing Scale. Child behavior was evaluated using the Houpt scale during sedation visits, which was video-recorded and independently analyzed by a single evaluator. Data were analyzed using Pearson's chi-squared test, Mann-Whitney U test, and stepwise multivariate logistic regression analyses. Results: The results showed no significant association among parental dental anxiety, pain catastrophizing, and child behaviors during MS. Specific parental coping strategies, such as acceptance, were positively associated with positive sedation outcomes (P = 0.03), while active coping strategies were linked to less favorable outcomes (P = 0.03). Female children had higher sedation failure rates (P = 0.02), and the number of dental treatments was positively associated with success rates (P = 0.03). Conclusion: Parental anxiety and pain catastrophizing did not significantly affect the success of sedation. However, acceptance as a coping strategy was significantly associated with sedation success in pediatric dental care under MS, whereas active coping strategies were associated with less favorable outcomes.

The Impact of Sedative Choice in the Management of Aneurysmal Subarachnoid Hemorrhage: A Scoping Review.

Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high mortality and morbidity. This scoping review assesses the current evidence regarding the use of sedatives and analgesics in the acute intensive care unit management of aSAH. We conducted a systematic search of Ovid MEDLINE, Ovid Embase, Ovid EmCare, APA PsycInfo, CINAHL, and the Cochrane Database of Systematic Reviews from inception to June 2023. Studies were included if they enrolled intensive care unit patients aged 18 or older with a significant proportion (> 20%) who had aSAH and evaluated the impact of one or more commonly used analgosedatives on physiological parameters in the management of aSAH. The methodological quality of the studies was assessed using the Methodological Index for Nonrandomized Studies score. Of 2,583 articles, 11 met the inclusion criteria. The median sample size was 47 (interquartile range 10-127), and the median Methodological Index for Nonrandomized Studies score was 9.5 (interquartile range 8-11). The studies' publication years ranged from 1980 to 2023. Dexmedetomidine and ketamine showed potential benefits in reducing the incidence of cortical spreading depolarization and delayed cerebral ischemia. Propofol and opioids appeared safe but lacked robust evidence for efficacy. Benzodiazepines were associated with increased delayed cerebral ischemia-related cerebral infarctions and cortical spreading depolarization events. The evidence available to guide the use of analgosedative medications in aSAH is critically inadequate. Dexmedetomidine and ketamine warrant further exploration in large-scale prospective studies because of their potential benefits. Improved study designs with consistent definitions and a focus on patient-centered outcomes are necessary to inform clinical practice.

General Anesthesia Improves Efficiency of High-Power Short-Duration Catheter Ablation for Atrial Fibrillation: Comparison with Mild Conscious Sedation.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia globally. High-power, short-duration radiofrequency (RF) catheter ablation (CA) for AF has recently emerged, reducing ablation times and enhancing patient tolerability with comparable efficacy and safety. While the benefits of general anesthesia (GA) for standard-power, standard-duration CA are well-established, data comparing GA to mild conscious sedation (MCS) for high-power, short-duration CA are limited. METHODS: We included patients undergoing high-power, short-duration CA for AF under GA (group 1) or MCS (group 2). Procedural characteristics, success rates, and mid-term outcomes were compared. RESULTS: In total, 131 patients, 47 in the GA group and 84 in the MCS group, were included. CA was performed for paroxysmal AF in 34 patients in group 1 (72.3%) and 68 patients in group 2 (80.9%). We found lower a mean total procedure time (100 [90-120] vs. 160 [130-180] min, p < 0.0001), lower radiation exposure (932.5 [625-1716] vs. 2445 [1228-4791] µGy, p < 0.0001 and 4.5 [3-7.1] 7.3 [4.2-13.5] min, p = 0.0003) and fewer RF applications (71 [54.8-83.8] vs. 103 [88.5-120.5], p < 0.0001) in the GA group. No major complications occurred. The 6-month AF recurrence rate was comparable between the groups (21.2% vs. 33.3%, p = 0.15). CONCLUSION: In patients undergoing high-power, short-duration RFCA for AF, the use of GA is associated with better procedural efficiency while simultaneously associated with an early recurrence rate comparable to MCS.

Hypnosis and nitrous oxide impact on the school aged patients' anxiety and cooperation candidate for tooth extraction: A randomized clinical trial.

