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2.
N Engl J Med ; 382(12): 1103-1111, 2020 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-32068366

RESUMO

BACKGROUND: In critically ill, mechanically ventilated patients, daily interruption of sedation has been shown to reduce the time on ventilation and the length of stay in the intensive care unit (ICU). Data on whether a plan of no sedation, as compared with a plan of light sedation, has an effect on mortality are lacking. METHODS: In a multicenter, randomized, controlled trial, we assigned, in a 1:1 ratio, mechanically ventilated ICU patients to a plan of no sedation (nonsedation group) or to a plan of light sedation (i.e., to a level at which the patient was arousable, defined as a score of -2 to -3 on the Richmond Agitation and Sedation Scale [RASS], on which scores range from -5 [unresponsive] to +4 [combative]) (sedation group) with daily interruption. The primary outcome was mortality at 90 days. Secondary outcomes were the number of major thromboembolic events, the number of days free from coma or delirium, acute kidney injury according to severity, the number of ICU-free days, and the number of ventilator-free days. Between-group differences were calculated as the value in the nonsedation group minus the value in the sedation group. RESULTS: A total of 710 patients underwent randomization, and 700 were included in the modified intention-to-treat analysis. The characteristics of the patients at baseline were similar in the two trial groups, except for the score on the Acute Physiology and Chronic Health Evaluation (APACHE) II, which was 1 point higher in the nonsedation group than in the sedation group, indicating a greater chance of in-hospital death. The mean RASS score in the nonsedation group increased from -1.3 on day 1 to -0.8 on day 7 and, in the sedation group, from -2.3 on day 1 to -1.8 on day 7. Mortality at 90 days was 42.4% in the nonsedation group and 37.0% in the sedated group (difference, 5.4 percentage points; 95% confidence interval [CI], -2.2 to 12.2; P = 0.65). The number of ICU-free days and of ventilator-free days did not differ significantly between the trial groups. The patients in the nonsedation group had a median of 27 days free from coma or delirium, and those in the sedation group had a median of 26 days free from coma or delirium. A major thromboembolic event occurred in 1 patient (0.3%) in the nonsedation group and in 10 patients (2.8%) in the sedation group (difference, -2.5 percentage points; 95% CI, -4.8 to -0.7 [unadjusted for multiple comparisons]). CONCLUSIONS: Among mechanically ventilated ICU patients, mortality at 90 days did not differ significantly between those assigned to a plan of no sedation and those assigned to a plan of light sedation with daily interruption. (Funded by the Danish Medical Research Council and others; NONSEDA ClinicalTrials.gov number, NCT01967680.).


Assuntos
Sedação Consciente , Estado Terminal/terapia , Hipnóticos e Sedativos/administração & dosagem , Respiração Artificial , Idoso , Idoso de 80 Anos ou mais , Coma/complicações , Sedação Consciente/métodos , Estado Terminal/mortalidade , Delírio/complicações , Feminino , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva , Análise de Intenção de Tratamento , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Propofol/administração & dosagem , Respiração Artificial/efeitos adversos , Tromboembolia/etiologia
3.
J Biol Regul Homeost Agents ; 34(1 Suppl. 1): 55-62, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32064836

RESUMO

The aim of this study is to evaluate the success of functional rehabilitation of one dental session in patients with severe disabilities such as severe autism, baby bottle syndrome and severe odontophobia, and to assess how patient compliance pre- and post-intervention changes in moderate sedation. Between the beginning of 2016 and the end of 2018, 20 pedodontic patients with severe odontophobia, severe autism and baby bottle syndrome who needed dental treatment came to our attention. Patients were aged between 3 and 12 years, including 9 males and 11 females, including 10 odontophobics, 6 with severe autism and 4 with baby bottle syndrome. During the first visit, these patients were evaluated with a rating scale to evaluate the need to carry out dental intervention in a moderate sedation regime. We were able to treat 18 of the 20 patients, and carried out a total of 45 extractions, 4 oral hygiene sessions, 60 dental caries, 29 root canal treatments and 13 sealing pits and fissures. Before and after treatment, each patient's mood was assessed by using a test. Control visits were performed after 30 days, 3 months and the last one after 6 months. After the last follow-up visit, the patient was asked to complete the assessment test of his mood so that it could be compared with the one completed before the intervention. Complete functional and aesthetic rehabilitation of the patient's oral cavity was carried out in a single session. Emotional state and patient compliance improved one year after surgery in about 67% of patients, especially in children with odontophobia. Children with severe autism showed less collaboration in post-intervention assessment. The approach with moderate sedation was effective for the elimination of pain and for the treatment of preventive care, also improving the compliance and the mood of young patients.


