Sedation in colonoscopy by using three different propofol infusion methods and analysis of plasma concentration levels: a prospective comparative study / Sedação em colonoscopia: utilização do propofol em estudo comparativo entre três diferentes modos de administração

ABSTRACT Background: The propofolemia becomes directly linked to the clinical effects of this anesthetic and is the focus for studies comparing propofol clinical use, in different administration methods routinely used in endoscopy units where sedation is widely administered to patients. Aim: To evaluate the effects of three different regimens of intravenous propofol infusion in colonoscopies. Methods: A total of 50 patients that underwent colonoscopies were consecutively assigned to three groups: 1) intermittent bolus infusion; 2) continuous manually controlled infusion; 3) continuous automatic infusion. Patients were monitored with Bispectral IndexTM (BIS) and propofol serum levels were collected at three different timepoints. The development of an original dilution of propofol and an inventive capnography catheter were necessary. Results: Regarding clinical outcomes, statistical differences in agitation (higher in group 1, p=0.001) and initial blood pressure (p=0.008) were found. As for propofol serum levels, findings were similar in consumption per minute (p=0.748) and over time (p=0.830). In terms of cost analysis, group 1 cost was R$7.00 (approximately US$2,25); group2, R$17.50 (approximately US$5,64); and group 3, R$112.70 (approximately US$36,35, p<0.001). Capnography was able to predict 100% of the oxygen saturation drop (below 90%). Conclusion: The use of propofol bolus administration for colonoscopies, through continuous manually controlled infusion or automatic infusion are similar regarding propofolemia and the clinical outcomes evaluated. The use of an innovative capnography catheter is liable and low-cost solution for the early detection of airway obstruction.

RESUMO Racional: A propofolemia está diretamente relacionada com os efeitos clínicos desse anestésico e é foco de diversos estudos comparando os usos clínicos do propofol e os diferentes métodos de administração, como realizado amplamente nos centros de endoscopia. Objetivo: Avaliar os efeitos de três diferentes regimes de infusão de propofol intravenoso em colonoscopias. Métodos: Ao todo 50 pacientes que foram submetidos à colonoscopia foram consecutivamente divididos em três grupos: 1) infusão em bolus intermitente; 2) perfusão contínua controlada manualmente; 3) infusão automática contínua. Os pacientes foram monitorados com Bispectral IndexTM (BIS) e os níveis séricos de propofol foram coletados em três momentos diferentes. Foi necessário a preparação de uma diluição específica de propofol e o desenvolvimento de um cateter de capnografia original manufaturado para a realização do estudo. Resultados: Em relação aos desfechos clínicos, houve diferença estatística na agitação (maior no grupo 1, p=0,001) e pressão arterial inicial (p=0,008). Com relação aos níveis séricos de propofol, os resultados foram semelhantes no consumo por minuto (p=0,748) e ao longo do tempo (p=0,830). Em termos de análise de custo, no grupo 1 o custo foi de R$ 7,00 (aproximadamente US$ 2,25); grupo 2, R$ 17,50 (aproximadamente US$ 5,64); e grupo 3, R$ 112,70 (cerca de US$ 36,35, p<0,001). A capnografia foi capaz de diagnosticar 100% das dessaturações de oxigênio (abaixo de 90%). Conclusão: O uso de propofol em bolus para colonoscopias, por meio de infusão contínua controlada manualmente ou infusão automática são semelhantes quanto à propofolemia e os resultados clínicos avaliados. Além disso, o uso de um cateter de capnografia inovador é solução de baixo custo para a detecção precoce da obstrução da via aérea.

SEDATION IN COLONOSCOPY BY USING THREE DIFFERENT PROPOFOL INFUSION METHODS AND ANALYSIS OF PLASMA CONCENTRATION LEVELS: A PROSPECTIVE COMPARATIVE STUDY.

