Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 3.386
Filtrar
1.
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
2.
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
3.
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
4.
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
5.
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
6.
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
7.
J Clin Nurs ; 28(23-24): 4207-4224, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31410922

RESUMO

INTRODUCTION: Patients undergoing minimally invasive procedures under a light conscious sedation perceive pain and anxiety. Hypnosis used together with analgesics has been investigated in numerous studies. AIMS AND METHODS: To assess the effectiveness of hypnotic analgesia in management of pain, anxiety, analgesic consumption, procedure length and adverse events in adults undergoing minimally invasive procedures. Clinical controlled trials in which hypnosis was used together with pharmacological analgesia compared to pharmacological analgesia alone during invasive procedures were included. Seven databases were searched. The methodological quality of the studies was assessed by two reviewers using a standardised instrument for critical appraisal from Joanna Briggs Institute, 'Meta-Analysis of statistics assessment and review Instrument'. Meta-analyses using the review manager version 5.3 software were conducted on procedure length and adverse events. Results for pain, anxiety and analgesics were synthesised in narrative summaries. Conduction of the review adheres to the PRISMA checklist. RESULTS: Ten studies comprising 1,365 participants were included. A reduction in the consumption of pain medication was found between 21%-86% without aggravating pain intensity and anxiety. In few studies, significant reduction in pain intensity and anxiety was found. Meta-analysis including seven studies revealed a small beneficial effect on reducing procedure length. A meta-analysis on adverse events showed no significant reduction. Statistical heterogeneity was found among the studies included. CONCLUSION: For patients undergoing invasive procedures, hypnotic analgesia was effective in reducing consumption of analgesics. Only a slight effect was, however, found on experienced anxiety and pain intensity. It did not prolong the procedure and was safe to provide. RELEVANCE TO CLINICAL PRACTICE: Hypnosis is recommended as pain management for adults during invasive procedures. A reduced consumption of pain medication potentially has a major impact on monitoring and observation of patients following the procedure, thus improving patient safety and reducing resource consumption.


Assuntos
Sedação Consciente/métodos , Hipnose , Dor Processual/terapia , Analgésicos/administração & dosagem , Ansiedade/etiologia , Humanos , Medição da Dor
10.
Medicine (Baltimore) ; 98(35): e16978, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31464945

RESUMO

INTRODUCTION: Inhalation sedation is a proven safe method for reducing children's dental anxiety and has been used worldwide for decades. There is controversy regarding the use of acclimatization or familiarization visits for dental sedation treatment pathways for children. This may increase acceptance to the treatment based on desensitization and acclimatization principles underpinning many behavior management techniques. This study aims to identify whether, an inhalation sedation acclimatization visit is effective in reducing the stress level in anxious children as measured by salivary Alpha Amylase and Cortisol levels. METHODS: The study is a single-center, single blinded, parallel group 2 arm clinical trial. Children in need of inhalation sedation aged 5 to 15 years from September 2019 through March 2020 attending the Postgraduate Pediatric Clinic at the Hamdan Bin Mohammed College of Dental Medicine, in Dubai, will be allocated randomly and equally to either:At the initial visit a salivary sample will be collected at the beginning of the visit and the sedation need score will be recorded using the pediatric indicator of sedation need. Treatment for both groups will commence at the second visit. Salivary samples will be collected 15 minutes before the start of the treatment and 15 minutes after the conclusion of the treatment. The following outcomes will be recorded: completion of dental treatment, anxiety scores at baseline and after treatment using Frankl rating behavior scale and physiological anxiety related changes will be recorded using salivary Alpha Amylase and Cortisol levels. Mean changes of physiologic anxiety levels and corresponding 95% confidence intervals will be determined to compare the 2 treatments (sedation with familiarization and sedation without familiarization). DISCUSSION: This is will be the first study to measure the effect of the acclimatization visit of nitrous oxide inhalation sedation on the level of physiological anxiety and the behavior of the pediatric patients during treatment.


