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1.
Medicine (Baltimore) ; 100(14): e25324, 2021 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-33832107

RESUMO

BACKGROUND: Awake fiberoptic endoscope intubation (AFOI) is the primary strategy for managing anticipated difficult airways. Adequate sedation, most commonly being achieved with remifentanil and dexmedetomidine, is integral to this procedure. This meta-analysis aimed to compare the safety and efficacy of these 2 sedatives. METHODS: We conducted electronic searches in Embase, Web of Science, PubMed, Google Scholar, Medline, Springer, and Web of Science with no language restrictions. Studies comparing safety and efficacy between the sole use of remifentanil and dexmedetomidine among patients who underwent AFOI were included. Eight randomized controlled trials, comprising 412 patients, met the inclusion criteria. The primary outcomes were first attempt intubation success rate and incidence of hypoxia. The secondary outcomes were the Ramsay Sedation Scale score at intubation, memory recall of endoscopy, and unstable hemodynamic parameters during intubation. RESULTS: Dexmedetomidine significantly reduced the incidence of hypoxemia during AFOI (risk ratio: 2.47; 95% confidence [CI]: 1.32-4.64]) compared with remifentanil; however, the first intubation success rates were equivalent (risk ratio: 1.12; 95% CI: 0.87-1.46]. No significant differences between the 2 sedatives were found for the Ramsay Sedation Scale score at intubation (mean difference: -0.14; 95% CI: -0.66-0.38) or unstable hemodynamic parameters during intubation (risk ratio: 0.83; 95% CI: 0.59-1.17). Dexmedetomidine reduced memory recall of endoscopy (risk ratio: 1.39; 95% CI: 1.13-1.72). CONCLUSIONS: While both remifentanil and dexmedetomidine are effective for AFOI and well-tolerated, dexmedetomidine may be more effective in reducing the incidence of hypoxemia and memory recall of endoscopy. PROSPERP REGISTRATION NUMBER: CRD42020169612.


Assuntos
Sedação Consciente/métodos , Dexmedetomidina/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Intubação Intratraqueal/métodos , Remifentanil/uso terapêutico , Dexmedetomidina/administração & dosagem , Dexmedetomidina/efeitos adversos , Endoscopia/instrumentação , Endoscopia/métodos , Tecnologia de Fibra Óptica , Hemodinâmica , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipóxia/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Remifentanil/administração & dosagem , Remifentanil/efeitos adversos
2.
Medicine (Baltimore) ; 100(9): e25033, 2021 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-33655976

RESUMO

ABSTRACT: Children evaluated in the emergency department for head trauma often undergo computed tomography (CT), with some uncooperative children requiring pharmacological sedation. Chloral hydrate (CH) is a sedative that has been widely used, but its rectal use for child sedation after head trauma has rarely been studied. The objective of this study was to document the safety and efficacy of rectal CH sedation for cranial CT in young children.We retrospectively studied all the children with head trauma who received rectal CH sedation for CT in the emergency department from 2016 to 2019. CH was administered rectally at a dose of 50 mg/kg body weight. When sedation was achieved, CT scanning was performed, and the children were monitored until recovery. The sedative safety and efficacy were analyzed.A total of 135 children were enrolled in the study group, and the mean age was 16.05 months. The mean onset time was 16.41 minutes. Successful sedation occurred in 97.0% of children. The mean recovery time was 71.59 minutes. All of the vital signs were within normal limits after sedation, except 1 (0.7%) with transient hypoxia. There was no drug-related vomiting reaction in the study group. Adverse effects occurred in 11 patients (8.1%), but all recovered completely. Compared with oral CH sedation, rectal CH sedation was associated with quicker onset (P < .01), higher success rate (P < .01), and lower adverse event rate (P < .01).Rectal CH sedation can be a safe and effective method for CT imaging of young children with head trauma in the emergency department.