Background: This randomized clinical trial (RCT) investigated whether hypnosis would lead to favorable outcomes in reducing anxiety, enhancing cooperation, and improving physiological responses in school-aged children undergoing tooth extraction compared to nitrous oxide/oxygen (N2O/O2) and conventional behavior guidance (CBG). Methods: Sixty-six school-aged children (mean age: 7.87 ± 1.18 years) who needed one posterior primary tooth extraction were included. Children with low-to-moderate anxiety were randomly divided into three groups (n = 22 each): hypnosis, N2O/O2, and CBG. Anxiety levels during and after anesthetic injection and tooth extraction were assessed using the Venham Clinical Anxiety Scale (VCAS) and the Venham Picture Test (VPT). Changes in heart rate (HR) and oxygen saturation (SpO2) were monitored. Children's cooperation levels were measured using the Venham Clinical Cooperation Scale (VCCS). Results: The VPT scores were significantly higher in the CBG group than in the N2O/O2 and hypnosis groups (p < 0.001). The VCAS scores in the N2O/O2 group were lower than those in the CBG group (p < 0.05) and were comparable to those in the hypnosis group. The VCCS scores were significantly higher in the CBG group than in the N2O/O2 and hypnosis groups (p < 0.05). HR changes in the N2O/O2 group were significantly lower than in the hypnosis and CBG groups (p < 0.05). No significant difference in pain was observed between the groups the day after the intervention. Conclusion: N2O/O2 inhalation and hypnosis are effective in reducing self-reported and observed anxiety and improving cooperation levels in pediatric patients during dental extraction. Moreover, the frequency of reported pain was lower in the hypnosis group compared to the other groups.

Propofol Versus Dexmedetomidine for Conscious Sedation During Vaginal Hysterectomy With Pre-emptive Local Anesthesia: A Prospective Cohort Study.

BACKGROUND/AIM: Hysterectomy is the most frequent gynecological surgery. Vaginal hysterectomy (VH) seems to be related to favorable perioperative outcomes compared to abdominal or laparoscopic approaches. As the population ages, anesthesia that is safer for the elderly, such as local anesthesia (LA) with conscious sedation, is gaining popularity and is related to favorable outcomes in patients' recovery compared to general or regional anesthesia. We aimed to evaluate the efficacy of dexmedetomidine versus propofol for women undergoing VH for uterine prolapse under LA and conscious sedation. PATIENTS AND METHODS: A prospective study on 40 women with uterine prolapse stage ≥3 who had VH under LA with conscious sedation under either dexmedetomidine (n=20) or propofol (n=20) was performed. A standardized surgical approach with continuous hemodynamic monitoring and sedation assessment using the Ramsay Sedation Scale (RSS) was conducted. The primary endpoint of the study was to determine the percentage of patients receiving intraoperative fentanyl. RESULTS: Analysis of outcomes demonstrated a significant reduction in the proportion of patients requiring intraoperative rescue fentanyl (35% vs. 5%, respectively, p=0.04) and in postoperative pain scores, with more patients achieving an optimal RSS score of 3 in the dexmedetomidine group. CONCLUSION: Based on the findings of the present study, dexmedetomidine offered superior analgesia and patient comfort compared to propofol, suggesting a favorable anesthetic profile for VH under LA.

General anaesthesia compared to conscious sedation for first-time atrial fibrillation catheter ablation-a Danish nationwide cohort study.

AIMS: Catheter ablation (CA) is a well-established treatment option for atrial fibrillation (AF), where sedation and analgesia are pivotal for patient comfort and lesion formation. The impact of anaesthesia type on AF recurrence rates remains uncertain. This study aimed to examine AF recurrence rates depending on conscious sedation (CS) vs. general anaesthesia (GA) during CA. METHODS AND RESULTS: Utilizing nationwide data from the Danish healthcare registries, we conducted this cohort study involving adults (≥18 years) undergoing first-time CA for AF between 2010 and 2018. Patients were categorized by anaesthesia type (CS or GA), with the primary endpoint being AF recurrence, defined by a composite endpoint of either antiarrhythmic drug (AAD) prescriptions, AF-related hospital admissions, electrical cardioversions, or AF re-ablation. The impact of anaesthesia type was evaluated using multivariable Cox proportional hazards analysis. The study cohort comprised 7957 (6421 CS and 1536 GA) patients. Persistent AF, hypertension, and heart failure, as well as use of AAD, were more prevalent in the GA group. Cumulative incidences of recurrent AF were higher in the CS group at 1 (46% vs. 37%) and at 5 (68% vs. 63%) years. Multivariate analysis revealed CS as significantly associated with increased risk of AF recurrence at 5-year follow-up [hazard ratio 1.26 (95% confidence interval 1.15-1.38)], consistent across paroxysmal and persistent AF subtypes. CONCLUSION: This nationwide cohort study suggests a higher risk of AF recurrence with CS during CA compared to GA. These results advocate for considering GA as the preferred anaesthesia type for improved CA outcomes.

