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1.
Einstein (Sao Paulo) ; 18: eAO5168, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31994609

RESUMO

OBJECTIVE: To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. METHODS: A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. RESULTS: Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. CONCLUSION: This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.


Assuntos
Analgesia/métodos , Sedação Profunda/métodos , Delírio/diagnóstico , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Pediatras/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Analgesia/efeitos adversos , Analgesia/estatística & dados numéricos , Brasil , Sedação Profunda/efeitos adversos , Sedação Profunda/estatística & dados numéricos , Delírio/etiologia , Humanos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Inquéritos e Questionários
2.
J UOEH ; 41(2): 217-223, 2019.
Artigo em Japonês | MEDLINE | ID: mdl-31292367

RESUMO

The victim was a morbidly obese and bull-necked woman in her twenties. She had the disorders, due to Down's syndrome, including severe mental retardation, advanced hearing loss, congenital cataract surgery, and amblyopia at postoperative glaucoma. She was deeply sedated for rest with an intravenous drip infusion of 350 mg of thiopental (TP) for 5 minutes during an intraocular pressure examination with secondary glaucoma at a hospital. The examination was finished within 10 minutes after the TP injection, but her respiratory condition deteriorated rapidly when the doctor left the patient. Although immediate artificial respiration was carried out, she was declared dead about 20 hours after the examination. Medical malpractice was suspected for her death. At autopsy, no fatal disease or injury was observed in the victim. The serum TP level was 0.80 µg /ml. TP is an ultra-short-acting intravenous anesthetic, and usually only the smallest amount should be administered by frequent additions after pre-anesthesia administration while maintaining contact with patients. Although contact with patients with a disability can be difficult, it was diagnosed that the death was caused by both respiratory arrest due to a single dose of TP and delay in resuscitation due to the absence of a doctor.


Assuntos
Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Autopsia , Sedação Profunda/efeitos adversos , Síndrome de Down/complicações , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Imperícia/legislação & jurisprudência , Insuficiência Respiratória/induzido quimicamente , Tiopental/administração & dosagem , Tiopental/efeitos adversos , Adulto , Técnicas de Diagnóstico Oftalmológico/efeitos adversos , Evolução Fatal , Feminino , Glaucoma/diagnóstico , Glaucoma/etiologia , Humanos , Infusões Intravenosas , Pressão Intraocular , Adulto Jovem
3.
Curr Opin Anaesthesiol ; 32(4): 453-456, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31169549

RESUMO

PURPOSE OF REVIEW: Capnography is an excellent tool for early detection of hypoxemia and apnea in patients undergoing sedation for gastrointestinal endoscopy. The current American Society of Anesthesiology (ASA) guidelines recommend the use of capnography in any patient undergoing moderate sedation. The purpose of this review was to compile the most recent data available on capnography use in gastrointestinal endoscopy with the focus primarily on the use of capnography in moderate sedation cases. RECENT FINDINGS: Recent high-quality studies have evaluated the utility of capnography in low risk patients undergoing moderate sedation and have found no benefit with addition of capnography. SUMMARY: Capnography is beneficial when used for patients who are at a higher risk for sedation-related complications. There is no benefit when capnography is used in low risk patients undergoing routine upper endoscopy and colonoscopy under moderate sedation but there is benefit when used in advanced endoscopic procedures that require deeper sedation and have longer procedure times.


Assuntos
Capnografia/normas , Sedação Consciente/efeitos adversos , Sedação Profunda/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Monitorização Fisiológica/normas , Dor Processual/prevenção & controle , Apneia/diagnóstico , Apneia/etiologia , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Monitorização Fisiológica/métodos , Dor Processual/etiologia , Guias de Prática Clínica como Assunto , Fatores de Risco , Fatores de Tempo
4.
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
5.
Curr Opin Anaesthesiol ; 32(4): 464-471, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31219871