Assuntos
Hidrato de Cloral/administração & dosagem , Sedação Consciente/métodos , Traumatismos Craniocerebrais/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Administração Retal , Pré-Escolar , Feminino , Seguimentos , Humanos , Hipnóticos e Sedativos/administração & dosagem , Lactente , Masculino , Estudos Retrospectivos
3.
N Engl J Med ; 384(15): 1424-1436, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33528922

RESUMO

BACKGROUND: Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS: In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 µg per kilogram of body weight per hour) or propofol (5 to 50 µg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS: Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 µg per kilogram per hour, and 208 received propofol at a median dose of 10.21 µg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS: Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).


Assuntos
Sedação Consciente/métodos , Dexmedetomidina , Hipnóticos e Sedativos , Propofol , Respiração Artificial , Sepse/terapia , Adulto , Cognição/efeitos dos fármacos , Estado Terminal , Dexmedetomidina/administração & dosagem , Método Duplo-Cego , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Estimativa de Kaplan-Meier , Propofol/administração & dosagem , Sepse/mortalidade
4.
Medicine (Baltimore) ; 100(7): e24786, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33607831

RESUMO

INTRODUCTION: Routine anesthesia modality for modified radical mastectomy (MRM) includes general anesthesia (GA), epidural blockade-combined GA and nerve blockade-combined GA. However, GA has been associated with postoperative adverse effects such as vertigo, postoperative nausea and vomiting and requirement for postoperative analgesia, which hinders recovery and prognosis. Moreover, combined blockade of thoracic paravertebral nerves or intercostal nerves and adjuvant basic sedation for massive lumpectomy provided perfect anesthesia and reduced opioid consumption, whereas the excision coverage did not attain the target of MRM. Regional anesthesia strategies involving supplementation of analgesics in ultrasound-guided multiple nerve blocks have garnered interests of clinicians. Nevertheless, the precise effects of intercostal nerves, brachial plexus and supraclavicular nerves in MRM in patients with breast cancer remain obscure. METHODS: Eighty female patients with breast cancer scheduled for MRM were recruited in the present trial between May, 2019 and Dec., 2019 in our hospital. The patients ranged from 30 to 65 years of age and 18∼30 kg/m2 in body-mass index, with the American Society of Anesthesiologists I or II. The patients were randomized to ultrasound-guided multiple nerve blocks group and GA group. The patients in multiple nerve blocks group underwent ultrasound guided multiple intercostal nerve blocks, interscalene brachial plexus and supraclavicular nerve blocks, (local anesthesia with 0.3% ropivacaine: 5 ml for each intercostal nerve block, 8 ml for brachial plexus block, 7 mL for supraclavicular nerve block) and basic sedation and intraoperative mask oxygen inhalation. The variations of hemodynamic parameters such as mean arterial pressure, heart rate (HR) and pulse oxygen saturation were monitored. The visual analog scale scores were recorded at postoperative 0 hour, 3 hour, 6 hour, 12 hour and 24 hour in resting state. The postoperative adverse effects, including vertigo, postoperative nausea, and vomiting, pruritus, and urinary retention and so on, as well as the analgesic consumption were recorded. CONCLUSIONS: The ultrasound guided multiple intercostal nerve blocks, brachial plexus and supraclavicular nerve blocks could provide favorable anesthesia and analgesia, with noninferiority to GA and the reduced incidence of adverse effects and consumption of postoperative analgesics.


Assuntos
Neoplasias da Mama/cirurgia , Sedação Consciente/métodos , Mastectomia Radical Modificada/métodos , Bloqueio Nervoso/métodos , Anestesia Geral/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Dor Pós-Operatória/prevenção & controle , Ultrassonografia de Intervenção/métodos
5.
Br J Anaesth ; 126(3): 684-691, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33495020