Assuntos
Sedação Consciente , Cárie Dentária , Odontopediatria , Criança , Pré-Escolar , Assistência Odontológica , Feminino , Humanos , Masculino , Higiene Bucal
4.
BMC Health Serv Res ; 20(1): 28, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31914990

RESUMO

BACKGROUND: Moderate and deep sedation are well-established techniques in many developed countries, and several guidelines have been published. However, they have received attention in China only in recent years. The aim of this study is to investigate current paediatric sedation practices in tertiary children's hospitals and tertiary maternity and children hospitals in China. METHODS: All tertiary children's hospitals and tertiary maternity and children hospitals registered with the National Health Commission of the People's Republic of China were invited to participate in an electronic survey, which included information on the sedation caseload, facility availability, staff structure, clinical skill requirements for sedation providers, fasting guidelines, patient-monitoring practices, and choice of sedatives. RESULTS: Fifty-eight of the 63 hospitals that completed the survey (92.1%) provided moderate and deep sedation. Dedicated sedation rooms and post-sedation recovery rooms were found in 14 (24.1%) and 19 (32.8%) hospitals, respectively. Sedation for non-invasive procedures was primarily performed by anaesthesiologists (69.0%); however, 75.9% of the sedation providers had not received paediatric basic or advanced life-support training. Children were asked to fast from clear liquids for at least 2 h in 44.8% of hospitals and up to 6 h in 5.2% of hospitals; they were asked to fast from solid food/milk for at least 4 h in 27.6% of hospitals and more than 8 h in 1.7% of hospitals. The most commonly used sedative in all groups was chloral hydrate. For rescue, propofol was the most widely used sedative, particularly for children older than 4 years. CONCLUSIONS: Moderate and deep sedation practices vary widely in tertiary children's hospitals and tertiary maternity and children hospitals in China. Optimised practices should be established to improve the quality of moderate and deep sedation.


Assuntos
Sedação Consciente/estatística & dados numéricos , Sedação Profunda/estatística & dados numéricos , Maternidades/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Criança , Pré-Escolar , China , Pesquisas sobre Serviços de Saúde , Humanos , Lactente
5.
West J Emerg Med ; 21(2): 272-281, 2020 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-31999250

RESUMO

INTRODUCTION: Two protocols were developed to guide the use of subdissociative dose ketamine (SDDK) for analgesia and dissociative sedation ketamine for severe agitation/excited delirium in the emergency department (ED). We sought to evaluate the safety of these protocols implemented in 18 EDs within a large health system. METHODS: We conducted a retrospective chart review to evaluate all adult patients who received intravenous (IV) SDDK for analgesia and intramuscular (IM) dissociative sedation ketamine for severe agitation/excited delirium in 12 hospital-based and six freestanding EDs over a one-year period from the protocol implementation. We developed a standardized data collection form and used it to record patient information regarding ketamine use, concomitant medication use, and any comorbidities that could have impacted the incidence of adverse events. RESULTS: Approximately 570,000 ED visits occurred during the study period. SDDK was used in 210 ED encounters, while dissociative sedation ketamine for severe agitation/excited delirium was used in 37 ED encounters. SDDK was used in 83% (15/18) of sites while dissociative sedation ketamine was used in 50% (9/18) of sites. Endotracheal intubation, non-rebreather mask, and nasal cannula ≥ four liters per minute were identified in one, five, and three patients, respectively. Neuropsychiatric adverse events were identified in 4% (9/210) of patients who received SDDK. CONCLUSION: Patients experienced limited neuropsychiatric adverse events from SDDK. Additionally, dissociative sedation ketamine for severe agitation/excited delirium led to less endotracheal intubation than reported in the prehospital literature. The favorable safety profile of ketamine use in the ED may prompt further increases in usage.