RESUMO

PURPOSE OF REVIEW: This review summarizes key features of adverse airway and respiratory events for which sedation providers must be prepared to diagnose and treat in a timely manner. Key features include elements of the presedation patient evaluation that predict adverse airway and respiratory events; patient profiles, target sedation levels, and procedure types that should prompt a consult with an anesthesiologist; necessary clinical skills, essential equipment, and reversal drugs necessary to manage adverse airway and respiratory events; and a proposed airway rescue pathway that describes a sequence of interventions and prompts to call for help when encountering an adverse airway or respiratory event. RECENT FINDINGS: Several studies have reported adverse events from sedation. Although the overall rate can approach 4.5%, the incidence of events associated with severe harm is low (e.g., <0.5%). Some that are most harmful are prolonged ventilatory compromise leading to hypoxic brain injury or death. Inadequate clinical skills that contribute to these poor outcomes include undetected or delayed detection of hypopnea, apnea, and partial or complete airway obstruction, inadequate rescue skills to manage drug-induced ventilatory depression or airway obstruction, and/or a delay or no attempt to call for expert help followed by a timely response and intervention from that expert help. SUMMARY: To improve outcomes in detecting and managing adverse airway and respiratory events, nonanesthesiologists sedation practitioners must be trained in patient selection, monitoring, pharmacology, physiology, and airway management. One gap in sedation training curriculum is a roadmap to use when managing an adverse airway or respiratory events. This review puts forth a suggested airway rescue pathway for nonanesthesiologist sedation practitioners to use as a decision aid during an adverse airway or respiratory event associated with procedural sedation.


Assuntos
Manuseio das Vias Aéreas/métodos , Sedação Consciente/efeitos adversos , Sedação Profunda/efeitos adversos , Hipnóticos e Sedativos/efeitos adversos , Insuficiência Respiratória/terapia , Competência Clínica , Tomada de Decisão Clínica/métodos , Procedimentos Clínicos , Humanos , Hipnóticos e Sedativos/administração & dosagem , Monitorização Fisiológica , Dor Processual/prevenção & controle , Seleção de Pacientes , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/etiologia
6.
Medicine (Baltimore) ; 98(22): e15906, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31145352

RESUMO

This study aimed to investigate the risk factors and whether acute hypercapnia contributes to postoperative delirium (POD) during bronchoscopic intervention under general anesthesia or deep sedation.A prospective study was conducted with 119 consecutive patients who had undergone bronchoscopic intervention between February 2016 and December 2016 at the Emergency General Hospital.Twenty-eight patients (23.8%) were diagnosed with POD. The patients were divided into 2 groups: the POD (n = 28) and the control group (n = 91). The mean age of the POD group was higher than that of the control group (P < .01). All the blood gas values, PaCO2 (P < .01), PaO2 (P < .01), and PH (P < .01), were significantly different. Multivariate analyses revealed that age (P < .01), operation duration (P = .01), and PO2 (P = .01) were independent predictive factors of POD, while hypercapnia (P = .54) was established as not being a predictive factor of POD.Age, operation duration, and PO2 were determined as independent predictive factors of POD, whereas moderate hypercapnia is not likely to contribute to POD in patients undergoing bronchoscopic intervention. Clinical Trial Registration Identifier: ChiCTR-POC-15007483.


Assuntos
Anestesia Geral/efeitos adversos , Broncoscopia/efeitos adversos , Sedação Profunda/efeitos adversos , Delírio/etiologia , Hipercapnia/complicações , Complicações Pós-Operatórias/etiologia , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Duração da Cirurgia , Complicações Pós-Operatórias/psicologia , Fatores de Risco
7.
Eur J Anaesthesiol ; 36(6): 390-399, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30950900

RESUMO

BACKGROUND: Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. OBJECTIVES: To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. DESIGN: An observational study. SETTING: Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. PATIENTS: The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. MAIN OUTCOME MEASURES: The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. RESULTS: Mean ±â€ŠSD age of the children was 8.5 ±â€Š4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful. CONCLUSION: The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome. TRIAL REGISTRATION: ISRCTN70362666.


Assuntos
Anestesia Geral/efeitos adversos , Sedação Profunda/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Monitorização Neurofisiológica Intraoperatória , Adolescente , Anestesia Geral/métodos , Criança , Pré-Escolar , Sedação Profunda/métodos , Estudos de Viabilidade , Feminino , Humanos , Incidência , Lactente , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Masculino , Prevalência , Estudos Prospectivos , Medição de Risco , Fatores de Risco
8.
Crit Care ; 23(1): 130, 2019 04 17.
Artigo em Inglês | MEDLINE | ID: mdl-30995940

RESUMO

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.