RESUMO

BACKGROUND: With the increasing prevalence of children who are overweight and with obesity, anaesthesiologists must determine the optimal dosing of medications given the altered pharmacokinetics and pharmacodynamics in this population. We therefore determined the single dose of dexmedetomidine that provided sufficient sedation in 95% (ED95) of children with and without obesity as measured by a minimum Ramsay sedation score (RSS) of 4. METHODS: Forty children with obesity (BMI >95th percentile for age and gender) and 40 children with normal weight (BMI 25th-84th percentile), aged 3-17 yr, ASA physical status 1-2, undergoing elective surgery, were recruited. The biased coin design was used to determine the target dose. Positive responses were defined as achievement of adequate sedation (RSS ≥4). The initial dose for both groups was dexmedetomidine 0.3 µg kg-1 i.v. infusion for 10 min. An increment or decrement of 0.1 µg kg-1 was used depending on the responses. Isotonic regression and bootstrapping methods were used to determine the ED95 and 95% confidence intervals (CIs), respectively. RESULTS: The ED95 of dexmedetomidine for adequate sedation in children with obesity was 0.75 µg kg-1 with 95% CI of 0.638-0.780 µg kg-1, overlapping the CI of the ED95 estimate of 0.74 µg kg-1 (95% CI: 0.598-0.779 µg kg-1) for their normal-weight peers. CONCLUSIONS: The ED95 values of dexmedetomidine administered over 10 min were 0.75 and 0.74 µg kg-1 in paediatric subjects with and without obesity, respectively, based on total body weight. CLINICAL TRIAL REGISTRATION: ChiCTR1800014266.


Assuntos
Sedação Consciente/métodos , Dexmedetomidina/administração & dosagem , Cálculos da Dosagem de Medicamento , Hipnóticos e Sedativos/administração & dosagem , Obesidade/metabolismo , Adolescente , Índice de Massa Corporal , Criança , Pré-Escolar , Sedação Consciente/estatística & dados numéricos , Dexmedetomidina/farmacocinética , Relação Dose-Resposta a Droga , Procedimentos Cirúrgicos Eletivos , Humanos , Hipnóticos e Sedativos/farmacocinética , Infusões Intravenosas
6.
Pediatr Blood Cancer ; 68(1): e28650, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32779871

RESUMO

A standardized multidisciplinary step-by-step approach to improve the compliance of young (or difficult) children having to undergo radiotherapy was described and applied. The procedure is called SIESTA, which stands for show-imagination-evaluation-support-treatment-anesthesia. Preliminary assessments suggest that the SIESTA approach was effective: the rate of young patients (≤6 years) requiring anesthesia decreased from 27% (14/52 cases) in 2011-2012 (before the procedure was adopted) to 13% (6/46) in 2018.


Assuntos
Anestesia Geral/métodos , Sedação Consciente/métodos , Comunicação Interdisciplinar , Neoplasias/radioterapia , Cooperação do Paciente/estatística & dados numéricos , Radioterapia (Especialidade)/normas , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Prognóstico
7.
Emerg Med Clin North Am ; 39(1): 203-216, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33218658

RESUMO

There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Sedação Consciente , Indução e Intubação de Sequência Rápida , Lesões Encefálicas Traumáticas/fisiopatologia , Sedação Consciente/métodos , Serviço Hospitalar de Emergência , Humanos , Indução e Intubação de Sequência Rápida/métodos
8.
Ann Emerg Med ; 77(1): 91-102, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33353592

RESUMO

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.


Assuntos
Sedação Consciente , Serviço Hospitalar de Emergência , Regulamentação Governamental , Centers for Medicare and Medicaid Services, U.S./normas , Sedação Consciente/métodos , Serviço Hospitalar de Emergência/legislação & jurisprudência , Humanos , Estados Unidos , United States Food and Drug Administration/normas
9.
Av. odontoestomatol ; 36(4): 180-185, sept.-dic. 2020. ilus, tab, graf
Artigo em Espanhol | IBECS | ID: ibc-198587

RESUMO

OBJETIVO: El objetivo del estudio fue evaluar si la sedación consciente reconduce o no la conducta del paciente pediátrico, en la consulta dental. METODOLOGÍA: La muestra del estudio clínico se obtuvo de sesenta y cinco pacientes que no permiten el tratamiento dental en la consulta odontológica,con edades comprendidas entre los 4 y 9 nueve años de edad. RESULTADOS: De los 65 pacientes que representa el 100% de la muestra, se obtuvo que el 86,15% pudo reconducir la conducta después de la sedación consciente. Sin embargo, en el 13,85% el comportamiento después de la sedación consciente no se pudo reconducir. CONCLUSIÓN: La sedación conscientepuede ayudar a reducir la fobia, estrés que los pacientes pediátricos presentes en la consulta dental. Asimismo, nos permiten llevar a cabo el tratamiento previsto, además de ayudar a reconducir la conducta del paciente