Background: The propofolemia becomes directly linked to the clinical effects of this anesthetic and is the focus for studies comparing propofol clinical use, in different administration methods routinely used in endoscopy units where sedation is widely administered to patients. Aim: To evaluate the effects of three different regimens of intravenous propofol infusion in colonoscopies. Methods: A total of 50 patients that underwent colonoscopies were consecutively assigned to three groups: 1) intermittent bolus infusion; 2) continuous manually controlled infusion; 3) continuous automatic infusion. Patients were monitored with Bispectral IndexTM (BIS) and propofol serum levels were collected at three different timepoints. The development of an original dilution of propofol and an inventive capnography catheter were necessary. Results: Regarding clinical outcomes, statistical differences in agitation (higher in group 1, p=0.001) and initial blood pressure (p=0.008) were found. As for propofol serum levels, findings were similar in consumption per minute (p=0.748) and over time (p=0.830). In terms of cost analysis, group 1 cost was R$7.00 (approximately US$2,25); group2, R$17.50 (approximately US$5,64); and group 3, R$112.70 (approximately US$36,35, p<0.001). Capnography was able to predict 100% of the oxygen saturation drop (below 90%). Conclusion: The use of propofol bolus administration for colonoscopies, through continuous manually controlled infusion or automatic infusion are similar regarding propofolemia and the clinical outcomes evaluated. The use of an innovative capnography catheter is liable and low-cost solution for the early detection of airway obstruction.

Racional: A propofolemia está diretamente relacionada com os efeitos clínicos desse anestésico e é foco de diversos estudos comparando os usos clínicos do propofol e os diferentes métodos de administração, como realizado amplamente nos centros de endoscopia. Objetivo: Avaliar os efeitos de três diferentes regimes de infusão de propofol intravenoso em colonoscopias. Métodos: Ao todo 50 pacientes que foram submetidos à colonoscopia foram consecutivamente divididos em três grupos: 1) infusão em bolus intermitente; 2) perfusão contínua controlada manualmente; 3) infusão automática contínua. Os pacientes foram monitorados com Bispectral IndexTM (BIS) e os níveis séricos de propofol foram coletados em três momentos diferentes. Foi necessário a preparação de uma diluição específica de propofol e o desenvolvimento de um cateter de capnografia original manufaturado para a realização do estudo. Resultados: Em relação aos desfechos clínicos, houve diferença estatística na agitação (maior no grupo 1, p=0,001) e pressão arterial inicial (p=0,008). Com relação aos níveis séricos de propofol, os resultados foram semelhantes no consumo por minuto (p=0,748) e ao longo do tempo (p=0,830). Em termos de análise de custo, no grupo 1 o custo foi de R$ 7,00 (aproximadamente US$ 2,25); grupo 2, R$ 17,50 (aproximadamente US$ 5,64); e grupo 3, R$ 112,70 (cerca de US$ 36,35, p<0,001). A capnografia foi capaz de diagnosticar 100% das dessaturações de oxigênio (abaixo de 90%). Conclusão: O uso de propofol em bolus para colonoscopias, por meio de infusão contínua controlada manualmente ou infusão automática são semelhantes quanto à propofolemia e os resultados clínicos avaliados. Além disso, o uso de um cateter de capnografia inovador é solução de baixo custo para a detecção precoce da obstrução da via aérea.

[Trends in the consumption of anxiolytic and hypnotic drugs in a Colombian population]. / Tendencias de consumo de medicamentos ansiolíticos e hipnóticos en una población colombiana, 2008-2013.

INTRODUCTION: In Latin America, psychotropic medications are the third most marketed drug group, especially antidepressants (35%) and anxiolytics (5%). The objective of this study was to determine the trends in the consumption and the costs of anxiolytic and hypnotic drugs in a population of patients enrolled in the Health System of Colombia. MATERIAL AND METHODS: A descriptive, observational study was performed using the data recorded inprescriptions for any anxiolytic or hypnotic drug prescribed to outpatients in the period between January 2008 and December 2013 in a population of 3.5 million people. Sociodemographic, pharmacological variables, overall costs, and cost per thousand inhabitants per day (CHD), were also recorded. RESULTS: The number of patients who received the drugs studied varied from 11,097 to 19,231 between 2008 and 2013. The most used drugs were clonazepam (44.1% of formulations), alprazolam (31.2%), and lorazepam (13.2%). The invoiced value of anxiolytics increased from US$ 207,673.63 in 2008 to US$ 488,977 in 2013, an increase of 135.4%. The CHD was US$ 0.31 for benzodiazepines, and US$ 0.02 for zaleplon, zolpidem and zopiclone (Z drugs) for 2008, and US$ 0.36 and US$ 0.02 in 2013 respectively. The CHD declined after 2010 following the introduction of generic drugs. CONCLUSIONS: Patients receiving benzodiazepines in Colombia are mostly women, average age 55 years, with very low frequency in defined daily doses per thousand inhabitants when compared with other countries.