Assuntos
Sedação Consciente/normas , Sedação Profunda/normas , Resultado do Tratamento , APACHE , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Analgésicos/uso terapêutico , Antipsicóticos/administração & dosagem , Antipsicóticos/efeitos adversos , Antipsicóticos/uso terapêutico , Estudos de Coortes , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Sedação Profunda/efeitos adversos , Sedação Profunda/métodos , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Bloqueadores Neuromusculares/administração & dosagem , Bloqueadores Neuromusculares/efeitos adversos , Bloqueadores Neuromusculares/uso terapêutico , Razão de Chances , Peru , Estudos Prospectivos , Respiração Artificial/métodos
9.
Semin Pediatr Surg ; 28(1): 33-42, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30824132

RESUMO

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.


Assuntos
Analgesia/métodos , Sedação Consciente/métodos , Cuidados Críticos/métodos , Sedação Profunda/métodos , Delírio , Assistência Perioperatória/métodos , Analgesia/efeitos adversos , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia/psicologia , Ansiolíticos/uso terapêutico , Ansiedade/tratamento farmacológico , Ansiedade/etiologia , Criança , Sedação Consciente/efeitos adversos , Sedação Consciente/psicologia , Cuidados Críticos/psicologia , Estado Terminal , Sedação Profunda/efeitos adversos , Sedação Profunda/psicologia , Delírio/diagnóstico , Delírio/etiologia , Delírio/prevenção & controle , Delírio/psicologia , Humanos , Pediatria , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/psicologia
10.
Med. intensiva (Madr., Ed. impr.) ; 43(1): 3-9, ene.-feb. 2019. tab, graf
Artigo em Inglês | IBECS | ID: ibc-181524

RESUMO

Objective: Cognitive impairment after intensive care unit (ICU) admission is becoming increasingly recognized. High-dose deep sedation has been suggested to play an important role in the development of cognitive impairment. However, the impact of heavy sedation as a single cause in the development of cognitive impairment in ICU patients remains unclear. In this study we investigated whether a three-day deep sedation protocol could reduce cognitive function in mechanically ventilated non-critical patients. Design: A prospective observational study was carried out. Patients: A total of 17 surgical patients were studied. Intervention: None. Variables of interest: Cognitive function before and after ICU admission. Results: Thirty-one patients requiring three days of sedation after microvascular reconstruction were initially enrolled in the study. Sedation in the ICU was maintained with propofol and dexmedetomidine combined with fentanyl. Cognitive function was assessed using a battery of 6 neuropsychological tests two days before surgery and three weeks after surgery. Finally, a total of 17 patients were included in the analysis. Cognitive impairment (defined as a decline of >20% from the pre-admission cognitive evaluation scores in at least two of 6 tests) was observed in 5 of the 17 patients (29%). However, there were no significant differences between the pre- and post-admission cognitive evaluations in 6 tests. Conclusions: Middle-term cognitive function can be impaired in some patients subjected to deep sedation during several days following maxillary-mandibular oral surgery with microvascular reconstruction


Objetivo: Cada vez existe un mayor consenso sobre la afectación cognitiva tras el ingreso en la unidad de cuidados intensivos (UCI). Se ha sugerido que la sedación profunda con dosis elevada desempeña un papel importante en el desarrollo de la alteración cognitiva. Sin embargo, todavía existen dudas sobre el impacto de este tipo de sedación como causa única del desarrollo de alteraciones cognitivas en pacientes ingresados en la UCI. En este estudio, investigamos si la aplicación de un protocolo de sedación profunda durante 3 días disminuía la función cognitiva en pacientes no críticos bajo ventilación mecánica. Diseño: Se llevó a cabo un estudio observacional prospectivo. Pacientes: Se estudió a un total de 17 pacientes quirúrgicos. Intervenciones: Ninguna. Variables de interés: Función cognitiva antes y después del ingreso en la UCI. Resultados: En este estudio se incluyó inicialmente a 31 pacientes que requerían 3 días de sedación tras una reconstrucción microvascular. Se mantuvo la sedación en la UCI con propofol y dexmedetomidina en combinación con fentanilo. Se evaluó la función cognitiva mediante un grupo de 6 pruebas neurofisiológicas antes de la intervención y 3 días después de esta. Por último, se incluyó a un total de 17 pacientes en el análisis. Se observó alteración cognitiva (definida como una reducción>20% frente a las puntuaciones de la evaluación cognitiva previa al ingreso en al menos 2 de las 6 pruebas) en 5 de los 17 pacientes (29%). Sin embargo, no se observaron diferencias significativas entre las evaluaciones previas y posteriores al ingreso en 6 pruebas. Conclusiones: La función cognitiva a medio plazo puede verse afectada en algunos pacientes sometidos a sedación profunda durante varios días tras una cirugía oral maxilar-mandibular con reconstrucción microvascular