INTRODUCTION: The objective of the study was to evaluate whether conscious sedation redirected or not the behavior of the pediatric patient, in the dental office. MATERIALS AND METHODS: The clinical study sample was obtained from sixty-five patients who do not allow treatment in the dental office, aged between 4 and 9 years. RESULTS: Of the 65 patients representing 100% of the sample, it was obtained that 86.15% was able to redirect the behavior after conscious sedation. However, in 13.85% the behavior after conscious sedation could not be redirected. CONCLUSION: Conscious sedation can help reduce phobia, stress that pediatric patients present in the dental office. They also allow us to carry out the planned treatment, in addition to helping to redirect the patient's behavior


Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Comportamento Infantil/psicologia , Sedação Consciente/métodos , Assistência Odontológica para Crianças/psicologia , Estudos Transversais , Odontopediatria/organização & administração , Assistência Odontológica para Crianças/organização & administração
10.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(6): 279-288, nov.-dic. 2020. tab, ilus
Artigo em Espanhol | IBECS | ID: ibc-197922

RESUMO

INTRODUCCIÓN: Los tumores cerebrales gliales precisan habitualmente de un tratamiento neuroquirúrgico y se asocian con diversas alteraciones cognitivas, emocionales y comportamentales. El mapeo cerebral intraoperatorio es la técnica por excelencia utilizada para optimizar el equilibrio oncofuncional. La valoración e intervención desde la perspectiva neuropsicológica tiene gran relevancia en este tipo de procedimientos. Actualmente, se carece de una estructura protocolizada para la exploración y el seguimiento neuropsicológico que estos pacientes necesitan. MÉTODO: Se realiza un estudio descriptivo retrospectivo de 52 pacientes, todos ellos con diagnóstico de tumor glial, describiendo la estructura del protocolo desarrollado en nuestro centro. Se analizan los datos de la evaluación neuropsicológica, comparando el rendimiento inicial de los pacientes con su rendimiento posterior a la cirugía a corto y a largo plazo. RESULTADOS: Se describe nuestra experiencia en algunas las fases del protocolo, detallando las tareas que se han desarrollado para valorar a los pacientes dentro del quirófano. Los resultados de los datos de las evaluaciones neuropsicológicas objetivan déficits en el momento posterior a la cirugía que remiten en la valoración a largo plazo. CONCLUSIONES: Destacamos la necesidad de dar espacio y protocolizar en la asistencia hospitalaria los aspectos cognitivos y emocionales de los pacientes que sufren cualquier patología que conlleve daño cerebral adquirido. Este tipo de abordaje está orientado a aumentar la calidad de vida de los pacientes oncológicos estructurando y optimizando las tareas durante su intervención quirúrgica, pero también atendiendo a las dificultades neuropsicológicas que manifiesten


INTRODUCTION: Glial brain tumours usually require neurosurgical treatment and they are associated with cognitive, emotional and behavioural impairments. Awake intraoperative brain mapping is the gold standard technique used to optimize the onco-functional balance. Neuropsychological assessment and intervention have relevance in this type of procedures. Currently, there is a lack of protocolled structure for the neuropsychological intervention being able to satisfy patient needs. METHOD: A retrospective descriptive study of 52 patients was performed, all of them with a diagnosis of glial tumour. The structure of the protocol developed in our centre is reported, also data of neuropsychological evaluation, comparing baseline performance with both immediate posterior performance, and long term performance. RESULTS: We describe our experience in each step of the intervention, highlighting the development of eight neurocognitive protocols for intraoperative brain mapping. The results of the neuropsychological examination objectify deficits in the immediate after surgery assessment which are reduced in the long-term assessment. CONCLUSIONS: We emphasize the need of providing and structuring the cognitive and emotional aspects of patients suffering from any pathology that entails acquired brain damage in hospital environment. This type of approach is aimed at increasing the quality of life of cancer patients by structuring and optimizing tasks during their surgical intervention and attending to the neuropsychological difficulties they suffer