Diazepam or midazolam for orotracheal intubation in the ICU?

OBJECTIVE: to compare clinical and cost effectiveness of midazolam and diazepam for urgent intubation. METHODS: patients admitted to the Central ICU of the Santa Casa Hospital Complex in Porto Alegre, over the age of 18 years, undergoing urgent intubation during 6 months were eligible. Patients were randomized in a single-blinded manner to either intravenous diazepam or midazolam. Diazepam was given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute. Midazolam was given as an intravenous bolus of 5 mg with further aliquots of 2.5 mg each minute. Ramsay sedation scale 5-6 was considered adequate sedation. We recorded time and required doses to reach adequate sedation and duration of sedation. RESULTS: thirty four patients were randomized, but one patient in the diazepam group was excluded because data were lost. Both groups were similar in terms of illness severity and demographics. Time for adequate sedation was shorter (132 ± 87 sec vs. 224 ± 117 sec, p = 0.016) but duration of sedation was similar (86 ± 67 min vs. 88 ± 50 min, p = 0.936) for diazepam in comparison to midazolam. Total drug dose to reach adequate sedation after either drugs was similar (10.0 [10.0-12.5] mg vs. 15.0 [10.0-17.5] mg, p = 0.248). Arterial pressure and sedation intensity reduced similarly overtime with both drugs. Cost of sedation was lower for diazepam than for midazolam (1.4[1.4-1.8] vs. 13.9[9.4-16.2] reais, p <0.001). CONCLUSIONS: intubation using intravenous diazepam and midazolam is effective and well tolerated. Sedation with diazepam is associated to a quicker sedation time and to lower costs.

Diazepam or midazolam for orotracheal intubation in the ICU? / Diazepam ou midazolam para entubação orotraqueal na UTI?

Objective: to compare clinical and cost effectiveness of midazolam and diazepam for urgent intubation. Methods: patients admitted to the Central ICU of the Santa Casa Hospital Complex in Porto Alegre, over the age of 18 years, undergoing urgent intubation during 6 months were eligible. Patients were randomized in a single-blinded manner to either intravenous diazepam or midazolam. Diazepam was given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute. Midazolam was given as an intravenous bolus of 5 mg with further aliquots of 2.5 mg each minute. Ramsay sedation scale 5-6 was considered adequate sedation. We recorded time and required doses to reach adequate sedation and duration of sedation. Results: thirty four patients were randomized, but one patient in the diazepam group was excluded because data were lost. Both groups were similar in terms of illness severity and demographics. Time for adequate sedation was shorter (132 ± 87 sec vs. 224 ± 117 sec, p = 0.016) but duration of sedation was similar (86 ± 67 min vs. 88 ± 50 min, p = 0.936) for diazepam in comparison to midazolam. Total drug dose to reach adequate sedation after either drugs was similar (10.0 [10.0-12.5] mg vs. 15.0 [10.0-17.5] mg, p = 0.248). Arterial pressure and sedation intensity reduced similarly overtime with both drugs. Cost of sedation was lower for diazepam than for midazolam (1.4[1.4-1.8] vs. 13.9[9.4-16.2] reais, p <0.001). Conclusions: intubation using intravenous diazepam and midazolam is effective and well tolerated. Sedation with diazepam is associated to a quicker sedation time and to lower costs. .