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Sedação Profunda/efeitos adversos , Respiração Artificial , Procedimentos Cirúrgicos Bucais , Cuidados Críticos , Disfunção Cognitiva/induzido quimicamente , Estudos Prospectivos , Unidades de Terapia Intensiva , Neurofisiologia , Período Pós-Operatório , Sedação Profunda/métodos , Cognição/efeitos dos fármacos
11.
J Cardiovasc Electrophysiol ; 30(1): 141-148, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30230098

RESUMO

INTRODUCTION: The subcutaneous implantable cardioverter-defibrillator (S-ICD) is most commonly implanted under general anesthesia (GA), due to the intraoperative discomfort associated with tunneling and dissection. Postoperative pain can be substantial and is often managed with opioids. There is a growing interest in transitioning away from the routine use of GA during S-ICD implantation, while also controlling perioperative discomfort without the use of narcotics. As such, we assessed the feasibility of a multimodal analgesia regimen that included regional anesthesia techniques in patients undergoing S-ICD implantation. METHODS AND RESULTS: Twenty patients received truncal plane block (TBL) immediately before S-ICD implantation. The first 10 patients were implanted under general anesthesia (GA + TBL), and the next 10 patients were implanted under deep sedation (DS + TBL). Additionally, the DS + TBL patients were also prescribed a structured regimen of nonopioid analgesics in the perioperative period. Opioid consumption was calculated as milligram morphine equivalents (MME). In-hospital opioid consumption was significantly lower in the patients implanted with DS + TBL (MME = 0) as compared with patients receiving GA + TBL (MME = 60; P = 0.004). CONCLUSIONS: Subcutaneous ICD implantation with anesthesia-delivered DS and a multimodal anesthetic regimen that includes TBL is feasible and associated with significantly less perioperative opioid consumption.


Assuntos
Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/administração & dosagem , Anestesia Geral , Bloqueio Nervoso Autônomo , Sedação Profunda , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Dor Pós-Operatória/prevenção & controle , Implantação de Prótese/instrumentação , Adulto , Idoso , Analgésicos não Entorpecentes/efeitos adversos , Analgésicos Opioides/efeitos adversos , Anestesia Geral/efeitos adversos , Bloqueio Nervoso Autônomo/efeitos adversos , Sedação Profunda/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Implantação de Prótese/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento
12.
J Cardiovasc Med (Hagerstown) ; 20(1): 16-22, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30394961

RESUMO

AIMS: Electrical cardioversion is still the preferred method to restore sinus rhythm in patients with atrial fibrillation. The main disadvantage is that electrical cardioversion requires deep sedation, generally administered by anaesthesiologists, for safety concern. An exclusively cardiologic management of deep sedation should have the advantage to reduce resources and time consumed. METHODS: All consecutive patients admitted to our division with persistent atrial fibrillation or atrial flutter to undergo elective electrical cardioversion from June 2002 to December 2016 were included. The sedation protocol was managed only by cardiologists and involved the administration of a 5-mg bolus of midazolam, followed by increasing doses of propofol to achieve the desired sedation level. Exclusion criteria were strictly observed. Complications were recorded. A retrospective analysis on a deidentified database has been performed. RESULTS: A total of 1188 electrical cardioversions were scheduled in our centre. A total of 1195 patients were scheduled in our centre, of whom 1188 met inclusion criteria. Electrical cardioversion was performed in 1073 cases (90.3%). Electrical cardioversion was successful in restoring sinus rhythm in 1030 (96.0%) patients. Immediate recurrence of atrial fibrillation occurred in 89 patients (8.3%). 99/1073 (9.22%) patients underwent trans-oesophagel echocardiography before cardioversion. Deep sedation, according to our protocol, was effective in 100% of cases. Midazolam was administered at a dosage of 5 mg to all patients, while propofol was administered at a dosage ranging from 20 to 80 mg (25.1 ±â€Š11.0 mg SD). No anaesthesia-related complications were observed, neither significant respiratory depression requiring intubation nor anaesthesiologist support. CONCLUSION: The exclusively cardiological procedure of deep sedation seems to be safe and effective.