Assuntos
Humanos , Masculino , Feminino , Adulto , Procedimentos Neurocirúrgicos/métodos , Testes Neuropsicológicos , Glioma/cirurgia , Neoplasias Encefálicas/cirurgia , Vigília , Sedação Consciente/métodos , Protocolos Clínicos , Estudos Retrospectivos , Cuidados Pós-Operatórios
12.
Medicine (Baltimore) ; 99(46): e23147, 2020 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-33181685

RESUMO

Whether a strategy of postoperative non-sedation produces better outcomes compared with sedation in patients after head and neck reconstruction remains controversial. Therefore, we retrospectively investigated outcomes in 150 of these patients in our institution.Patients with head and neck cancer that received free anterolateral thigh flap were studied retrospectively, and were categorized in terms of their postoperative care into "sedation" and "non-sedation" groups. The related parameters of each patient were collected for analysis.Overall, 150 patients were included (sedation protocol (N = 56) and non-sedation strategy (N = 94)). No significant differences were observed between groups in patient demographics or postoperative outcomes. Significantly shorter durations of mean and median intensive care unit (ICU) length of stay, mechanical ventilation, hospitalization, and operative time were observed in the non-sedation group than in the sedation group. Among all patients, the sedation and flap reopen were the common variables related to prolonged ICU stay, mechanical ventilator duration, and hospitalization.The current study suggested the strategy of postoperative non-sedation is associated with a significant decrease in the duration of mechanical ventilation, ICU length of stay, hospitalization. Regardless of hospital stay, there were no differences in postoperative outcome between 2 groups.


Assuntos
Sedação Consciente , Duração da Terapia , Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço/cirurgia , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Reconstrutivos , China/epidemiologia , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Sedação Consciente/estatística & dados numéricos , Feminino , Retalhos de Tecido Biológico/efeitos adversos , Retalhos de Tecido Biológico/irrigação sanguínea , Retalhos de Tecido Biológico/transplante , Neoplasias de Cabeça e Pescoço/epidemiologia , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos
13.
Isr Med Assoc J ; 22(10): 599-601, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33070480

RESUMO

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the pathogen that causes coronavirus disease-2019 (COVID-19), is thought to be transmitted via droplets and aerosols, and was detected in saliva of infected individuals. These droplets from the upper airway may infect the inhalation sedation mask and tubing. The authors determined the adequate measures needed to prevent the transmission of COVID-19 by nitrous-oxide (N2O) system during inhalation sedation in dentistry and provided evidence on mask and tubing sterilization. Additional measures to protect patients and healthcare workers from COVID-19 that may be transmitted by the inhalation sedation system are discussed. The authors recommend minimal use of a N2O system during inhalation sedation in dentistry. In case of need, the practitioners should have more than one scavenger kit and nasal masks for each N2O/O2 mixer. Biologic barriers should be mounted between the scavenger's tubing and the central evacuation system. Strict cleansing and sterilization should be performed for all parts of the N2O system. The use a disposable scavenger system and nasal mask should be considered as a viable option.


Assuntos
Anestesia Dentária/métodos , Sedação Consciente/efeitos adversos , Infecções por Coronavirus/prevenção & controle , Surtos de Doenças/prevenção & controle , Óxido Nitroso/farmacologia , Pandemias/prevenção & controle , Equipamento de Proteção Individual/estatística & dados numéricos , Pneumonia Viral/prevenção & controle , Administração por Inalação , Anestesia Dentária/efeitos adversos , Sedação Consciente/métodos , Infecções por Coronavirus/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Prova Pericial , Feminino , Humanos , Controle de Infecções/organização & administração , Israel , Masculino , Saúde do Trabalhador , Segurança do Paciente , Pneumonia Viral/epidemiologia
15.
Stroke ; 51(10): 2951-2959, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32895016

RESUMO

BACKGROUND AND PURPOSE: The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice. METHODS: Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used. RESULTS: Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts. CONCLUSIONS: In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.