Objetivo: comparar eficácia clínica e custo de midazolam e diazepam para intubação urgente. Métodos: pacientes internados na UTI Central do Complexo Hospitalar Santa Casa de Porto Alegre, >18 anos de idade e submetidos a entubação urgente durante seis meses eram elegíveis. Pacientes foram randomizados para receber diazepam ou midazolam intravenoso. Diazepam foi dado como bolus IV de 5 mg seguido por alíquotas de 5 mg a cada minuto. Midazolam foi dado como um bolus IV de 5 mg, com alíquotas adicionais de 2,5 mg a cada minuto. Escala de sedação de Ramsay 5-6 foi considerada sedação adequada. Registramos tempo e doses necessárias para atingir sedação adequada e sua duração. Resultados: trinta e quatro pacientes foram randomizados; um paciente no grupo diazepam foi excluído por perda dos dados. Grupos foram semelhantes para gravidade da doença e demografia. Tempo de sedação adequada foi mais curto (132 ± 87 vs. 224 ± 117 segundos, p = 0,016), mas a duração da sedação foi similar (86 ± 67 vs. 88 ± 50 min., p = 0,936) para o diazepam em comparação com o midazolam. Dose total da droga para atingir a sedação adequada foi semelhante para ambas as drogas (10,0 [10,0-12,5] vs. 15,0 [10,0-17,5] mg, p = 0,248). Pressão arterial e intensidade da sedação reduziram da mesma forma para ambas as drogas ao longo do tempo. O custo da sedação foi menor para diazepam do que para midazolam (1,4[1,4-1,8] vs. 13,9[9,4-16,2] reais, p < 0,001). Conclusões: entubação usando diazepam e midazolam intravenosos é eficaz e bem tolerada. Sedação com diazepam está associada a sedação mais rápida e menores custos. .

Insurance status and demographic and clinical factors associated with pharmacologic treatment of depression: associations in a cohort in Buenos Aires.

OBJECTIVE: There is a paucity of evidence about insurance status and the likelihood of receiving medical services in Latin America. The objective of this analysis was to examine the association between insurance status and pharmacologic treatment for depression. METHODS: Patients referred to a memory clinic of a public hospital in Buenos Aires, Argentina, and identified with any of four types of depression (subsyndromal, dysthymia, major, and due to dementia) were included. Age, years of education, insurance status, Beck Depression Inventory score, and number of comorbidities were considered. Associations between these factors and not receiving pharmacologic treatment for depression were examined with logistic regression. Use of prescription neuroleptics, hypnotics, and anticholinesterase inhibitors was also explored. RESULTS: Out of 100 patients, 92 with insurance status data were used. Sixty-one patients (66%) had formal insurance and 31 patients (34%) lacked insurance. Twenty-seven (44%) insured patients and 23 (74%) uninsured patients did not receive antidepressants (P = 0.001). Controlling for other factors, uninsured patients had 7.12 higher odds of not receiving treatment compared to insured patients (95% confidence interval 1.88-28.86). Older patients and those with more comorbidities had higher odds of not receiving treatment. More educated patients, those with higher Beck Depression Inventory score, and those without subsyndromal depression had lower odds of not receiving treatment. None of those associations were statistically significant. CONCLUSIONS: These results suggest a potential negative effect of the lack of formal insurance regarding pharmacologic treatment for depression. These findings should be confirmed with larger samples, and for other diseases.

Utilization pattern and cost of sedation, analgesia and neuromuscular blockade in a multidisciplinary intensive care unit / Patrón de utilización y costo de la sedación, analgesia y bloqueo neuromuscular en una unidad multidisciplinaria de cuidados intensivos

OBJECTIVES: To study the utilization pattern and the cost of sedatives, analgesics and neuromuscular blocking agents in a multidisciplinary intensive care unit (ICU) METHODS: A prospective observational study was conducted in the ICU of the Eric Williams Medical Sciences Complex, Trinidad and Tobago, for a period of twelve weeks. All patients admitted to the ICU were enrolled. No interventions were done. Data collected included demographics, diagnoses on admission, length of stay in the ICU, status of mechanical ventilation, patient outcome, quantity of sedatives, analgesics and neuromuscular blocking agents used in every patient and their cost. RESULTS: There were 333 patient-days encountered from 34 patients studied. Midazolam, fentanyl and cisatracurium were the most commonly used sedative, opioid and neuromuscular blocking agents respectively. The total cost of drugs used for sedation, analgesia and neuromuscular blockade was approximately US$ 19 600 per annum. Cost for this treatment alone accounted for more than 50% of the total ICU drug costs. The costs were significantly higher in patients who stayed more than two weeks in the ICU when compared to those who stayed less than two weeks (p < 0.001). CONCLUSIONS: The study highlights the utilization pattern and financial burden of sedation, analgesia and neuromuscular blockade in the delivery of critical care.