A comparison of conscious sedation and local anesthesia for thrombectomy in acute ischemic stroke: a multicenter study.

Introduction: Ischemic cerebrovascular disease (ICVD) is a serious health problem in which brain tissue suffers from hypoxic damage due to obstruction in cerebral vessels. Mechanical thrombectomy is a commonly used method in the treatment of these patients. However, the effects of local anesthesia (LA) and conscious sedation (CS) during thrombectomy are still unclear. We evaluated whether there was a relationship between the two anesthesia regimens in terms of 90-day modified Rankin Scale (mRS) scores. Methods: In this study, a retrospective observational study was conducted to evaluate the effects of LA and CS used during mechanical thrombectomy in four comprehensive stroke centers among ICVD patients. Patients were divided into the LA group and the CS group. Statistical analysis was performed before and after 1:1 matching under propensity score matching (PSM) analysis. The primary outcome measure was an mRS score of 0-2 at 90 days. Secondary outcomes were procedure times, recanalization rates, symptomatic and asymptomatic hemorrhage rates, and procedural complications. Results: A total of 193 patients (118 patients with LA and 75 patients with CS) were included in the final analysis before PSM. After 1:1 PSM, 98 patients-49 patients from each group-were included in the study. There was no difference in clinical outcomes between the LA- and CS-applied groups (p = 0.543). When blood pressure (BP) values at follow-up after endovascular treatment (EVT) were compared, the lowest systolic and lowest diastolic BP were found to be lower in the CS group (p = 0.001 and p = 0.009). There was no significant difference between the two groups in terms of recanalization rates, symptomatic intracranial hemorrhage (sICH) rates, 90-day mRS, and procedure-related complication rates (p = 0.617, p = 0.274, p = 0.543, and p = 1.000). Conclusion: This study did not reveal the superiority of CS applied during EVT on 90-day mRS, sICH, recanalization rates, or procedural complications. However, the risk of developing hypotension during the CS application was found to be high.

Technique of Awake Computed Tomography-guided Percutaneous Balloon Compression of the Gasserian Ganglion for Trigeminal Neuralgia.

BACKGROUND: The classic percutaneous balloon compression (PBC) technique is used to complete an operation under the guidance of C-arm radiography under general anesthesia, making communication with patients during the operation impossible. It is not accurate or objective to predict the classic technique's curative effect solely by determining whether the projection of the x-ray lateral image of the filled balloon is pear-shaped. OBJECTIVES: This study aimed to upgrade classic PBC to awake computed tomography (CT)-guided PBC technology under conscious local anesthesia and analgesia monitoring. STUDY DESIGN: Prospective clinical study. SETTING: Department of Anesthesiology and Pain Medical Center, Jiaxing, People's Republic of China. METHODS: Puncture was designed and guided by CT scanning, and the curative effect was assessed by asking the patients about what they are feeling during the operation. RESULTS: CT can design the puncture path and accurately guide puncture, observe the position and shape of the balloon through 3-dimensional reconstruction during the operation, and judge the curative effect according to the patient's chief concern. LIMITATIONS: Local anesthetic analgesia is not perfect, resulting in some patients experiencing pain during surgery. CONCLUSIONS: PBC can be completed under conscious local anesthesia and analgesia. Its curative effect and operative end standard can be determined according to the patient's chief concern. Under CT guidance, the puncture path can be designed to complete an accurate puncture and to intuitively understand the position and shape of the balloon.

Comparison of propofol versus dexmedetomidine sedation for awake C-MAC® D-Blade video laryngoscopic nasotracheal intubation in patients with difficult airway: A randomised clinical study.