Assuntos
Anestésicos Dissociativos , Delírio/tratamento farmacológico , Serviço Hospitalar de Emergência , Ketamina , Manejo da Dor , Adulto , Analgesia , Anestésicos Dissociativos/administração & dosagem , Sedação Consciente , Feminino , Humanos , Intubação Intratraqueal , Ketamina/administração & dosagem , Masculino , Dor/tratamento farmacológico , Estudos Retrospectivos
6.
Isr Med Assoc J ; 22(1): 5-7, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31927797

RESUMO

BACKGROUND: Many procedures requiring sedation in the pediatric emergency department are performed by consultants from outside the department. This team usually includes orthopedic surgeons and general surgeons. As sedation is now a standard of care in such cases, we evaluated consultants' views on sedation. OBJECTIVES: To evaluate consultants' views on sedation. METHODS: A questionnaire with both open-ended questions and Likert-type scores was distributed to all orthopedic surgeons and general surgeons performing procedures during the study period. The questionnaire was presented at three medical centers. RESULTS: The questionnaire was completed by 31 orthopedic surgeons and 16 general surgeons. Although the vast majority (93-100%) considered sedation important, a high percentage (64-75%) would still perform such procedures without sedation if not readily available. CONCLUSIONS: Sedation is very important for patients and although consultants understand its importance, the emergency department staff must be vigilant in both being available and not allowing procedures to "escape" the use of sedation.


Assuntos
Sedação Consciente , Consultores/estatística & dados numéricos , Serviço Hospitalar de Emergência , Atitude do Pessoal de Saúde , Criança , Sedação Consciente/métodos , Sedação Consciente/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Cirurgiões Ortopédicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Inquéritos e Questionários
7.
J Clin Pediatr Dent ; 44(1): 60-65, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31995415

RESUMO

Objective: Sedation using 50% nitrous oxide (N2O) concentration is common in pediatric dentistry. The aim to assess sedation and cooperation levels following sedation with 60% and 70% N2O concentrations in children whose dental treatment failed using 50% N2O concentration. Study design: Children (n=51) aged 5-10 years were included. Sedation started with N2O concentration of 50%; when appropriate cooperation and sedation were not achieved, N2O concentration was increased to 60%, and subsequently to 70% during the same session. Sedation and cooperation levels were the primary outcomes. Adverse events were defined as secondary outcomes. Results: At 50% N2O concentration, five children reached adequate sedation and cooperation and completed their dental treatment, where 32 children completed the treatment at 60% N2O concentration. Fourteen children required a concentration of 70% to complete treatment. For ten of the latter, treatment was successfully completed, while for four, treatment failed, despite the achievement of adequate sedation. Adverse events were observed in 9%, 22%, of the children who received 60%, 70% N2O concentrations, respectively. Conclusions: When sedation with 50% N2O concentration does not achieve satisfactory cooperation to complete pediatric dental treatment, 60% N2O concentration appears to be more effective than 50% and safer than 70%.


Assuntos
Anestesia Dentária , Anestésicos Inalatórios , Criança , Pré-Escolar , Sedação Consciente , Humanos , Hipnóticos e Sedativos , Óxido Nitroso , Odontopediatria
8.
J Zoo Wildl Med ; 50(4): 868-873, 2020 Jan 09.
Artigo em Inglês | MEDLINE | ID: mdl-31926517

RESUMO

Blue poison dart frogs (Dendrobates tinctorius azureus) are commonly maintained in zoological institutions and are becoming popular in the pet trade industry. Sedation or light anesthesia is required for safe and effective handling of this species. In this study, the sedative effects of subcutaneously administered alfaxalone-midazolam-dexmedetomidine (AMD) (20, 40, 5 mg/kg, respectively) and ketamine-midazolam-dexmedetomidine (KMD) (100, 40, 5 mg/kg, respectively) were compared in a prospective, randomized, blinded, crossover study in juvenile blue poison dart frogs (n = 10). Both protocols were partially reversed 45 min after administration of either protocol with subcutaneously administered flumazenil (0.05 mg/kg) and atipamezole (50 mg/kg). Heart rate, pulmonic respiratory rate, various reflexes, and behavioral parameters were monitored after drug administration. Both protocols resulted in rapid loss of righting reflex [median (range): AMD, 5 min (5-5 min); KMD, 5 min (5-10 min)]. Time to complete recovery was similar with both protocols (mean ± SD: AMD, 97.5 ± 11.4 min; KMD, 96.5 ± 25.4 min). The AMD protocol resulted in pulmonic respiratory depression, whereas no significant difference in heart rate was found between the two protocols. All frogs were observed eating within 24 hr of chemical restraint. Gastric prolapses occurred in four frogs (AMD 3, KMD 1) that were easily reduced with a cotton-tip application. No other adverse reactions were observed. The results of this study provide two different subcutaneous chemical restraint protocols in juvenile blue poison dart frogs.


