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Biomedical subjects

Baruch Krauss

Publications and source records attributed to Baruch Krauss.

At least 19 recordsLinked to original sources
PubMed2007

Capnography for procedural sedation and analgesia in the emergency department.

Although it is standard of care for patient safety monitoring in anesthesia, capnography is not routinely used for emergency department procedural sedation and analgesia. We discuss the use of capnography as a diagnostic monitoring modality for procedural sedation and analgesia, focusing on the physiology and interpretation of the CO2 waveform and recognition of normal, abnormal, and drug-induced ventilatory patterns.

Analgesia↗
PubMed2006

Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory.

Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.

Analgesia↗
PubMed2006

Procedural sedation and analgesia in children.

Procedural sedation and analgesia for children--the use of sedative, analgesic, or dissociative drugs to relieve anxiety and pain associated with diagnostic and therapeutic procedures--is now widely practised by a diverse group of specialists outside the operating theatre. We review the principles underlying safe and effective procedural sedation and analgesia and the spectrum of procedures for which it is currently done. We discuss the decision-making process used to determine appropriate drug selection, dosing, and sedation endpoint. We detail the pharmacopoeia for procedural sedation and analgesia, reviewing the pharmacology and adverse effects of these drugs. International differences in practice are described along with current areas of controversy and future directions.

Analgesia↗
PubMed2006

Recurrent episodes of intractable laryngospasm during dissociative sedation with intramuscular ketamine.

We report 2 cases of dissociative sedation with intramuscular ketamine with recurrent episodes of laryngospasm that we were unable to ventilate with bag-mask ventilation, in 1 case leading to endotracheal intubation to protect the airway. Supplemental oxygen was given throughout the sedations, and ventilatory status was noninvasively monitored on a continuous basis, providing detailed and objective documentation of the patients' clinical status throughout the sedations. We were, therefore, able to rapidly assess and confirm apnea, laryngospasm, and airway dysfunction.

Anesthetics, Dissociative↗
PubMed2006

End-tidal carbon dioxide as a measure of acidosis among children with gastroenteritis.

OBJECTIVES: We aimed to determine the correlation between end-tidal carbon dioxide levels and serum bicarbonate concentrations among patients with gastroenteritis, to compare the end-tidal carbon dioxide with other clinical parameters that might also be associated with the degree of acidosis, and to examine the relationship between end-tidal carbon dioxide levels and return visits. METHODS: Our prospective sample included patients presenting to the emergency department with a chief complaint of vomiting and/or diarrhea. The association between end-tidal carbon dioxides and serum bicarbonate concentrations was determined with simple linear-regression analysis. Receiver operating characteristic curves were computed to determine the predictive ability of the end-tidal carbon dioxide to detect metabolic acidosis. RESULTS: One hundred thirty of 146 subjects who were approached were included in the final analysis. For those for whom laboratory studies were performed, the mean serum bicarbonate concentration was 17.3 +/- 4.3 mmol/L and the mean end-tidal carbon dioxide level was 34.2 +/- 5.2 mm Hg. End-tidal carbon dioxide levels and serum bicarbonate concentrations were correlated linearly in bivariate analysis. Receiver operating characteristic curves were calculated for end-tidal carbon dioxide as a predictor of serum bicarbonate concentrations of < or = 13, < or = 15, and < or = 17 mmol/L, with areas under the curves of 0.94, 0.95, and 0.90, respectively. The relationship between end-tidal carbon dioxide levels and serum bicarbonate concentrations was independent of other potential predictors of acidosis in multivariable analysis. The mean end-tidal carbon dioxide level for patients who required an unanticipated return visit (33.0 +/- 4.0 mm Hg) was lower than the level for those who did not seek reevaluation (36.6 +/- 3.6 mm Hg). CONCLUSIONS: End-tidal carbon dioxide levels were correlated with serum bicarbonate concentrations among children with vomiting and diarrhea, independent of other clinical parameters. Capnography offers an objective noninvasive measure of the severity of acidosis among patients with gastroenteritis.

Acidosis, Respiratory↗
PubMed2005

The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.