Assuntos
Sedação Consciente/métodos , Ansiedade ao Tratamento Odontológico/prevenção & controle , Ansiedade ao Tratamento Odontológico/fisiopatologia , Aceitação pelo Paciente de Cuidados de Saúde , alfa-Amilases Salivares/análise , Adolescente , Criança , Comportamento Infantil , Pré-Escolar , Feminino , Humanos , Hidrocortisona/sangue , Masculino , Projetos de Pesquisa , Método Simples-Cego , Emirados Árabes Unidos
11.
Cardiol Young ; 29(9): 1189-1195, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31451130

RESUMO

OBJECTIVE: There are several agents used for conscious sedation by various routes in children. The aim of this prospective randomised study is to compare the effectiveness of three commonly used sedatives: intranasal ketamine, intranasal midazolam, and oral chloral hydrate for children undergoing transthoracic echocardiography. METHODS: Children who were referred to paediatric cardiology due to a heart murmur for transthoracic echocardiography were prospectively randomised into three groups. Seventy-three children received intranasal midazolam (0.2 mg/kg), 72 children received intranasal ketamine (4 mg/kg), and 72 children received oral chloral hydrate (50 mg/kg) for conscious sedation. The effects of three agents were evaluated in terms of intensity, onset, and duration of sedation. Obtaining high-quality transthoracic echocardiography images (i.e. absence of artefacts) were regarded as successful sedation. Side effects due to medications were also noted. RESULTS: There was no statistical difference in terms of sedation success rates between three groups (95.9, 95.9, and 94.5%, respectively). The median onset of sedation in the midazolam, ketamine, and chloral hydrate was 14 minutes (range 7-65), 34 minutes (range 12-56), and 40 minutes (range 25-57), respectively (p < 0.001 for all). However, the median duration of sedation in study groups was 68 minutes (range 20-75), 55 minutes (range 25-75), and 61 minutes (range 34-78), respectively (p = 0.023, 0.712, and 0.045). Gastrointestinal side effects such as nausea and vomiting were significantly higher in the chloral hydrate group (11.7 versus 0% for midazolam and 2.8% for ketamine, respectively, p = 0.002). CONCLUSION: Results of our prospectively randomised study indicate that all three agents provide adequate sedation for successful transthoracic echocardiography. When compared the three sedatives, intranasal midazolam has a more rapid onset of sedation while intranasal ketamine has a shorter duration of sedation. Intranasal ketamine can be used safely with fewer side effects in children undergoing transthoracic echocardiography.


Assuntos
Hidrato de Cloral/administração & dosagem , Sedação Consciente/métodos , Ecocardiografia/métodos , Ketamina/administração & dosagem , Midazolam/administração & dosagem , Administração Intranasal , Administração Oral , Pré-Escolar , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Hipnóticos e Sedativos/administração & dosagem , Lactente , Masculino , Estudos Prospectivos
12.
Pain Physician ; 22(4): E287-E294, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31337170

RESUMO

BACKGROUND: Transforaminal epidural steroid injection (TFESI) can be administered with or without sedation in clinical practice. OBJECTIVES: The aim of this study was to compare both procedures in terms of patient and physician satisfaction, preoperative anxiety level, procedural pain level, and complications. STUDY DESIGN: A prospective randomized trial. SETTING: A university hospital interventional pain management center. METHODS: The study included patients scheduled for single-level unilateral TFESI. The patients were randomized into 2 groups. The first group underwent TFESI without sedation, whereas the second group underwent TFESI with sedation. The Likert scale was used to determine the patient and physician satisfaction, and the Numeric Rating Scale (NRS-11) was used to determine the procedural pain level. Cases in which the procedure was to be repeated, the patient was questioned if they desired to undergo the procedure with the same technique. RESULTS: A total of 64 patients, (31 [48.4%] in the sedation group) were included. In the sedation group, the patient and physician satisfaction were significantly higher (P = 0.0001), the periprocedural NRS-11 scores were significantly lower (P = 0.0001), and the rate of desire to have the intervention with the same technique was higher (P = 0.001). After the regression analysis, we reported that there was a significant correlation between being in the sedation group and NRS-11 procedure scores, the desire to have the same technique, and patient and physician satisfaction (odds ratio [OR], 0.341; OR, 0.648; OR, 0.329; OR, 0.514; P = 0.0001). LIMITATIONS: Both patients and physicians were unblinded. CONCLUSIONS: Coadministration of TFESI with sedation improves patient and physician satisfaction. Additionally, the low periprocedural pain level results in patients' demand for the intervention to be performed with sedation in the event of repetition of the procedure. KEY WORDS: Patient satisfaction, transforaminal epidural steroid injection, sedation, physician satisfaction.