Assuntos
Dexmedetomidina/farmacologia , Midazolam/farmacologia , Pregnanodionas/farmacologia , Antagonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Antagonistas de Receptores Adrenérgicos alfa 2/farmacologia , Envelhecimento , Analgésicos/administração & dosagem , Analgésicos/farmacologia , Anestésicos/administração & dosagem , Anestésicos/farmacologia , Animais , Antídotos/administração & dosagem , Antídotos/farmacologia , Anuros , Sedação Consciente , Estudos Cross-Over , Dexmedetomidina/administração & dosagem , Quimioterapia Combinada , Flumazenil/administração & dosagem , Flumazenil/farmacologia , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/farmacologia , Imidazóis/administração & dosagem , Imidazóis/farmacologia , Ketamina/administração & dosagem , Ketamina/farmacologia , Midazolam/administração & dosagem , Pregnanodionas/administração & dosagem
9.
Int Heart J ; 61(1): 60-66, 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-31956143

RESUMO

Transcatheter aortic valve implantation (TAVI) using a transfemoral approach under local anesthesia with conscious sedation (LACS) is becoming an increasingly common TAVI strategy. However, patients who are awake during the TAVI procedure can experience stress, anxiety, and pain, even when LACS is used. Clinical hypnotherapy is an anxiolytic intervention that can be beneficial for patients undergoing invasive surgery. This study aimed to assess the perioperative outcomes of adjunctive hypnotherapy undergoing transfemoral TAVI with LACS.Consecutive patients (n = 143) with symptomatic severe aortic stenosis who underwent transfemoral TAVI with LACS only (n = 107) or with LACS and hypnotherapy (n = 36) between January 2015 and April 2016 were retrospectively included in the study. The clinical outcomes were compared between the two groups. The LACS with hypnotherapy group had a significantly shorter length of stay in the intensive care unit (ICU; LACS only versus LACS with hypnotherapy: 4.0 (4.0-5.5) days versus 3.0 (3.0-5.0) days, P < 0.01). Moreover, the use of anesthetics (propofol and remifentanil) and norepinephrine was significantly lower in the LACS with hypnotherapy group (e.g., for propofol, LACS only versus LACS with hypnotherapy: 96.4 ± 104.7 mg versus 15.0 ± 31.8 mg, P < 0.001). The multiple regression analysis showed that being male, hypnotherapy, and the composite complication score were independently associated with the length of stay in the ICU.The adjunctive hypnotherapy on LACS among transfemoral TAVI patients may facilitate perioperative management. However, a prospective randomized study is necessary to confirm the efficacy of hypnotherapy among TAVI patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Sedação Consciente/métodos , Hipnose/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia Local , Feminino , Humanos , Masculino , Norepinefrina/administração & dosagem , Período Perioperatório , Complicações Pós-Operatórias , Propofol/administração & dosagem , Estudos Prospectivos , Análise de Regressão , Remifentanil/administração & dosagem , Estudos Retrospectivos , Resultado do Tratamento
10.
Anaesthesia ; 75(3): 374-385, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31792941

RESUMO

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.