Assuntos
Anestésicos Combinados/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Fibrilação Atrial/terapia , Flutter Atrial/terapia , Cardiologistas , Sedação Profunda/métodos , Cardioversão Elétrica , Midazolam/administração & dosagem , Propofol/administração & dosagem , Idoso , Anestésicos Combinados/efeitos adversos , Anestésicos Intravenosos/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Bases de Dados Factuais , Sedação Profunda/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Midazolam/efeitos adversos , Pessoa de Meia-Idade , Propofol/efeitos adversos , Recidiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Fluxo de Trabalho
14.
Gastrointest Endosc ; 89(4): 855-862, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30217726

RESUMO

BACKGROUND AND AIMS: ERCP is a complex procedure often performed in patients at high risk for sedation-related adverse events (SRAEs). However, there is no current standard of care with regard to mode of sedation and airway management during ERCP. The aim of this study was to assess the safety of general endotracheal anesthesia (GEA) versus propofol-based monitored anesthesia care (MAC) without endotracheal intubation in patients undergoing ERCP at high risk for SRAEs. METHODS: Consecutive patients undergoing ERCP at high risk for SRAEs at a single center were invited to participate in this randomized controlled trial comparing GEA and MAC. Inclusion criteria were STOP-BANG score ≥3, abdominal ascites, body mass index ≥35, chronic lung disease, American Society of Anesthesiologists class >3, Mallampati class 4 airway, and moderate to heavy alcohol use. Exclusion criteria were preceding EUS, emergent ERCP, tracheostomy, unstable airway, gastric outlet obstruction or delayed gastric emptying, and altered foregut anatomy. The primary endpoint was composite incidence of SRAEs: hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, and respiratory failure. Secondary outcomes included procedure duration, cannulation success, in-room time, and immediate adverse events. RESULTS: Two hundred patients (mean age, 61.1 ± 13.6 years; 36.5% women) were randomly assigned to GEA (n = 101) or MAC (n = 99) groups. Composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs 9.9%, P < .001). This was primarily driven by the frequent need for airway maneuvers in the MAC group. Additionally, ERCP was interrupted in 10.1% of patients in the MAC group to convert to GEA because of respiratory instability refractory to airway maneuvers (n = 8) or significant retained gastric contents (n = 2). There were no statistically significant differences in cannulation, in-room, procedure, or fluoroscopy times between the 2 groups. All patients undergoing GEA were successfully extubated in the procedure room at completion of ERCP, and Aldrete scores in recovery did not differ between the 2 groups. There were no immediate adverse events. CONCLUSION: In patients at high risk for SRAEs undergoing ERCP, sedation with GEA is associated with a significantly lower incidence of SRAEs, without impacting procedure duration, success, recovery, or in-room time. These data suggest that GEA should be used for ERCP in patients at high risk for SRAEs (Clinical trial registration number: NCT02850887.).


Assuntos
Anestesia Endotraqueal/efeitos adversos , Anestesia Geral/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Sedação Profunda/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Idoso , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia Endotraqueal/métodos , Anestesia Geral/métodos , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Sedação Profunda/métodos , Feminino , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/epidemiologia , Hipotensão/etiologia , Hipóxia/epidemiologia , Hipóxia/etiologia , Incidência , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Vasoconstritores/uso terapêutico
15.
An Pediatr (Barc) ; 90(1): 32-41, 2019 Jan.
Artigo em Espanhol | MEDLINE | ID: mdl-29650431