OBJETIVOS: Estudiar el patrón de utilización y costo de los sedantes, analgésicos, y agentes de bloqueo neuromuscular en una Unidad Multidisciplinaria de Cuidados Intensivos (UCI). MÉTODOS: Se llevó a cabo un estudio prospectivo en la UCI del Complejo de Ciencias Médicas Eric Williams, en Trinidad y Tobago, por un período de doce semanas. Todos los pacientes ingresados a la UCI fueron enrolados. No se realizaron intervenciones. Los datos recogidos incluyeron demografías, diagnósticos de ingreso, longitud de la estadía en la UCI, estatus de ventilación mecánica, evolución del paciente, así como la cantidad y el costo de los sedantes, analgésicos y agentes de bloqueo neuromuscular usados en cada paciente. RESULTADOS: Se encontraron 333 días-pacientes a partir de 34 pacientes estudiados. La midazolama, el fentanil y el cisatracurio fueron los agentes sedativos, opioides y de bloqueo neuromuscular más comúnmente usados. El costo total de los medicamentos usados para la sedación, la analgesia y el bloqueo neuromuscular fue de aproximadamente $19 600 USD por año. El costo sólo para este tratamiento representó más del 50% del total de los costos de medicamentos de la UCI. Los costos fueron significativamente más altos en pacientes que permanecieron más de dos semanas en la UCI, en comparación con aquellos que permanecieron menos de dos semanas (p < 0.001). CONCLUSIONES: El estudio pone de relieve el patrón de utilización de la carga financiera de la sedación, analgesia y bloqueo muscular a la hora de ofrecer atención crítica.

Utilization pattern and cost of sedation, analgesia and neuromuscular blockade in a multidisciplinary intensive care unit.

OBJECTIVES: To study the utilization pattern and the cost of sedatives, analgesics and neuromuscular blocking agents in a multidisciplinary intensive care unit (ICU). METHODS: A prospective observational study was conducted in the ICU of the Eric Williams Medical Sciences Complex, Trinidad and Tobago, for a period of twelve weeks. All patients admitted to the ICU were enrolled. No interventions were done. Data collected included demographics, diagnoses on admission, length of stay in the ICU, status of mechanical ventilation, patient outcome, quantity of sedatives, analgesics and neuromuscular blocking agents used in every patient and their cost. RESULTS: There were 333 patient-days encountered from 34 patients studied. Midazolam, fentanyl and cisatracurium were the most commonly used sedative, opioid and neuromuscular blocking agents respectively. The total cost of drugs used for sedation, analgesia and neuromuscular blockade was approximately US$ 19,600 per annum. Cost for this treatment alone accounted for more than 50% of the total ICU drug costs. The costs were significantly higher in patients who stayed more than two weeks in the ICU when compared to those who stayed less than two weeks (p < 0.001). CONCLUSIONS: The study highlights the utilization pattern and financial burden of sedation, analgesia and neuromuscular blockade in the delivery of critical care.

[Usefulness of bispectral index in pharmaceutical cost reduction for anesthesia]. / Utilidad del índice biespectral (BIS) en la reducción del costo de fármacos para la anestesia.

BACKGROUND: The bispectral index (BIS) is a value derived from an electroencephalograph (EEG); it is correlated with depth of sedation and loss of consciousness. Therefore, it has been considered that its control on sedation depth could influence cost saving in drugs as well as decreased anesthesia costs. METHODS: A total of 175 patients were studied. One hundred patients were given intravenous (i.v.) anesthesia, 50 were observed with a BIS monitor, and the remainder went into the control group. Seventy five patients were given balanced general anesthesia: fifty were observed with BIS monitor, while the remainder functioned as the control group. Drug consumption per patient was measured a to maintain BIS value between 60 and 40, and the cost was calculated. RESULTS: Average drug costs for anesthesia were greater in BIS-controlled groups. Anesthesia cost/h was lower in prolonged procedures (>4 h). The bispectral Index as a sedation monitor during anesthesia is an excellent tool, although it did not show a real economic advantage, and we considered that it world only be feasible during long-term procedures.