Assuntos
Anestesia Local , Isquemia Encefálica/cirurgia , Sedação Consciente/métodos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento
16.
Med. paliat ; 27(3): 192-200, jul.-sept. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-197372

RESUMO

La pandemia por COVID-19 ha provocado una crisis sanitaria sin precedentes en nuestra historia reciente, con unas peculiaridades clínicas y sociales que han generado un importante papel de los equipos de cuidados paliativos (CP), destacando su participación en la toma de decisiones al final de la vida y en la elaboración de protocolos de sedación paliativa (SP). Una proporción significativa de pacientes con mala evolución, sin mejoría con los tratamientos disponibles ni criterios de ingreso en Unidades de Cuidados Intensivos (UCI), presentaron una alta carga sintomática y elevados niveles de sufrimiento por la refractariedad de los síntomas; por ello, de igual manera que sucede en otras enfermedades terminales, se requirió frecuentemente de la SP. A pesar del elevado número de trabajos sobre la infección por SARS-CoV-2, existe escasez de publicaciones hasta la fecha sobre SP en pacientes COVID. En este artículo revisamos la bibliografía existente y presentamos nuestra experiencia en tres unidades de cuidados paliativos hospitalarias respecto a las indicaciones de SP, fármacos y dosis, considerando además los importantes aspectos éticos en este contexto, como son la información al paciente y a la familia y la toma de decisiones en una situación de confinamiento de la población y de duras medidas de aislamiento. La pandemia por COVID-19 ha supuesto un desafío para todo el sistema sanitario, incluyendo los CP. Debemos aprovechar esta oportunidad para garantizar en el futuro el menor sufrimiento posible de nuestros pacientes, mediante el acceso a medidas terapéuticas como la SP


The COVID-19 pandemic has provoked an unprecedented health crisis in our recent history, with clinical and social peculiarities that have created an important role for Palliative Care (PC) teams, highlighting their participation in decision-making at the end of life and in the development of Palliative Sedation (PS) protocols. A significant percentage of patients with a negative evolution, without improvement with available treatments, or meeting admission criteria in an Intensive Care Unit (ICU) present with a high symptom loads and high levels of suffering due to symptom refractoriness; therefore, as is also the case with other terminal diseases, PS is frequently required. Despite the abundance of literature about the SARS-CoV-2 infection, there is so far a shortage of publications about PS in COVID patients. In this article we review the existing literature and present our experience in three Hospital Palliative Care Units regarding PS indications, drugs, and doses, considering also important ethical aspects in this context such as patient and family information, and decision-making in a situation of population confinement and strict isolation measures. The COVID-19 pandemic has been a challenge for the whole health care system, including PC. We must seize this opportunity to ensure that our patients suffer as little as possible in the future through access to therapeutic measures such as PS


Assuntos
Humanos , Hipnóticos e Sedativos/uso terapêutico , Cuidados Paliativos/métodos , Sedação Consciente/métodos , Sedação Profunda/métodos , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Tomada de Decisões , Cuidados Paliativos na Terminalidade da Vida/métodos , Respiração Artificial/métodos , Pandemias
17.
Medicine (Baltimore) ; 99(31): e21008, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756086