Background and Aims: Awake intubation is the preferred method for securing difficult airways. We compared intravenous (IV) propofol and dexmedetomidine for C-MAC® D-blade-guided anticipated difficult nasotracheal intubation under conscious sedation. Methods: This randomised study included 60 patients with difficult airway (El-Ganzouri Score 4-9). After adequate airway preparation with IV midazolam 0.03 mg/kg and IV fentanyl 1 µg/kg, in Group P, propofol was infused at 250 µg/kg/min and in Group D, dexmedetomidine was infused at 1 µg/kg over 10 min, then at 0.5 µg/kg/h till a bispectral index (BIS) value 65-70 was achieved. Patients underwent C-MAC® D-blade video laryngoscope-guided nasotracheal intubation. The intubation score was the primary outcome measure. Secondary outcome measures included haemodynamic parameters, intubation time, number of attempts, the incidence of failed awake intubation, glottic view, time to achieve desired BIS, complications, study drug consumption and patient-reported satisfaction with the awake intubation technique. Quantitative variables were compared between groups using unpaired t-test/Welsch test/Mann-Whitney Test. Qualitative variables were correlated using the Chi-square test/Fisher's exact test. A P value of <0.05 was considered statistically significant. Results: The intubation score was significantly higher in Group D versus Group P (P = 0.007). Patient reaction to intubation, haemodynamic parameters and percentage of glottis opening score were more favourable in Group P. Coughing and vocal cord movement were comparable between the groups (P > 0.05). The time to target BIS was four times longer, and the time to intubate was 6 seconds longer in Group D. Conclusion: Successful awake C-MAC® D-blade video laryngoscopic intubation can be performed under dexmedetomidine/propofol conscious sedation, with propofol giving a better intubation score.

Dental Conscious Sedation for the Treatment of Children With Autism Spectrum Disorder: A Narrative Review.

Conscious sedation has been shown to be a reliable behavior management tool that can be used during dental treatments in children who are less cooperative with dental treatment. The purpose of this study is to review the currently available research on the use of conscious sedation during dental procedures for children diagnosed with autism spectrum disorder (ASD). A web-based search for published articles was conducted. Different electronic databases were searched, including PubMed, Google Scholar, Online Review, and the Cochrane Library database, for papers published until February 2023. Studies providing descriptive protocols for dental conscious sedation for children with ASD were included. The search strategy found two studies that met the included criteria. The use of nitrous oxide in conjunction with oral benzodiazepines was found to be effective in sedating children with ASD. This review highlights the lack of research on sedation techniques for children with ASD. Future studies are needed to determine the specific types of sedative medications, their combinations and dosages, and the best methods for conscious sedation during dental procedures for autistic children.

Nomogram for Predicting Emergent Conversion to General Anaesthesia in Stroke Patients During Thrombectomy.

RATIONALE AND OBJECTIVES: The aim of this study was to develop and validate a nomogram for predicting emergent conversion to general anaesthesia (GA) in stroke patients during thrombectomy. METHODS: In this retrospective study, 458 patients (320 and 138 were randomised into the training and validation cohorts) were enroled. Univariable and multivariable logistic regression analyses were employed to identify risk factors for emergent conversion to GA. Subsequently, a nomogram was constructed based on the identified risk factors. The discriminative ability, calibration, and clinical utility of the nomogram were assessed in both the training and validation cohorts using receiver operating characteristic (ROC) curve analysis, Hosmer-Lemeshow test, and decision curve analysis (DCA). RESULTS: The emergent conversion to GA occurred in 56 cases (12.2%). In the training cohort, four independent predictors of emergent conversion to GA were identified and incorporated into the nomogram: core infarct volume > 70 mL, severe aphasia, severe cerebral vessel tortuosity, and vertebrobasilar occlusion. The ROC curves illustrated area under curve values of 0.931 (95% CI: 0.863-0.998) and 0.893 (95% CI: 0.852-0.935) for the training and validation cohorts, respectively. Hosmer-Lemeshow testing resulted in average absolute errors of 0.028 and 0.031 for the two cohorts. DCA demonstrated the nomogram's exceptional utility and accuracy across a majority of threshold probabilities. CONCLUSION: The constructed nomogram displayed promising predictive accuracy for emergent conversion to GA in stroke patients during thrombectomy, thereby providing potential assistance for clinical decision-making.