Assuntos
Sedação Consciente/métodos , Injeções Epidurais/métodos , Deslocamento do Disco Intervertebral/tratamento farmacológico , Manejo da Dor/métodos , Satisfação do Paciente , Adulto , Idoso , Feminino , Humanos , Deslocamento do Disco Intervertebral/complicações , Masculino , Metilprednisolona/administração & dosagem , Pessoa de Meia-Idade , Estudos Prospectivos , Radiculopatia/tratamento farmacológico , Radiculopatia/etiologia
13.
Early Hum Dev ; 137: 104828, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31357084

RESUMO

BACKGROUND: Neonates that have been subjected to perinatal asphyxia and fulfill criteria for therapeutic hypothermia are cooled to 33.5 °C for 72 h. There is no consensus regarding sedation and analgesic use during hypothermia, but there is evidence supporting the importance of pain relief and adequate sedation. There is a need for assessment of the neonates need for pain relief and sedation, and for adjustments of medication to ensure adequate treatment. There are many different scoring tools available. We found the N-PASS (Neonatal Pain, Agitation and Sedation Scale) scoring tool to be the most suitable for this patient group as it assesses both pain and sedation. METHODS: We translated the scoring tool according to guidelines published by Wilder et al., and scored neonates treated with therapeutic hypothermia. Sedation and analgesia were adjusted according to scoring results. At the end of the study a questionnaire was filled out by the nurses in charge of this group of patients. RESULTS: Both pain and sedation scores did not reach the desired levels until day 3. The nurses reported a high level of satisfaction (79.7% were extremely of very satisfied), and 96.7% of the nurses found the neonates to be better pain relieved after the initiation of the study. CONCLUSION: The implementation of the N-PASS scoring tool in our unit has been successful, and has led to better pain relief and sedation than before the implementation.


Assuntos
Sedação Consciente/normas , Hipotermia Induzida/métodos , Terapia Intensiva Neonatal/normas , Manejo da Dor/normas , /métodos , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Feminino , Humanos , Hipotermia Induzida/efeitos adversos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/normas , Terapia Intensiva Neonatal/métodos , Masculino , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos
14.
Urology ; 132: 37-42, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31310773

RESUMO

OBJECTIVES: To examine the safety and effectiveness of placing ureteral stents in an office-based setting vs in the operating room (OR). METHODS: A retrospective chart review was performed to examine outcomes, specifically complication rate, unanticipated hospitalizations, and stent failures, when patients received JJ stents in the clinic procedure suite, using local analgesia and/or nitrous oxide gas analgesia, compared to patients who had ureteral stents placed in the OR, typically with general anesthesia. Additionally, multivariable analysis was performed to determine predictors of complications. RESULTS: Around 565 procedures were performed in the clinic and 179 were performed in the OR. The complication rate for the clinic group was 4.1%, compared to 7.8% in the OR group. Unplanned admissions to the hospital occurred after 3.0% of clinic procedures and 9.5% of OR procedures. Stent placements failed in 1.1% of clinic procedures and 0.56% of OR procedures. Clinic procedure time was 10 minutes vs 12 minutes in the OR (P <0.01). Clinic vs OR setting was not predictive of complications (P = 0.99). We did not identify factors that impacted complication rate in ureteral stent placement in the clinic vs OR setting. Notably, the procedure time for a clinic stent placement was significantly shorter than the OR stent placement. CONCLUSIONS: This study demonstrates excellent outcomes with a novel approach to a standard procedure, with shorter procedure time and no difference in complication rates.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Analgésicos não Entorpecentes , Sedação Consciente/métodos , Óxido Nitroso , Salas Cirúrgicas , Stents , Ureter/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Adulto Jovem
15.
Tex Heart Inst J ; 46(2): 120-123, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31236076

RESUMO

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.