Assuntos
Sedação Consciente/métodos , Sedação Consciente/normas , Jejum , Adolescente , Adulto , Algoritmos , Criança , Pré-Escolar , Sedação Consciente/efeitos adversos , Consenso , Técnica Delfos , Fidelidade a Diretrizes , Humanos , Lactente , Recém-Nascido , Aspiração Respiratória de Conteúdos Gástricos/prevenção & controle
12.
Eur Arch Paediatr Dent ; 21(1): 25-30, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30879260

RESUMO

BACKGROUND: Inhalation sedation (IHS), using nitrous oxide and oxygen, is a commonly used form of pharmacological behaviour management in paediatric dentistry. Previous studies suggest that IHS causes a delay in reaction time, which recovers to baseline within 10 min. AIM: To observe the reaction times (RT) of children before and after undergoing IHS for dental treatment. DESIGN: Sixty children from clinics at St Thomas' Hospital (London, UK) participated in this observational study. RT was measured using an eight-point choice reaction time system (MOART computer panel, Lafayette Instruments). RT was measured twice: before (prior to patient entering clinic for treatment) and after (immediately after discharge from the clinic). A paired-samples t test was used to analyse data. RESULTS: Fifty-two patients completed the study. There was a statistically significant delay in RT after treatment (p = 0.022). There was no significant correlation between RT and concentration of nitrous oxide, or length of the recovery period. CONCLUSION: Children may have a small impairment in reaction times following recovery from IHS in the clinical setting, regardless of the strength of nitrous oxide given, or the length of the recovery period. The child's escort should be aware of the need to supervise the child following discharge.


Assuntos
Anestesia Dentária , Anestésicos Inalatórios , Assistência Odontológica para Crianças , Criança , Sedação Consciente , Humanos , Óxido Nitroso , Oxigênio , Tempo de Reação
13.
Dent Traumatol ; 36(1): 19-24, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31162805

RESUMO

BACKGROUND/AIMS: Ketamine sedation has not been reported to be widely used as a pharmacological behavioural management strategy to facilitate the treatment of acute paediatric oro-dental trauma. The aim of this study was to investigate the safety and effectiveness of intramuscular ketamine sedation for managing paediatric oro-dental trauma in a paediatric Emergency Department (ED). METHODS: The database of all paediatric procedural sedations performed in the hospital ED from 01 January 2014 to 31 December 2016 was reviewed to identify cases where intramuscular ketamine sedation was administered for dentists' treatment of oro-dental trauma. Patient demographics and epidemiological data, the type and number of sedation-related adverse events, and interventions performed were extracted from the database. Clinical notes were reviewed to verify the dental diagnoses and dental treatment performed. Adverse events were further risk stratified using the World SIVA adverse event reporting tool. RESULTS: In the study period, 167 intramuscular ketamine sedations were administered by ED doctors for dental treatment of oro-dental trauma. The patients' median age was 3.6 years (range 1.1 to 12 years). All dental procedures were successfully completed. Nineteen adverse events were reported (11.4%, n = 19) with the most common being emesis (9.0%) followed by transient desaturation (1.8%) and hypersalivation (0.6%). The lowest oxygen saturation level was 90%. None of the patients aspirated, and none required assisted ventilation or chest compression. The most common dental diagnosis was primary tooth luxation (49.1%). The most common dental treatment was primary teeth extraction (70.7%). When adverse events were stratified using the World SIVA tool, there were only 17 (10.2%) minor risk outcomes. CONCLUSIONS: The data support the safety and effectiveness of intramuscular ketamine sedation administered by trained ED doctors to facilitate the management of paediatric oro-dental trauma emergencies.


Assuntos
Analgésicos , Anestesia , Sedação Consciente , Traumatismos Craniocerebrais , Ketamina , Traumatismos Dentários , Analgésicos/administração & dosagem , Criança , Pré-Escolar , Sedação Consciente/métodos , Serviço Hospitalar de Emergência , Humanos , Lactente , Ketamina/administração & dosagem , Boca/lesões
14.
Br J Radiol ; 93(1106): 20190781, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31868522

RESUMO

OBJECTIVE: Sedation for pediatric patients undergoing interventional procedures in radiology is in increasing demand. Once only anesthesiology-performed, there is a demand for sedation services to perform sedations for these procedures. However, the safety of performing long sedations by non-anesthesiologists in interventional radiology has not been reported. This pilot study aimed at describing a single center's experience and outcome with sedation. METHODS: This study reviews the sedations performed at a single center by a pediatric emergency physician who performed the sedation. The results regarding safety and satisfaction were reviewed. RESULTS: A total of 52 sedations were documented. Four cases of significant adverse events and three adverse events occurred. In all cases, the procedures were completed. None of the patients required intubation or admission following the sedation. There was high satisfaction by the interventional radiologists. CONCLUSION: This small pilot study shows that sedations for procedures in interventional radiology can be performed safely and successfully by dedicated non-anesthesiology sedation services. This may be considered as an alternative when anesthesiology service is not available. ADVANCES IN KNOWLEDGE: This small, single center pilot study examines the safety of sedation by a non-anesthesiologist for interventional radiology procedures. This may offer an additional method of performing procedures in the pediatric population while anesthesia is not readily available.


Assuntos
Sedação Consciente/métodos , Medicina de Emergência/estatística & dados numéricos , Malformações Vasculares/cirurgia , Adolescente , Anestesiologistas , Criança , Pré-Escolar , Sedação Consciente/efeitos adversos , Medicina de Emergência/normas , Métodos Epidemiológicos , Feminino , Humanos , Lactente , Masculino , Segurança do Paciente
15.
J Pediatr Orthop ; 40(1): e14-e18, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30973474

RESUMO

BACKGROUND: Recent studies indicate that formal postreduction radiographs may be unnecessary for closed, isolated pediatric wrist, and forearm when mini C-arm fluoroscopy is used for reduction. Our institution changed the Emergency Department (ED) management protocol to reflect this by allowing orthopaedic providers to determine if fluoroscopy was acceptable to assess fracture reduction. We hypothesized that using fluoroscopy as definitive postreduction imaging would decrease total encounter time, without an increase in the rate of rereduction or surgery. METHODS: Patients with closed, isolated distal radius/distal ulna (DR/DU) or both bone forearm (BBFA) fractures that required sedation and reduction under mini C-arm fluoroscopy at our Level 1 pediatric ED were reviewed for 6 months both before and after this policy change. Before, all patients had formal postreduction radiographs; after, the decision was left to the orthopaedic physician. Timestamp data were collected, as was the need for rereduction or surgery. In addition to descriptive statistics, between-group differences were analyzed with the Student t test, χ test, and multivariable regression as appropriate. RESULTS: A total of 243 patients (119 before, 124 after) had 165 DR/DU and 78 BBFA fractures. Demographic data were similar before and after. After protocol implementation, univariable analysis (Student t test) showed that sedation times were longer, while total ED time and the time from sedation beginning to discharge were similar. The proportion of patients requiring rereduction or surgery were similar.After multivariable regression, "fluoroscopy as definitive imaging" was the only independent determinant of the time intervals compared with using conventional radiography. Sedation was an average of 13.8 minutes longer (P<0.001), while the interval from sedation beginning to discharge was 15.8 minutes shorter (P=0.007), and total ED time was 33.0 minutes shorter (P=0.018). Fluoroscopy as definitive imaging was not a predictor of surgery (odds ratio=0.63, P=0.520), although having a BBFA increased the likelihood (odds ratio=4.50, P=0.008). CONCLUSIONS: Implementing a protocol in which the provider could use mini C-arm fluoroscopy for definitive postreduction imaging did not result in increased rates remanipulation or need for surgery. Regression analysis further demonstrated time savings associated with foregoing conventional radiographs. LEVEL OF EVIDENCE: Level III-therapeutic.


Assuntos
Redução Fechada , Sedação Consciente , Fluoroscopia , Tempo de Internação , Fraturas do Rádio/diagnóstico por imagem , Fraturas da Ulna/diagnóstico por imagem , Criança , Serviço Hospitalar de Emergência , Feminino , Antebraço , Humanos , Masculino , Radiografia , Fraturas do Rádio/cirurgia , Fatores de Tempo , Fraturas da Ulna/cirurgia , Punho
19.
Br Dent J ; 227(10): 923-927, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31758135

RESUMO

Substance abuse is an issue that has been widely recognised both in the medical and dental professions. Many different recreational drugs exist and their use can have important consequences in relation to conscious sedation. As the use of illicit drugs is growing, it is important to have an understanding of the impact of substance abuse on determining if a patient is a suitable candidate for conscious sedation. It is important to appreciate that while human studies in this area are limited, animal studies and observation of the reactions of substance abusers to sedative agents demonstrate a potential link between illicit drug use and conscious sedation through drug interaction. This paper aims to discuss the importance of understanding substance abuse, the potential effects such substances can have in relation to conscious sedation and appropriate management techniques for substance abusers in order to provide optimum safe care when undergoing conscious sedation techniques.