Sedación y analgesia para procedimientos pediátricos fuera del pabellón / Sedation and analgesia during procedures affecting children outside the operating room

Antecedentes: Existe un número importante de procedimientos en niños que requieren sedación y analgesia, la mayoría de los cuales son realizados en pabellón quirúrgico. Objetivos: Evaluar de manera prospectiva la eficacia y seguridad de la sedoanalgesia en niños sometidos a diferentes procedimientos invasivos realizados fuera de pabellón y revisar sus costos. Hipótesis: El uso de sedantes de corta duración permiten realizar procedimientos invasivos fuera de pabellón de manera segura y con ventajas costo efectividad. Pacientes y Métodos: Niños mayores de un mes, fuera de la Unidad de cuidados intensivos, sometidos a procedimientos invasivos. Como sedación se utilizó propofol, como agente único o asociado a otros sedoanalgésicos. Se registraron dosis utilizadas, efectos secundarios calidad de la sedación administrada, y se comparó costos y tiempo de hospitalización con los mismos procedimientos realizados en pabellón quirúrgico. Resultados: Se realizaron 51 procedimientos en igual número de pacientes. En 30/51 se utilizó solamente propofol; 21/51 recibieron además otros sedoanalgésicos. La dosis total promedio de propofol fue de 3,6 mg/kg, no hubo diferencias en la dosis con el grupo que recibió asociación de drogas. La mediana del tiempo de recuperación fue de 20 min con un rango entre 4-45 min. De acuerdo a una escala predefinida de 1 a 10, la calidad de la sedación fue calificada, al final de cada procedimiento, con una mediana de 10 (rango 7-10). En 13 pacientes se registraron 16 eventos no deseados, el más frecuente fue la depresión respiratoria (8 niños), todos transitorios y sin secuelas. Los costos asociados a los procedimientos fueron más de seis veces menores ($ 14 000) a los correspondientes si se hubiesen realizado en pabellón ($ 90 000). El tiempo total estimado para los procedimientos realizados en pabellón hubiese sido de 3 horas versus 40 minutos para aquellos realizados en la sala de procedimientos. Conclusión: En este estudio la sedación y analgesia administradas fuera de pabellón en procedimientos invasivos en niños, fue segura y eficaz, logrando disminuir costos y tiempos de hospitalización en relación con los mismos procedimientos realizados en pabellón quirúrgico. El uso de propofol representó una buena alternativa como sedoanalgesia en este grupo de pacientes

Price stickers do not alter drug usage.

Anaesthetists choose daily among wide varieties of neuromuscular blocking drugs and rapidly acting hypnotic agents. This study sought to determine whether definitive, immediate knowledge of drug cost might influence clinician choices, ultimately reducing the cost of anaesthesia care. Faculty anaesthetists, residents in training, and nurse anaesthetists served as subjects in this prospective, sequential, blinded study of prescribing habits. Weekly inventories of selected neuromuscular blocking and rapidly acting hypnotic agents were performed over 24 wk at a tertiary-care hospital. Supermarket style price stickers plainly indicating the hospital cost of each unit of drug appeared continually for 13 wk following an initial 11 wk control period. Both actual usage data in priced units as well as data normalized by total anaesthesia duration underwent comparison between control and priced periods. The usage of pancuronium, vecuronium, atracurium, mivacurium, succinylcholine, thiopentone, etomidate, and propofol did not differ in the control from the priced periods. Pipecuronium decreased after sticker placement (2 vs 1 vials.wk-1 median, P < 0.05), as did methohexitone (39 +/- 9.0 [SD] vs 29 +/- 11 syringes.wk-1, P < 0.05). Ketamine usage normalized by total anaesthesia duration increased (P < 0.05) following sticker placement. The weekly cost of all drugs inventoried normalized for caseload did not differ during the measurement periods. Immediate cost awareness, implemented simply as price stickers on drug units, had minimal impact on clinicians' drug usage in a tertiary care setting.