RESUMO

BACKGROUND: Dexmedetomidine (Dex) and chloral hydrate (CH) are the most frequently used sedative agents in pediatric patients. We aimed to systematically review the literature comparing the efficacy and safety of Dex and CH for sedation in pediatric patients. METHODS: Seven electronic databases and 3 clinical trial registry platforms were searched for articles published prior to October 2019. Randomized controlled trials (RCTs) evaluating the efficacy and safety of Dex versus CH for sedation in children were examined by 2 reviewers. The extracted information included the success rate of sedation, sedation latency, sedation duration, sedation recovery time, and adverse events. Moreover, the extracted data included 5 subgroups: the effects of 1, 1.5, 2, 2.5, and 3 µg/kg doses of Dex were compared with the effect of CH on the success rate of sedation. We also formed separate subgroups for different types of adverse events (incidence of vomiting, hypotension, bradycardia, etc). The outcomes were analyzed by Review Manager 5.3 software and are expressed as relative risks (RR) or the mean difference (MD) with the 95% confidence interval (CI). Heterogeneity was assessed with I-squared (I) statistics. RESULTS: A total of 15 RCTs involving 2128 children with Dex versus CH for sedation were included in the meta-analysis. The dose range of Dex ranged from 1 to 3 µg/kg. Compared with CH, the Dex group had a significantly higher success rate of sedation (RR = 1.14, 95% CI [1.05, 1.25], I = 79%, P = .003). Additionally, subgroup analysis revealed that there was no significant difference in the success rate of sedation between the CH group and the 1, 1.5, 2.5, and 3 µg/kg Dex groups; only the 2 µg/kg Dex group had a significantly higher success rate than the CH group (RR = 1.15, 95% CI [1.03, 1.29], I = 80%, P = .02). There was no significant difference in the number of subjects who required 2 doses or the duration of sedation between the CH and Dex groups. Furthermore, compared with the Dex group, the CH group had a significantly longer sedation latency (MD = -3.54, 95% CI [-5.94, -1.15], I = 95%, P = .004), sedation recovery time (MD = -30.08, 95% CI [-46.77, -13.39], I = 99%, P = .0004), and total time from sedative administration to discharge (MD = -12.73, 95% CI [-15.48, -9.97], I = 0%, P < .05), as well as a higher number of adverse events in total (RR = 0.25, 95% CI [0.11, 0.61], I = 89%, P = .002). Moreover, the subgroup analysis of adverse events revealed that CH was associated with higher risks of vomiting (RR = 0.07, 95% CI [0.03, 0.17], I = 0%, P < .0001), crying or resisting (RR = 0.22, 95% CI [0.07, 0.71], I = 60%, P = .01), and cough (RR = 0.15, 95% CI [0.05, 0.44], I = 0%, P = .0006); there was no significant difference in the risk of hypotension, supplemental oxygen, or respiratory events between CH and Dex. However, Dex was associated with a higher risk of bradycardia (RR = 4.08, 95% CI [1.63, 10.21], I = 0%, P = .003). CONCLUSIONS: Dex is an appropriate effective alternative to CH for sedation in pediatrics. However, considering the possibility of bradycardia, Dex should be used with caution.


Assuntos
Hidrato de Cloral/uso terapêutico , Sedação Consciente/métodos , Dexmedetomidina/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Criança , Humanos
19.
Medicine (Baltimore) ; 99(27): e20765, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629656

RESUMO

BACKGROUND: Remimazolam is a newly developed benzodiazepine as an alternative of conventional sedatives in the procedure of anesthesia. For the purpose of evaluating the efficacy and safety of remimazolam sedation during an endoscopy, we will perform a systematic review and meta-analysis of randomized controlled trials that compared remimazolam with midazolam and/or placebo. METHODS: We will search PubMed, Embase, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) from inception to December 2019 for randomized controlled trials that investigated efficacy and safety of remimazolam during an endoscopy. The job will be performed without language restriction. Experimental groups will include the interventions of remimazolam, while control groups will involve midazolam, placebo, or no controls. The primary outcome will be the onset time, followed by the secondary outcomes of the recovery time, the incidence of hypotension, the incidence of hypoxia and the incidence of bradycardia. Relative ratio or standardized mean difference will be used to measure the effect size of remimazolam. We will use I statistics to assess the between-study heterogeneity in each meta-analysis, Eager's test to detect publication bias. RESULTS: The results of this study will be published in a peer-reviewed journal. ETHICS AND DISSEMINATION: There is no need for ethical approval because all data used in this meta-analysis have been published. In addition, all data will be analyzed anonymously during the review process. PROTOCOL REGISTRATION NUMBER: CRD42020170745.


Assuntos
Analgesia/métodos , Benzodiazepinas , Sedação Consciente/métodos , Hipnóticos e Sedativos , Analgesia/efeitos adversos , Benzodiazepinas/efeitos adversos , Sedação Consciente/efeitos adversos , Humanos , Hipnóticos e Sedativos/efeitos adversos
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