Anesthetic effects of the ketamine and midazolam association by intranasal or intramuscular route in domestic chickens: prospective, blinded, randomized and crossover study.

This prospective, blinded, randomized crossover study aimed to assess the anesthetic effects of the combination of 30 mg/kg ketamine and 2 mg/kg midazolam via intranasal (IN) or intramuscular (IM) routes in twelve domestic chickens. Physiological parameters (respiratory rate - RR, heart rate - HR, and cloacal temperature -Tºcloacal) were monitored throughout the experiment, along with recovery time and sedation level (S0: awake, no recumbency, responsive to stimuli; S1: blinking eyes, recumbency, relaxed, response to stimulus, mild movement; S2: open eyes, recumbency, relaxed, mild response to stimuli; S3: closed eyes, recumbency, relaxed, no movement). In the IM group, all birds reached S3, while in IN 5/12 reached S3, 4/12 reached at most S1, and 1/12 at most S2. IM administration showed higher sedation at 5, 10, 15, 20, 30, 35, 40, and 45 minutes (p<0.05). IN administration exhibited a shorter total recovery time (26.3±21.4 min vs. 92.9±33.4 min; p<0.001). No time, group, or time-group interaction effects were observed in HR and cloacal Tº, with a trend to a decrease in RR both groups (p<0.001). Increased incidences of vocalization and agitation was observed via IM (4/12 vs. 0/12; p=0.028), with no difference in salivation. Despite faster recovery with less agitation and vocalization, the ketamine and midazolam combination via IN provided less consistent sedation compared to the IM route in chickens.

Este estudo crossover randomizado objetivou avaliar os efeitos anestésicos da associação de 30 mg/kg de cetamina e 2 mg/kg de midazolam via intranasal (IN) ou intramuscular (IM) em doze galinhas. Além dos parâmetros fisiológicos (frequência respiratória ­ FR e cardíaca ­ FC e temperatura cloacal ­ Tºcloacal), registrou-se o tempo de recuperação e o grau de sedação ao longo do experimento (S0: acordada, sem decúbito, responsiva a estímulos; S1: olhos piscando, decúbito, relaxada, resposta a estímulo, movimentação leve; S2: olhos abertos, decúbito, relaxada, resposta leve a estímulos; S3: olhos fechados, decúbito, relaxada, sem movimentação. Pela via IM, todas as aves atingiram o grau S3, enquanto pela via IN 5/12 alcançaram S3, 4/12 atingiram no máximo S1 e 1/12 no máximo S2. A via IM apresentou maior sedação em 5, 10, 15, 20, 30, 35, 40 e 45 min (p<0,05). A via IN apresentou menor tempo total até recuperação (26,3±21,4 min vs. 92,9±33,4 min; p<0,001). Não foram observados efeitos de tempo, grupo e interação tempo-grupo na FC e na Tºcloacal com uma tendência de queda da FR nos dois grupos (p<0,001). Observou-se maior incidência de vocalização e agitação pela via IM (4/12 vs. 0/12; p=0,028), não havendo diferença para sialorreia. Apesar da recuperação mais rápida e com menos agitação e vocalização, a associação cetamina e midazolam via IN levou a uma sedação menos consistente que a via IM em galinhas.

Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study.

Background: Minimalist transcatheter aortic valve replacement (TAVR) under monitored anesthesia care (MAC) emphasizes early recovery. Remimazolam is a novel benzodiazepine with a short recovery time. This study hypothesized that remimazolam is non-inferior to dexmedetomidine in terms of recovery after TAVR. Methods: In this retrospective observational study, remimazolam was compared to dexmedetomidine in patients who underwent TAVR under MAC at a tertiary academic hospital between July 2020 and July 2022. The primary outcome was timely recovery after TAVR, defined as discharge from the intensive care unit within the first day following the procedure. Propensity score matching was used to compare timely recovery between remimazolam and dexmedetomidine, applying a non-inferiority margin of -10%. Results: The study included 464 patients, of whom 218 received remimazolam and 246 received dexmedetomidine. After propensity score matching, 164 patients in each group were included in the analysis. Regarding timely recovery after TAVR, remimazolam was non-inferior to dexmedetomidine (152 of 164 [92.7%] in the remimazolam group versus 153 of 164 [93.3%] in the dexmedetomidine group, risk difference [95% CI]: -0.6% [-6.7% to 5.5%]). The use of remimazolam was associated with fewer postoperative vasopressors/inotropes (21 of 164 [12.8%] vs. 39 of 164 [23.8%]) and temporary pacemakers (TPMs) (76 of 164 [46.3%] vs. 108 of 164 [65.9%]) compared to dexmedetomidine. Conclusions: In patients undergoing TAVR under MAC, remimazolam was non-inferior to dexmedetomidine in terms of timely recovery. Remimazolam may be associated with better postoperative recovery profiles, including a lesser need for vasopressors/inotropes and TPMs.