STUDY OBJECTIVE: We evaluate the association between out-of-hospital use of continuous end-tidal carbon dioxide (ETCO2) monitoring and unrecognized misplaced intubations within a regional emergency medical services (EMS) system. METHODS: This was a prospective, observational study, conducted during a 10-month period, on all patients arriving at a regional Level I trauma center emergency department who underwent out-of-hospital endotracheal intubation. The regional EMS system that serves the trauma service area is composed of multiple countywide systems containing numerous EMS agencies. Some of the EMS agencies had independently implemented continuous ETCO2 monitoring before the start of the study. The main outcome measure was the unrecognized misplaced intubation rate with and without use of continuous ETCO2 monitoring. RESULTS: Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation. Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not. Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest. The overall incidence of unrecognized misplaced intubations was 9%. The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2 monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3% (95% confidence interval 13.4% to 36.0%). CONCLUSION: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.

Adolescent↗
PubMed2005

Capnography as a rapid assessment and triage tool for chemical terrorism.

The assessment and triage of victims of chemical terrorism in the emergency department and the prehospital setting has become an important priority. This article proposes the use of capnography as a prehospital assessment and triage tool for monitoring victims of chemical terrorism and for critically ill patients. Capnography provides the ABCs in less than 15 seconds and identifies the common complications of chemical terrorism. Further, the reliability of capnography is not affected by motion artifact or low perfusion and it is accurate and reliable in actively seizing patients. Emergency departments and emergency medical services systems should consider adding capnography to their chemical terrorism education and training.

Capnography↗
PubMed2005

Exhaled nitric oxide levels during acute asthma exacerbation.

OBJECTIVES: Fractional exhaled nitric oxide (FE(NO)) has been shown in laboratory settings and trials of patients with stable asthma to correlate with the degree of airway inflammation. The authors hypothesized that the technique of measuring FE(NO) would be reproducible in the setting of acute asthma in the emergency department (ED) and that the FE(NO) results during ED visits would potentially predict disposition, predict relapse following discharge, and correlate with the National Institutes of Health (NIH) asthma severity scale and peak expiratory flow measurements. METHODS: The authors prospectively measured FE(NO) in a convenience sample of ED patients with acute exacerbations of asthma, both at the earliest possible opportunity and then one hour later. Each assessment point included triplicate measurements to assess reproducibility. The authors also performed spirometry and classified asthma severity using the NIH asthma severity scale. Discharged patients were contacted in 72 hours to determine whether their asthma had relapsed. RESULTS: The authors discontinued the trial (n = 53) after a planned interim analysis demonstrated reproducibility (coefficient of variation, 15%) substantially worse than our a priori threshold for precision (4%). There was no association between FE(NO) response and corresponding changes in spirometry or clinical scores. Areas under the receiver operating characteristic curves for the prediction of hospitalization and relapse were poor (0.579 and 0.713, respectively). CONCLUSIONS: FE(NO) measurements in ED patients with acute asthma exacerbations were poorly reproducible and did not correlate with standard measures of asthma severity. These results suggest that using existing technology, FE(NO) is not a useful marker for assessing severity, response to treatment, or disposition of acute asthmatic patients in the ED.

Acute Disease↗
PubMed2005

Capnogram shape in obstructive lung disease.

Small, preliminary studies have suggested that capnograms of obstructive lung disease (OD) exhibit a characteristic shape and that this shape may be correlated to changes in forced expiratory volume in 1 s (FEV(1)). We evaluated the association between capnograms and spirometry from subjects with OD with normal and restrictive lung disease (RD) subjects. The study was conducted in a prospective, nonrandomized manner using a convenience sample of 262 subjects presenting to a pulmonary function laboratory. Capnograms were recorded before pulmonary function testing. Subjects with OD had capnograms that were significantly different from normal and RD subjects. These differences were progressive, increasing with disease severity. The average take-off angle of the ascending phase for severe OD was 7.2 degrees less (95% confidence interval [CI]: 4.0, 10.4) than for normals. The average alveolar plateau elevation angle was 0.8 degrees more (95% CI: 0.14, 1.4) for moderate OD than for normals, whereas the average elevation angle was 3.6 degrees more (95% CI: 2.9, 4.3) for severe OD than for normals. Differences between OD capnograms and normal and RD capnograms, correlating to changes in FEV(1), were sufficiently large enough to suggest that the capnogram could be used to discriminate between OD and normal.

Adult↗
PubMed2004

Can the bispectral index monitor the sedation adequacy of intubated ED adults?

The Bispectral Index Monitor (BIS) is validated as a measure of sedation depth during general anesthesia, but its value otherwise remains unclear. We hypothesized that BIS scores would correlate with standard subjective measures of assessing sedation in intubated adult ED patients and that BIS would predict inadequate sedation. Sedation was assessed by recording clinical features and by having treating physicians complete a visual analog scale (VAS; rated "not sedated" to "completely sedated") at 10, 30, and 60 minutes after intubation. Measurements of BIS were later paired with sedation assessments. Despite being statistically significant (p=.002), the correlation between BIS and VAS in our 147 paired readings was fair (Pearson's rho=-0.37) and displayed wide variability. Receiver operating characteristic curve analysis of BIS demonstrated no discriminatory power in predicting sedation adequacy (area under curve 0.53). BIS is not associated with and did not predict standard measures of sedation adequacy in intubated adults.

Adult↗
PubMed2004

Bispectral index monitoring quantifies depth of sedation during emergency department procedural sedation and analgesia in children.

STUDY OBJECTIVE: The bispectral index monitor uses processed electroencephalogram signals to measure sedation depth on a unitless scale from 0 to 100 (0, coma; 40 to 60, general anesthesia; 60 to 90, sedated; 100, awake). It has been validated in the operating room as an objective measure of sedation depth with nondissociative general anesthesia; however, its usefulness in the pediatric emergency department (ED) for procedural sedation and analgesia has not been established. We determine the ability of the bispectral index to monitor depth of nondissociative procedural sedation and analgesia in children. METHODS: This was an observational study conducted in a children's hospital ED. Procedural sedation and analgesia was performed in the standard manner, with the addition of bispectral index monitoring and simultaneous clinical sedation scoring (modified Ramsay Sedation Scale [range 1 to 8; 1=alert, 8=unresponsive]). Paired bispectral index and Ramsay Sedation Scale scores were assigned every 5 minutes during the sedation. Ramsay Sedation Scale scores were assigned by a single study investigator blinded to the bispectral index score. An emergency physician independently administered all medications for procedural sedation and analgesia. The correlation between the paired bispectral index/Ramsay Sedation Scale scores was determined by using a repeated-measures regression analysis. Receiver operator characteristic (ROC) curves were constructed to determine the ability of the bispectral index to discriminate various thresholds of sedation depth. RESULTS: A convenience sample of 20 patients was enrolled, providing 217 paired bispectral index/Ramsay Sedation Scale measurements. Median age was 4.6 years (range 0.4 to 16.7 years). Fourteen patients received midazolam with fentanyl; the remainder received pentobarbital. Bispectral index scores ranged from 40 to 98 (mean 81.6+/-16.1). Ramsay Sedation Scale scores ranged from 1 to 8 (median 3; interquartile range 2 to 4). The simple Pearson correlation between paired bispectral index and Ramsay Sedation Scale scores was -0.78 (95% confidence interval [CI] -0.83 to -0.72; P<.001). After adjustment for the nonindependence of intrapatient data with bivariate repeated-measures analysis, the correlation was -0.67 (95% CI -0.90 to -0.43; P<.001). The linear regression coefficient between bispectral index and Ramsay Sedation Scale scores was estimated to be between -5.7 and -12.7. ROC curve analysis demonstrated moderate to high discriminatory power of bispectral index scores in predicting level of sedation throughout the sedation continuum, with areas under the curve at least 0.87 for all Ramsay Sedation Scale score thresholds. Bispectral index scores between 60 and 90 predicted with moderate accuracy traditional clinical levels of sedation typically encountered during procedural sedation and analgesia in the pediatric ED. CONCLUSION: Bispectral index monitoring correlated with clinical sedation scores and may serve as a useful, objective adjunct in quantifying depth of nondissociative procedural sedation and analgesia in children.