Assuntos
Anestesia Local/métodos , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Sedação Consciente/métodos , Procedimentos Endovasculares/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Idoso , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Pessoa de Meia-Idade
16.
Curr Opin Anaesthesiol ; 32(4): 498-503, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31246712

RESUMO

PURPOSE OF REVIEW: Although the NORA setting continues to outgrow the main operating room in cases, there are few studies addressing efficiency metrics, and even fewer studies addressing those of a single specialty outpatient gastroenterology facility. In order to capitalize on this growing trend, gastrointestinal endoscopies must be scheduled in a way that prevents lost potential revenue while maintaining patient convenience, comfort, safety, and satisfaction. By standardizing our scheduling for procedure block time among various endoscopists and converting our sedation practices from conscious sedation to solely Propofol sedation in a 4 : 1 CRNA to Anesthesiologist model, we increased revenue while maximizing physician efficiency and site utilization. RECENT FINDINGS: The commonly used main operating room efficiency benchmarks cannot effectively be applied in NORA as these two locations have widely different procedure times, turn-around-times, and recovery times. In fact, procedures in gastrointestinal endoscopy suites can be completed in less time than a typical operating room takes for turnover. SUMMARY: By adapting our sedation practices to solely Propofol sedation and by standardizing our procedural schedule times among all the endoscopists, we maximized the number of cases and revenue in our outpatient gastrointestinal endoscopy suite while increasing patient satisfaction through reduction in overall patient facility time and procedure to discharge time.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Sedação Consciente/métodos , Eficiência Organizacional , Satisfação do Paciente , Admissão e Escalonamento de Pessoal/organização & administração , Instituições de Assistência Ambulatorial/economia , Sedação Consciente/economia , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/economia , Humanos , Dor Processual/etiologia , Dor Processual/prevenção & controle , Dor Processual/psicologia , Alta do Paciente , Admissão e Escalonamento de Pessoal/economia , Propofol/administração & dosagem , Fatores de Tempo
17.
Crit Care Nurse ; 39(3): 59-66, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31154332

RESUMO

Pain management and sedation strategies have become more complex in recent years, with accompanying documented increases in morbidity and mortality. Consequently, various government agencies and professional associations have issued requirements or recommendations designed to ensure optimal and safe pain management in different populations. The pediatric nurse must understand the rationale behind these guidelines, which pain and sedation assessment tools are valid and reliable, how and when to use these tools, and the purpose and limitations of each tool. This article summarizes the recent recommendations, identifies valid and reliable pediatric pain and sedation assessment tools, and describes the appropriate use of these tools to provide safe and high-quality patient care.


Assuntos
Sedação Consciente/normas , Hipnóticos e Sedativos/administração & dosagem , Manejo da Dor/métodos , Enfermagem Pediátrica/normas , Guias de Prática Clínica como Assunto , Criança , Pré-Escolar , Sedação Consciente/métodos , Educação Continuada em Enfermagem , Feminino , Humanos , Masculino , Dor/tratamento farmacológico , Pediatria , Reprodutibilidade dos Testes , Estados Unidos
18.
Pain Physician ; 22(3): 201-207, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31151329

RESUMO

Many of the patients undergoing interventional procedures have daily regimens of medications including analgesics, muscle relaxants, and other drugs that can have significant additive/synergistic effects during the perioperative period. Further, many patients also present with comorbid states, including obesity, cardiovascular, and pulmonary disease. Consequently, in the perioperative period, a significant number of patients have suffered permanent neurologic injury, hypoxic brain injury, and even death as a result of over sedation, hypoventilation, and spinal cord injury. In addition, physicians are concerned about aspiration, subsequent complications, and as a result, they ask patients to fast for several hours prior to the procedures. Based on extensive literature and consensus, a minimum fasting period is established as 2 hours before a procedure for clear liquids and 4 hours before procedure for light meals, rather than having all patients fast for 8 hours or even fasting beginning at midnight the night before the procedure. Gastrointestinal stimulants, gastric acid secretion blockers, and antacids may be used, even though not routinely recommended. Due to the nature of chronic pain and anxiety, many patients undergoing interventional techniques may require mild to moderate sedation. Deep sedation and/or general anesthesia for most interventional procedures is considered as unsafe, since the patient cannot communicate acute changes in symptoms, thus, resulting in morbidity and mortality, as well as creating compliance issues. We are adapting the published standards of the American Society of Anesthesiologists for monitoring patients under sedation, regardless of the location of the procedure, either office-based, in a surgery center, or a hospital outpatient department. These standards include monitoring of blood pressure, cardiac rhythm, temperature, pulse oximetry, and continuous quantitative end tidal CO2 monitoring. Sedation must be provided either by qualified anesthesia or non-anesthesia providers, with appropriate understanding of the medications, drug interactions, and resuscitative protocols.KEY WORDS: Guidelines, sedation, fasting status, monitoring, neurological complications.