Assuntos
Anestesia Dentária , Transtornos Relacionados ao Uso de Substâncias , Animais , Sedação Consciente , Humanos , Hipnóticos e Sedativos
20.
An. pediatr. (2003. Ed. impr.) ; 91(5): 317-327, nov. 2019. tab, graf, ilus
Artigo em Espanhol | IBECS | ID: ibc-186769

RESUMO

Objetivo: Evaluar el impacto de la técnica sedoanalgésica en el dolor experimentado por el paciente. Métodos: Estudio transversal realizado en pacientes consecutivos con parálisis cerebral (PC) que se infiltraron con toxina botulínica A (OnabotA). Los pacientes fueron divididos en 4 grupos según la estrategia analgésica asignada: Grupo I, sin sedación o crema anestésica tópica; Grupo II, inhalación de óxido nitroso; Grupo III, sedación intravenosa profunda y Grupo IV, sedación ligera con benzodiacepinas. El dolor se evaluó con diferentes escalas según la edad del paciente. Los padres clasificaron su satisfacción con la comodidad de su hijo mediante una escala tipo Likert de 5 puntos. La variable primaria de eficacia fue la proporción de pacientes que experimentaron un nivel de dolor ≤ 2, según las escalas de dolor, en los diferentes grupos de estudio. Resultados: De los 124 pacientes incluidos en el estudio, 56 (45,2%) experimentaron un nivel de dolor ≤ 2. En el Grupo III, una proporción significativamente mayor de pacientes presentó un nivel de dolor ≤ 2, p < 0,001, en comparación con todos los grupos de estudio, respectivamente. La inyección de OnabotA fue guiada por ultrasonografía en 109 (87,9%) pacientes y por referencia anatómica en 15 (12,1%). Conclusión: En los pacientes con PC tratados con infiltraciones de OnabotA, la estrategia sedoanalgésica tuvo un impacto significativo en el dolor experimentado por el sujeto. Seleccionar una estrategia analgésica apropiada es crucial para reducir el estrés asociado con la administración de inyecciones de OnabotA en niños con PC


Objective: To evaluate the impact of the sedation-analgesia technique on the pain experienced by the patient. Methods: This cross-sectional study was conducted on consecutive patients with cerebral palsy (CP) who underwent infiltration with botulinum toxin A (BoTNA). The patients were divided into 4 different groups according to the analgesic strategy assigned: Group I, without sedation or topical anaesthetic cream; Group II, inhalation of nitrous oxide; Group III, deep intravenous sedation; and Group IV, light sedation with benzodiazepines. Pain was assessed with different scales depending on patient age. Parents were asked to rate their satisfaction with their child's comfort by using a 5-point Likert-type scale. The primary end-point was the proportion of patients that experienced a pain level equal or lower than 2, according to pain scales, in the different study groups. Results: Of the 124 patients included in the study, 56 (45.2%) experienced a pain level ≤ 2. In the Group III a significantly greater proportion of patients were classified with a pain level score ≤ 2, P < .001, as compared with all the study groups, respectively. The BoTNA injection was guided by ultrasonography in 109 (87.9%) patients, and by palpation in 15 (12.1%). Conclusion: The results of this study suggested that, in patients with CP treated with BoTNA injections, the sedation-analgesic strategy had a significant impact on the pain experienced by the subject. Selecting an appropriate analgesic strategy is crucial for reducing the stress associated with the administration of BoTNA injections in children with CP


Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Adolescente , Paralisia Cerebral/tratamento farmacológico , Toxinas Botulínicas Tipo A/administração & dosagem , Sedação Consciente/métodos , Protocolos Clínicos , Protocolos , Estudos Transversais , Medição da Dor , Anestesia Local/métodos , Inquéritos e Questionários , Manejo da Dor
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