Comparison of anesthesia methods for intra-arterial therapy of patients with acute ischemic stroke: an updated meta-analysis and systematic review.

OBJECTIVES: Currently, there remains debate regarding the optimal anesthesia approach for patients undergoing intra-arterial therapy for acute ischemic stroke. Therefore, we conducted a comparative analysis to assess the effects of general anesthesia versus non general anesthesia on patient outcomes. METHODS: The research methodology entailed comprehensive searches of prominent databases such as the Cochrane Library, PubMed, Scopus, and Web of Science, covering the period from January 1, 2010, to March 1, 2024. Data synthesis employed techniques like risk ratio or standardized mean difference, along with 95% confidence intervals. The study protocol was prospectively registered with PROSPERO (CRD42024523079). RESULTS: A total of 27 trials and 12,875 patients were included in this study. The findings indicated that opting for non-general anesthesia significantly decreased the risk of in-hospital mortality (RR, 1.98; 95% CI: 1.50 to 2.61; p<0.00001; I2 = 20%), as well as mortality within three months post-procedure (RR, 1.24; 95% CI: 1.15 to 1.34; p<0.00001; I2 = 26%), while also leading to a shorter hospitalization duration (SMD, 0.24; 95% CI: 0.15 to 0.33; p<0.00001; I2 = 44%). CONCLUSION: Ischemic stroke patients who undergo intra-arterial treatment without general anesthesia have a lower risk of postoperative adverse events and less short-term neurological damage. In routine and non-emergency situations, non-general anesthetic options may be more suitable for intra-arterial treatment, offering greater benefits to patients. In addition to this, the neuroprotective effects of anesthetic drugs should be considered more preoperatively and postoperatively.

Comparing Patient Comfort During Bronchoscopy Under Conscious Sedation and Monitored Anesthesia Care: A Prospective, Observational, Controlled Study.

BACKGROUND: Flexible bronchoscopy (FB) often involves sedation, with the choice left to the bronchoscopist's discretion. Prior research on sedation in gastroscopic endoscopies yields conflicting information regarding the preferred method for FB. This study compares patient comfort levels during bronchoscopy with mindful sedation using fentanyl, nalbuphine, and midazolam versus monitored anesthesia care (MAC) using propofol, midazolam, and ketamine. METHODS: This prospective observational study assessed 83 patients undergoing bronchoscopy under either conscious sedation (CS) (n=40) or MAC (n=43). Patient comfort, sedation levels, emotional state, recovery time, safety, and the impact of smoking history and comorbidities were evaluated. Data collection included direct patient questioning and observation using the Modified Observed Assessment of Alertness and Sedation (MOAA/S) form. RESULTS: Comfort levels were similar between groups, with mean scores of 3.6±0.89 for CS and 3.3±0.54 for MAC. MAC induced deeper sedation (mean scores: 4.37±0.66 vs. 3.8±0.98). Recovery time and complications were comparable. Emotional states and medical history did not significantly differ between groups. CONCLUSION: CS is not inferior to MAC for bronchoscopy, providing comparable comfort and safety with less intense sedation and lower cost. These findings support the use of CS for bronchoscopy procedures, offering a cost-effective alternative without compromising patient comfort or safety.

Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol.

BACKGROUND: Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. AIM: To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. METHODS: We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. RESULTS: There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 µg vs 188.9 ± 74.1 µg; P = 0.10), flumazenil (0.3 ± 0.18 µg vs 0.17 ± 0.17 µg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. CONCLUSION: Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.