RESUMO

OBJECTIVES: To offer analgesia and sedation should be a priority in paediatric emergency departments. The aim of this study was to determine the effectiveness and safety of the sedation-analgesia procedure, as well as the satisfaction of the doctors, patients and parents. METHODS: A multicentre, observational, and prospective analytical study was conducted on the sedation-analgesia procedure performed on children younger than 18 years old in 18 paediatric emergency departments in Spain from February 2015 until January 2016. RESULTS: A total of 658 procedures were recorded. The effectiveness was good in 483 cases (76.1%; 95%CI: 72.7-79.4%), partial in 138 (21.7%; 95%CI: 18.5-24.9%), and poor in 14 (2.2%; 95%CI: 1.1-3.4). The effectiveness was better when the doctor in charge was an emergency paediatrician (OR: 3.14; 95%CI: 1.10-8.95), and when a deeper level of sedation was achieved (OR: 2.37; 95%CI: 1.68-3.35). Fifty two children (8.4%) developed adverse drug reactions, more usually gastrointestinal, neurological or respiratory ones (89.9% were resolved in <2h). One patient was intubated. The older child and a deeper level of sedation were found to be independent risk factors for adverse reactions (OR: 1.18; 95%CI: 1.09-1.28 and OR: 1.86; 95%CI: 1.22-2.83, respectively). Thirteen children (5%) developed late adverse drug reactions, more commonly, dizziness and nauseas. A combination of midazolam/ketamine had been used in all the cases (RR: 24.46; 95%CI: 11.78-50.76). The perceived satisfaction level (0-10) was obtained from 604 doctors (mean: 8.54; SD: 1.95), 526 parents (mean: 8.86; SD: 1.49), and 402 children (mean: 8.78; SD: 1.70). CONCLUSIONS: The sedation-analgesia procedure performed in paediatric emergency departments by trained paediatricians seems to be useful, effective and safe, as well as satisfactory for all participants.


Assuntos
Analgesia , Sedação Consciente , Sedação Profunda , Analgesia/efeitos adversos , Atitude do Pessoal de Saúde , Criança , Sedação Consciente/efeitos adversos , Sedação Profunda/efeitos adversos , Serviço Hospitalar de Emergência , Feminino , Humanos , Satisfação no Emprego , Masculino , Pais , Satisfação do Paciente , Estudos Prospectivos , Espanha , Resultado do Tratamento
16.
J Clin Anesth ; 54: 19-24, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30391445

RESUMO

STUDY OBJECTIVE: Morbid obesity is associated with adverse airway events including desaturation during deep sedation. Prior works have suggested that proprietary high-flow nasal cannula devices generate positive pressure to all airway structures and may be superior to standard (low-flow) nasal cannula for prevention of desaturation. We hypothesized that, at a similar fraction of inspired oxygen (FiO2), use of a High-Flow Nasal Cannula (HFNC) at maximum flow rate would result in a lower incidence of intra-procedural desaturation episodes in morbidly obese patients compared to standard nasal cannula (SNC) during deep sedation with propofol. DESIGN: This is a pragmatic, prospective, randomized clinical trial at one hospital (NCT03148262, UTSW#112016-058). Morbidly obese patients were randomized to HFNC during propofol sedation for colonoscopy. HFNC was performed using maximum flow rates of 60 liters per minute (LPM) and FiO2 of 0.36-0.40, whereas SNC was performed at 4LPM. The primary endpoint was incidence of arterial oxygen desaturation <90% measured by pulse oximetry. At midpoint enrollment the Data Monitoring Committee (DMC) performed a pre-planned O'Brien and Fleming futility test. MAIN RESULTS: Patients were randomized to HFNC (n = 28) or SNC (n = 31). Interim analysis of the primary endpoint showed that the desaturation rates in the HFNC group (39.3%) and the SNC group (45.2%) were not significantly different (p = 0.79). The DMC halted the trial at that point due to futility. CONCLUSION: At similar FiO2, HFNC was not significantly different from SNC for prevention of arterial oxygen desaturation in morbidly obese patients undergoing propofol sedation for colonoscopy.