Assuntos
Anestesiologia/métodos , Sedação Consciente/métodos , Monitorização Intraoperatória/métodos , Manejo da Dor/métodos , Jejum , Humanos , Masculino
19.
Curr Opin Anaesthesiol ; 32(4): 457-463, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31219870

RESUMO

PURPOSE OF REVIEW: The purpose of this review is to discuss current drugs used for intravenous moderate and deep sedation by nonanesthesiologists in the United States. We also explore training expectations for moderate and deep sedation as they play key roles in anesthetic selection and preprocedural planning. RECENT FINDINGS: Although opioids and benzodiazepines are considered the standard for moderate sedation, increased interest in propofol, dexmedetomidine, and other sedative-hyptonic drugs require additional attention in terms of training providers and complying with current practice guidelines. SUMMARY: Moderate sedation providers should be familiar with titrating benzodiazepines and opioids to achieve targeted sedation. The use of propofol and ketamine is generally reserved for deep sedation by qualified professionals. However, the role of dexmedetomidine in procedural sedation continues to evolve as its use is explored in moderate sedation. Providers of all sedation types should be aware of hypotension, apnea, hypoventilation, and hypoxia that can develop and they should be able to manage the patient under these circumstances. Preprocedural planning is an integral training expectation to minimize patient risks.


Assuntos
Anestesiologia/educação , Sedação Consciente/métodos , Sedação Profunda/métodos , Educação Médica Continuada , Hipnóticos e Sedativos/administração & dosagem , Administração Intravenosa , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestesiologia/normas , Apneia/diagnóstico , Apneia/etiologia , Benzodiazepinas/administração & dosagem , Benzodiazepinas/efeitos adversos , Sedação Consciente/efeitos adversos , Sedação Consciente/normas , Estado de Consciência/efeitos dos fármacos , Sedação Profunda/efeitos adversos , Sedação Profunda/normas , Dexmedetomidina/administração & dosagem , Dexmedetomidina/efeitos adversos , Relação Dose-Resposta a Droga , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/diagnóstico , Hipotensão/etiologia , Hipoventilação/diagnóstico , Hipoventilação/etiologia , Hipóxia/diagnóstico , Hipóxia/etiologia , Guias de Prática Clínica como Assunto , Propofol/administração & dosagem , Propofol/efeitos adversos
20.
Gastrointest Endosc ; 90(3): 502-505, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31102644

RESUMO

BACKGROUND AND AIMS: The debate between moderate sedation versus deep sedation for index average-risk screening colonoscopies is well known to gastroenterologists. Ensuring the best of all metrics to perform quality colonoscopies for colon cancer prevention is paramount for both patients and physicians alike, because colon cancer remains the leading cause of cancer death and is the most-used screening tool in the United States. The aim of this study was to determine if moderate sedation versus deep sedation affects outcomes of adenoma detection rate (ADR) or polyp detection rate (PDR) in index, average-risk colonoscopies for colon cancer screening. METHODS: A retrospective, single, tertiary care outpatient center study of 585 healthy average-risk patients who underwent index screening colonoscopy between June 1, 2015 to December 31, 2015 (moderate sedation only) and June 1, 2016,to December 31, 2016 (deep sedation only) was performed after Institutional Review Board approval. Demographic data and polyp details were collected to determine ADR and PDR. Patients who were not average risk were excluded from the study. RESULTS: A total of 585 index average-risk screening colonoscopies were included in this study with 57.7% moderate sedation and 42.2% deep sedation. Neither ADR nor PDR was significantly different between the 2 groups (44.1% vs 38.5% [P = .18] and 71.9% vs 67.6% [P = .27], respectively). CONCLUSIONS: In index average-risk screening colonoscopies, deep sedation appears to have no benefit compared with moderate sedation for ADR and PDR.


Assuntos
Adenoma/diagnóstico , Pólipos Adenomatosos/diagnóstico , Pólipos do Colo/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Sedação Consciente/métodos , Sedação Profunda/métodos , Detecção Precoce de Câncer , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA