Proceduralsedation and analgesia (PSA) is used to con- trol pain and distress during diagnostic and interven- tional medical procedures. PSA is generally considered to include the stages of moderate and deep sedation of the continuum of anaesthesia . Loss of consciousness is not an intended outcome, and cardiac and respiratory function may not be impaired with the doses and types of sedative and analgesic medications used . However, PSA is still associated with at the least the same or po- tentially even greater risk of serious sedation-related ad- verse events, such as death or permanent neurological disability, compared with general anaesthesia . Due to the potential that respiratory function may become im- paired as a result of sedation-induced depression of the central nervous system, frequent monitoring is recom- mended [1, 3]. Respiratory function is usually evaluated by observation of qualitative clinical signs (respiratory rate, depth and effort) and oxygen saturation monitoring . Capnography is a respiratory monitoring device that has become an accepted standard of care for PSA in many circumstances. For example, the American Society of Anesthesiology standards for Basic Anesthetic Moni- toring require the use of capnography for both moderate and deep sedation. In the UK, the Academy of Medical Royal Colleges Standards and Guidance for Safe Sed- ation Practice for Healthcare Procedures also include capnography as a developmental standard for patients receiving sedation where it has not already been imple- mented into practice.
Proceduralsedation and analgesia (PSA) has become a routine practice in the emergency department (ED); and even various types of outpatient Diagnostic and therapeutic measures, as well as managing patients in the intensive care unit are among interventions requiring PSA (1). Aspiration of stomach contents is one of the most important possible complications during PSA. For this purpose, current instructions recommend fasting before sedation to decrease the side effects due to aspiration of gastric contents (2, 3). However, some studies believe that long-term fasting does not lead to a decrease in gastric volume or increase in immunity to PSA side effects and just leads to unnecessary discomfort for the patient, and in emergency cases it may not be possible to use such recommendations (4). Therefore, many studies have attempted to somehow predict the occurrence of this complication. It seems that gastric ultrasound is a
The aim of proceduralsedation and analgesia (PSA) is to produce “a state of drug-induced tolerance of uncomfort- able or painful diagnostic or interventional medical, dental or surgical procedures” (p.1) . PSA is generally described as a continuum, with the risk of serious sedation-related adverse events, such as death or permanent neurological disability, increasing with the depth of sedation induced . Prompt detection of lapses into deeper than intended levels of sedation is required so that corrective interventions can be implemented. For this reason, frequent monitoring of level of consciousness is recommended [1, 2]. Level of con- sciousness is usually monitored during PSA by clinical ob- servation, which is performed by judging a sedated patient’s response to increasing levels of stimulation . A standar- dised sedation assessment scale that assigns a numerical rank to observable clinical behaviours that are known to be associated with changes in the level of consciousness can be used to supplement clinical observation methods for assessing changes in level of consciousness during PSA. Processed electroencephalogram-based depth of anaesthesia (DoA) monitoring devices provide an alternative method to monitor level of consciousness that can be used in addition to clinical observation.
Proceduralsedation and analgesia (PSA), defined as a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function, is com- monly utilized to reduce patient discomfort during man- ual reduction of displaced distal radius fracture in the emergency department outside the operating room [4, 5]. Pharmacologic options for PSA include a short- acting benzodiazepine, either alone or in combination with an opioid analgesic . Evidence to support the use of other sedatives including etomidate and propofol for PSA is also emerging in the literature  However, PSA has its own risks and considerations for different levels of monitoring for cardiorespiratory function. Hematoma block (HB), defined as a procedure with local anesthetic injected directly into the fracture site, is a safe and effective alternative technique for pain control in assist- ance with manual reduction for distal radius fracture . Its potential benefits include avoidance of PSA- associated risks, high cost-effectiveness, and time- sparing procedure. However, the highest level-evidence assessment relying on results from meta-analyses in 2002 cannot demonstrate the relative effectiveness of different methods of anesthesia including HB and PSA owing to lack of enough evidence from randomized trials .
Background: In women with abnormal uterine bleeding, fibroids are a frequent finding. In case of heavy menstrual bleeding and presence of submucosal type 0 – 1 fibroids, hysteroscopic resection is the treatment of first choice, as removal of these fibroids is highly effective. Hysteroscopic myomectomy is currently usually performed in the operating theatre. A considerable reduction in costs and a higher patient satisfaction are expected when proceduralsedation and analgesia with propofol (PSA) in an outpatient setting is applied. However, both safety and effectiveness – including the necessity for re-intervention due to incomplete resection – have not yet been evaluated.
Providing pain relief associated with diagnostic and therapeutic procedures is an ethical requirement in children. Additionally, it is measured as a quality of care component from the perspective of family for Pediatric Emergency Department (PED) visit. ProceduralSedation and Analgesia (PSA) is increasingly being used in the PED to relieve children of pain, stress and anxiety during painful and un- pleasant procedures while maintaining an adequate cardiorespiratory function. While serious adverse events are rare, PSA is associated with adverse events primarily affecting airway and respiratory system, in a small subset of patients . Furthermore, PSA can entail obtaining an intravenous access which by itself is a painful procedure. Hence, it is important to study the role of non-invasive modalities in reduction of pain and anxiety in children undergoing painful pro- cedures in the PED.
administration of proceduralsedation and analgesia (PSA) to children. It has been estimated that roughly a quarter million children will receive PSA in the emergency departments (EDs) annually and that children under 2 years of age constitute roughly 20–30% of those [1, 2]. It has been shown that pain in infants and toddlers is poorly recognized and documented [3, 4], predisposing them to receive less analgesia when compared with older children . Common- ly used medications for PSA such as ketamine are relatively contraindicated in very young children (<6 months of age) because of an association with increased risk of airway complications . Inadequate sedation and analgesia predis- poses to procedural failure, parental anxiety and dissatisfac- tion, and poor quality of care. The anatomic differences in the airway like smaller airway diameter, longer and floppy epiglottis, and the physiologic differences in drug metabo- lism between younger and older children could predispose younger children to a higher risk for adverse events related to sedation. Studies have shown contrasting results regarding association of age and adverse events related to PSA. While some studies have found children less than 2 years of age to be at an increased risk for adverse events related to PSA [7, 8], other studies have found no association between age and adverse events related to PSA [9, 10]. To our knowledge, there have been no studies that have focused exclusively on PSA in children less than 2 years of age. The main objective of our study is to describe PSA in children less than 2 years of age in the ED of a tertiary care children ’ s hospital. Addi- tionally, we will describe the indications for PSA, medi- cations used, efficacy of sedation, and adverse events related to sedation in this group of children.
Other countries report similar gaps between adult and paediatric PSA in the ED [13, 14]. McCoy et al. addressed the challenges of practice and provision of paediatric PSA in the UK and Ireland. They con- cluded that among others that lack of formal training and a lack of recognition of PSA as a specialised EM skill contributed to the difficulties to provide paediat- ric PSA in the ED . The unavailability of PSA around-the-clock for both the adult and paediatric populations in Dutch EDs is another concern. As shown in the results, EPs appear to be the foremost providers of PSA in the ED for both adult and paedi- atric patients. Currently, only 20.7% of the 87 EDs have 24/7-coverage by EPs. Increase of EP staff could therefore may be an effective step in reaching good quality emergency PSA service for all ED patients at all times. An additional positive side-effect may be further reduction of healthcare costs as ED sedation Table 2 Survey on adult and paediatric PSA training within the
was 11.3 min for ratio 1:2 and 8.0 min for 1:3 in our study. Then low level of Ketamine decreases recovery time with good sedation and analgesia. Silva PS et al used Ketofol of 1:1 to reach Ramsay score of 3-4in children with hematological diseases (7). The mean total dose of Ketofol administered was 1.25 mg/kg per each of Propofol and Ketamine while it was lower in our study to reach higher Ramsay score of 5. So, using of high dose Ketamine cannot help to increase sedation and analgesia. Whetheral A et al observed that Ketofol infusion successfully produced deep sedation for prolonged (153 min) pediatric orthopedic procedures in conjunction with regional analgesia (8). Similar to our study, they reported that Ketofol is safe and good combination for children. Erdogan kayhan G et al compared Ketofol1:1 with Propofol in electroconvulsive therapy. Ketofol had better results in their study (9). Erdogan Ma et al compaired Propofol with Ketofol in laryngeal mask insertion in elderly patient (10). They showed that the number of patients who required ephedrine and the total ephedrine dose were lower, and apnea duration was increased in the Ketofol group. Ephedrine treat hypotension and bradycardia due to Propofol and Ketamine can also do so. But increased apnea duration in their study could be related to high age. So, Ketamine similar to ephedrine improves the hemodynamic effects of Propofol. Phillips w et al studied the effect of Propofol versus Propofol/Ketamine for brief painful procedures (11). Similar to our study, none of the patient in either group had respiratory depression or required any intervention. The combination of Propofol and Ketamine provided an appropriate combination for painful proceduralsedation in the emergency department. Compared to Propofol alone, Ketofol provided less hypotension, better sedation, and increased patient comfort and safety. In another study by Andolfatto G et al, sedation and analgesia effects of Propofol alone versus Ketofol were compared (12). Ketofol did not show any result regarding to reduce incidence of adverse respiratory events compared with Propofol alone. Induction time, efficacy and sedation time were similar but, sedation depth presented to be more consistent with Ketofol. In this study we showed, the combination of the two drugs reduced the dose of each drug alone. Smischney NG et al studied hemodynamic effects of Ketofol in induction of general anesthesia (13). They observed that Ketofol improved hemodynamic during the first 10 minutes after induction, and it was a good induction agent. This finding is consistent with hemodynamic stability in our study.
11. Cheng Liang-Ying, Shi-Guang, Lu You-wen et al studied the efficacy and disadvantageous effects of postoperative analgesia with morphine and Tramadol given epidurally. Sixty pregnant women for cesarean section were randomly assigned into two groups with 30 in each group. For postoperative analgesia, morphine 2mg (2ml) with 8 ml normal saline given via epidural catheter given to M group and Tramadol 100mg(2ml) with 8 ml normal saline given epidurally to T group. Solution was injected during abdomen closure. Patients were observed for 24 hours and diastolic blood pressure, heart rate, oxygen saturation were monitored. Results showed that changes in circulation and respiration were not significant in both groups. The analgesic efficacy was satisfactory in both groups but was better in group T than group M. The disadvantageous influences were more in group M than group T.
22 | P a g e epidural and peripheral perineural injections, using single-shot injections and continuous infusions. Differential sensory/motor block is only apparent at low concentrations (0.2% and less). A significant amount of recent literature focuses on its use for peripheral blocks of the lower limbs, i.e, sciatic and femoral nerve blocks. The primary benefit of Ropivacaine is its lower toxicity, mainly lower cardiotoxicity, following accidental intravascular injection. This higher therapeutic index leads to an improved safety profile as compared with potent local anaesthetics such as racemic Bupivacaine. For that reason, Ropivacaine is a good choice for both intraoperative and postoperative regional anaesthesia and analgesia. (39)
Traditionally opioids are used as adjuvants in epidural and spinal anaesthesia. Alpha 2 agonist like Clonidine was also successfully used as adjuvant in the last decade as it produced excellent sedation and analgesia, but it also produced severe hypotension and bradycardia to overcome this newer alpha 2 agonist Dexmedetomidine was introduced and number of studies have been conducted successfully with Dexmedetomidine as adjuvant for both spinal and epidural blockade. Buprenorphine a long acting partial agonist, is a time honoured drug well known for its prolonged analgesic action but has a theoretical side effect of respiratory depression. Number of studies have also been conducted to elicit the safety and excellent analgesia produced by buprenorphine. Keeping in mind the side effect profile of both the drugs we carefully designed a study to extract the maximum out of these 2 drugs as epidural adjuvants avoiding side effects.
Cohorts from 2010 and 2016 were compared overall and for each region. Median and interquartile range (IQR) are presented for continuous variables, while count and proportion (n, %) are presented for categorical variables. For clinical practice (e.g., sedation use), differences in proportion of days were calculated and weighted individ- ual proportions were used to calculate standard errors and p values to account for varying length of stay and data points for each patient. Pearson’s chi-squared test was used to compare prevalence of delirium. In addition, a multinomial regression model was used to investigate associations of various risk factors with daily development of delirium or coma with normal (i.e., no delirium, no coma) as reference in the 2016 cohort. Model covariates included baseline variables (age, gender, BMI, SAPS II, region), previous day clinical variables (use of propofol, use of benzodiazepines, use of dexmedetomidine, use of analgesia, use of neuromuscular blockers), performance of spontaneous awakening trial, and day of admission.
quency during proceduralsedation/ anesthesia performed by pediatric specialists outside of the operating room. Our null hypothesis was that the frequency of major complications among pediatric specialists, when op- erating within the conﬁnes of an orga- nized sedation system, would be equiv- alent. We calculated event rates per 10 000 sedations for each type of pro- vider. Provider groups were anesthesi- ologist (both pediatric and general), pediatric intensivist, pediatric emer- gency medicine, pediatrician, and other (radiologist, surgeon, dentist, pediatric resident or fellow, advanced practice nurse, certiﬁed registered nurse anesthetist, or registered nurse). We then calculated odds ratios (ORs) and 95% conﬁdence intervals (CIs) using the anesthesiologist event rate as the reference group. Odds ra- tios and CI were further adjusted for age, emergency status, ASA physical status ⬎ 2, nil per os (NPO) for solids, propofol use, and clustering by site via multiple regression analysis because these factors have been suggested to have an effect on complication fre- quency during PPS. We recognize that observations within an institution may not be independent, so clustering ad- justments over site were incorporated in our models using a sandwich esti- mator. Stata 11 (Stata Corp, College Station, TX) was used for the statistical analysis. P ⱕ .05 was considered sta- tistically signiﬁcant.
Background: Critical patients in ICU have to experience pain, anxiety, and sleep deprivation which always cause delirium, which will prolong the hospit- al stay and come up with higher mortality. Analgesia based sedation can re- duce the accumulation of sedative effects, and shorten ventilator time and ICU length of stay. Process management of analgesia and sedation can reduce the incidence of delirium. Objectives: To explore the clinical benefits of pro- cedural analgesia and sedation for critical ill patients. Methods: This is a prospective, two-phase study that focuses on patients who required mechani- cal ventilation after surgery. Comparing patients’ pain and agitation scores, the species and dosage of sedative and analgesic, the incidence of delirium in the observation period and intervention period, data in two groups were col- lected and analyzed. Results: During the observational and interventional pe- riods, we enrolled 213 patients before protocol implantation and 196 patients after protocol implantation. We found that there existed impropriate pain and sedation assessment in patients involved, and after training for procedur- al protocol, the average dosage of sedatives was decreased ( p > 0.05). The percentage of reaching standard COPT score was 73.7% vs 84.1% ( p > 0.05) and RASS score was 70.9% vs 79.6% ( p > 0.05) in the observation period and intervention period, and the incidence of delirium was significantly reduced (31.9% vs 23.5%, p < 0.05). Conclusion: We concluded that protocol im- plantation of analgesia and sedation can reduce the incidence of delirium.
Similar to our study, karki sb et al found patients comfortable with both the anesthetic agents. Onset of anesthesia was faster in group a. Intraoperative sedation was comparable. Recovery from sedation was good. Postoperatively, nausea vomiting, severe pain, ketamine induced psychotomimetic effects were seen. They were treated well and discharged on the same day. 18
Vigorous and prolong colonoscopy can lead to intense vagal stimulation. This situation can be combined with over sedation of the patient and thus can pro- voke a lethal hypotensive episode. This could potentially lead to respiratory or cardiac arrest. Hence, it is vital to first avoid this life-threatening situation and if at all this does happen, then to be fully prepared to deal this catastrophic condi- tion.
atipamezole , which like Dexmedetomidine can reverse the sedation and sympatholysis and has a half-life of 1.5 to 2 hours . The combination of dexmedetomidine and atipamezole may be in the future be used as the basis for a reversible intravenous anesthetic technique that could provide recover independently from anesthesia and sedation. The use of Dexmedetomidine can be returned to the baseline level of consciousness if the patients are being stimulated. This property of Dexmedetomidine was shown by Hall et al 12 , who uses the Bispectral Index System , and the psychometric tests such as the Visual Analog Scale(VAS) for sedation, Digit Symbol Substitution Scale, observer's Assessment of Alertness/Sedation scale, and specific memory tests 12 . When atipamezole was used, it reversed the hemodynamic values returned to baseline after 4 hours of treatment. A more objective sign was the returned of the Bispectral Index System(BIS), where it uses a processe as electro- encephalogram signal analysis, when encouraged from 60 to 65 the stimulus was back to normal baseline values.
Assessment of pain, postoperative nausea and vomiting (PONV), pruritus and sedation was done by the obstetric analgesia acute pain service team who were blinded to the patient’s group allocation. The patients were assessed upon arrival and discharge from recovery, and at 6, 12 and 24 hours, postoperatively in the post natal ward. The presence and severity of pain was assessed using the visual analogue scale (VAS) score, in which patients were shown a ruler calibrated from 0-10, where 0 represented no pain and 10, the worst imaginable pain. Pain scores at rest and with movement (knee flexion) were recorded. PONV and pruritus was assessed using a four point scale scoring system: 0 - none; 1 - mild; 2 - moderate; 3 - severe. IV ondansetron 4 mg was given to any patient with a PONV score of 3. Sedation level was assessed using the following sedation scale: 0 - awake and alert; 1 - awake but passive; 2 - asleep but easily aroused; 3 - deep sleep. In the ward, both groups were given a standardized postoperative analgesic regime of oral paracetamol 1 gm 6 hourly and oral diclofenac sodium 50 mg 8 hourly. Intravenous patient controlled analgesia (PCA) using morphine was given as rescue treatment for inadequate analgesia. This was programmed to deliver on-demand bolus doses of 1 mg morphine with a lock-out interval of 5 minutes and a 4 hourly maximum dose of 40 mg morphine.
administration, and are centrally mediated responses that can interfere with respiratory function. The effect can be reversed with naloxone or interrupted with neuromuscular blocking agents. Although rare, occurrence of chest wall and laryngeal rigidity should be considered if respiratory dysfunction is noted following the administration of synthetic opioids, as such an effect may interfere with respiratory function and result in rapid oxygen desaturation and hypoxemia. To limit the incidence of such issues, a bolus dose should be infused around 2 to 3 minutes as more rapid infusion can cause chest wall rigidity. One other concern with remifentanil is the potential for the rapid development of tachyphylaxis and hence the need to rapidly escalate the dose even during short-term infusions of 24–48 hours. Although suggested in the literature, studies of its use in the ICU for sedation do not uniformly demonstrate this phenomenon. 24,25 Furthermore,