Assuntos
Colonoscopia/efeitos adversos , Sedação Profunda/efeitos adversos , Hipóxia/prevenção & controle , Ventilação não Invasiva/instrumentação , Obesidade Mórbida/complicações , Idoso , Cânula , Feminino , Humanos , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Oxigênio/análise , Dor Processual/prevenção & controle , Propofol/administração & dosagem , Propofol/efeitos adversos , Estudos Prospectivos , Resultado do Tratamento
17.
Med Intensiva ; 43(1): 3-9, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29258778

RESUMO

OBJECTIVE: Cognitive impairment after intensive care unit (ICU) admission is becoming increasingly recognized. High-dose deep sedation has been suggested to play an important role in the development of cognitive impairment. However, the impact of heavy sedation as a single cause in the development of cognitive impairment in ICU patients remains unclear. In this study we investigated whether a three-day deep sedation protocol could reduce cognitive function in mechanically ventilated non-critical patients. DESIGN: A prospective observational study was carried out. PATIENTS: A total of 17 surgical patients were studied. INTERVENTION: None. VARIABLES OF INTEREST: Cognitive function before and after ICU admission. RESULTS: Thirty-one patients requiring three days of sedation after microvascular reconstruction were initially enrolled in the study. Sedation in the ICU was maintained with propofol and dexmedetomidine combined with fentanyl. Cognitive function was assessed using a battery of 6 neuropsychological tests two days before surgery and three weeks after surgery. Finally, a total of 17 patients were included in the analysis. Cognitive impairment (defined as a decline of >20% from the pre-admission cognitive evaluation scores in at least two of 6 tests) was observed in 5 of the 17 patients (29%). However, there were no significant differences between the pre- and post-admission cognitive evaluations in 6 tests. CONCLUSIONS: Middle-term cognitive function can be impaired in some patients subjected to deep sedation during several days following maxillary-mandibular oral surgery with microvascular reconstruction.


Assuntos
Transtornos Cognitivos/prevenção & controle , Cognição/efeitos dos fármacos , Cuidados Críticos , Sedação Profunda/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Respiração Artificial , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Transtornos Cognitivos/induzido quimicamente , Dexmedetomidina , Neoplasias Faciais/cirurgia , Feminino , Fentanila , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Unidades de Terapia Intensiva , Masculino , Neoplasias Maxilares/cirurgia , Microcirculação , Pessoa de Meia-Idade , Neoplasias Bucais/cirurgia , Testes Neuropsicológicos , Complicações Pós-Operatórias/induzido quimicamente , Propofol , Estudos Prospectivos , Procedimentos Cirúrgicos Reconstrutivos , Fatores de Tempo
18.
Eur Rev Med Pharmacol Sci ; 22(22): 7916-7919, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30536338

RESUMO

We performed a systematic review of the literature starting from a real case of venous air embolism (VAE) in a young infant undergoing central catheterization during procedural sedation. Air embolism due to internal jugular vein catheterization during procedural sedation is very rare, but it is a potentially life-threatening complication of central catheterization that warrants attention. To our knowledge, this is the first case published in a similar scenario.


Assuntos
Cateterismo Venoso Central/efeitos adversos , Sedação Profunda/efeitos adversos , Embolia Aérea/etiologia , Embolia Pulmonar/etiologia , Humanos , Lactente , Masculino
19.
Rev. esp. anestesiol. reanim ; 65(9): 504-513, nov. 2018. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-177199

RESUMO

Objetivo: Describir las complicaciones que aparecen durante la anestesia/sedación en el ámbito de la endoscopia digestiva, comparando también procedimientos programados frente a urgentes. Métodos: Se diseñó un protocolo de pacientes y pruebas en los que siempre debe estar presente un anestesiólogo. Estos incluyen a pacientes ASA 3 y 4, pruebas complejas como polipectomías, colangiopancreatografía retrógrada endoscópica o ecoendoscopia, necesidad de sedación profunda o alteraciones anatómicas que dificulten el manejo de la vía aérea. Se analizó la seguridad con base a las complicaciones que se recogen a partir de los datos recogidos de forma automática directamente desde los monitores, tanto durante la sedación como en la unidad de recuperación. Se analizan los factores de riesgo asociados a las complicaciones cardiorrespiratorias, la eficacia en función de las pruebas completadas y el grado de satisfacción global a través de una entrevista empleando una escala de satisfacción. Resultados: Se estudió a 3.746 pacientes durante 7 años. La incidencia de complicaciones importantes durante la prueba fue baja, destacando las complicaciones hemodinámicas y respiratorias. Así encontramos una incidencia de hipoxemia del 3% en endoscopia programada frente al 5,7% en pruebas urgentes (p <0,05). También la hipotensión presenta diferencias significativas entre la sedación programada y urgente (6,4% vs. 18,8%, p <0,001). En nuestro estudio, no se ha suspendido ninguna prueba por mala tolerancia del paciente, y el grado de satisfacción es alto en más del 99% de los casos. Conclusión: La participación del anestesiólogo en la sedación para endoscopia digestiva ha demostrado en este estudio excelentes resultados en cuanto a seguridad y eficacia, principalmente en los pacientes más graves y pruebas complejas, y un alto grado de satisfacción


Objective: To describe the anaesthesia/sedation complications during gastrointestinal endoscopy, as well as comparing scheduled procedures versus urgent procedures. Methods: A protocol was developed to define the anaesthesia/sedation in gastrointestinal endoscopy, where the anaesthetist should always be present. These include ASA 3 and 4 patients, complex tests such as polypectomies, endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound, deep sedation, or patients with probable difficult airway management. An analysis was made of the safety based on the complications recorded from the data directly collected automatically from the monitors, both during the sedation and in the recovery unit. An analysis was also performed on the risk factors associated with cardiorespiratory complications, the effectiveness based on the completed tests and the overall level of satisfaction through an interview using a satisfaction scale. Results: The study included a total of 3746 patients over a 7 year-period. The incidence of major complications was low, especially haemodynamic and respiratory complications. An incidence of hypoxaemia of 3% was found in scheduled endoscopy versus 5.7% in urgent endoscopy (P<.05). The rate of hypotension was also low, with significant differences between scheduled and urgent endoscopy (6.4% vs. 18.8%, P<.001). In present study, no test had to be suspended due to poor patient tolerance, and the satisfaction was high in more than 99% of cases. Conclusion: The participation of the anaesthetist in sedation for gastrointestinal endoscopy has shown excellent results in this study, in terms of safety and efficacy, mainly in the most serious patients and complex tests, as well as a high level of satisfaction


Assuntos
Humanos , Endoscopia do Sistema Digestório/métodos , Sedação Profunda/efeitos adversos , Eficiência , Anestesia/efeitos adversos , Estudos Prospectivos , Fatores de Risco , Hipotensão/epidemiologia , Satisfação do Paciente/estatística & dados numéricos , Obesidade/epidemiologia , Doença Pulmonar Obstrutiva Crônica/epidemiologia
20.
BMJ Open ; 8(10): e023423, 2018 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-30344178

RESUMO

INTRODUCTION: In mechanically ventilated patients, sedation strategies are a major determinant of outcome. The emergency department (ED) is the earliest exposure to mechanical ventilation for hundreds of thousands of patients annually in the USA. The one retrospective study that exists regarding ED sedation for mechanically ventilated patients showed a strong association between deep sedation in the ED and worse clinical outcomes. This finding suggests that the ED may be an optimal location to study the impact of early sedation on outcome, yet a lack of prospective studies represents a knowledge gap in this arena. This protocol describes a prospective observational study aimed at further characterising ED sedation practices and assessing the relationship between ED sedation and clinical outcomes. An association between ED sedation and clinical outcomes across multiple sites would suggest the need for changes in the current sedation strategies used in the ED, and provide evidence for future interventional studies in this field. METHODS AND ANALYSIS: This is a multicentre, prospective cohort study testing the hypothesis that deep sedation in the ED is associated with worse clinical outcomes. A cohort of over 300 mechanically ventilated ED patients will be included. The primary outcome is ventilator-free days, and secondary outcomes include hospital mortality, incidence of acute brain dysfunction and lengths of stay. Multivariable linear regression will test the hypothesis that deep sedation in the ED is associated with a decrease in ventilator-free days. ETHICS AND DISSEMINATION: Approval of the study by the Institutional Review Board (IRB) at each participating site has been obtained prior to data collection on the first patient. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.


Assuntos
Sedação Consciente/estatística & dados numéricos , Sedação Profunda/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Protocolos Clínicos , Sedação Consciente/efeitos adversos , Sedação Profunda/efeitos adversos , Sedação Profunda/métodos , Humanos , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Resultado do Tratamento
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