Adolescent↗
PubMed2004

Clinical practice guideline for emergency department ketamine dissociative sedation in children.

We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.

Age Factors↗
PubMed2003

Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department.

STUDY OBJECTIVE: Assessment of preprocedural fasting is considered essential in minimizing the risks of procedural sedation and analgesia. Established fasting guidelines are difficult to follow in the emergency department (ED). We characterize the fasting status of patients receiving procedural sedation and analgesia in a pediatric ED and assess the relationship between fasting status and adverse events. METHODS: A prospective case series was conducted in a children's hospital ED during an 11-month period. All consecutive patients requiring procedural sedation and analgesia were included. Preprocedural fasting state and adverse events were recorded. The percentage of patients undergoing procedural sedation and analgesia who did not meet fasting guidelines was determined. Adverse events were analyzed in relation to fasting status. RESULTS: One thousand fourteen patients underwent procedural sedation and analgesia, and data on fasting status were available for 905 (89%) patients. Of these 905 patients, 509 (56%; 95% confidence interval [CI] 53% to 60%) did not meet fasting guidelines. Seventy-seven adverse events occurred in 68 (6.7%; 95% CI 5.2% to 8.4%) of the 1,014 patients. All adverse events were minor and successfully treated. Adverse events occurred in 32 (8.1%; 95% CI 5.6% to 11.2%) of 396 patients who met and 35 (6.9%; 95% CI 4.8% to 9.4%) of 509 patients who did not meet fasting guidelines. There was no significant difference in median fasting duration between patients with and without adverse events and between patients with and without emesis. Emesis occurred in 15 (1.5%) patients. There were no episodes of aspiration (1-sided 97.5% CI 0% to 0.4%). CONCLUSION: Fifty-six percent of children undergoing ED procedural sedation and analgesia were not fasted in accordance with established guidelines. There was no association between preprocedural fasting state and adverse events.

Adjuvants, Anesthesia↗
PubMed2003

A study of the Bispectral Index Monitor during procedural sedation and analgesia in the emergency department.

STUDY OBJECTIVE: The Bispectral Index Monitor has been validated as an objective measure of sedation depth in the operating room; however, its value for states other than general anesthesia remains unclear. We hypothesized that bispectral index monitoring would reliably correlate with traditional definitions of sedation depth in emergency department patients undergoing procedural sedation and analgesia. METHODS: In this prospective observational study we measured the Bispectral Index score and a modified Ramsay Sedation Scale score every 5 minutes in a convenience sample of adult ED patients undergoing procedural sedation and analgesia. Investigators and treating physicians were blinded to Bispectral Index scores, which were later correlated with modified Ramsay Sedation Scale scores. We constructed receiver operating characteristic curves to determine the most discriminatory Bispectral Index score thresholds for sedation depth. RESULTS: Two hundred seventy paired readings were obtained from 37 patients. Despite being statistically significant (P <.0005), the correlation between the Bispectral Index Monitor and modified Ramsay Sedation Scale scores was only moderate (Spearman rho=-0.690) and displayed wide variability. A modified Ramsay Sedation Scale score consistent with mild-to-moderate sedation corresponded to Bispectral Index scores of 34 (general anesthesia) to 98 (fully awake), whereas a modified Ramsay Sedation Scale score consistent with deep sedation corresponded to Bispectral Index scores of 40 to 98. Areas under receiver operating characteristic curves demonstrated moderate (0.83 to 0.86) discriminatory power at all modified Ramsay Sedation Scale thresholds, with the exception of a modified Ramsay Sedation Scale score of 7 or less, which demonstrated high discriminatory power (0.95). A Bispectral Index score of greater than 83 reliably excluded general anesthesia, and a Bispectral Index score of 70 or less reliably identified general anesthesia. CONCLUSION: Bispectral index monitoring reliably predicted patients undergoing procedural sedation and analgesia who were sedated to the point of general anesthesia from those with lesser degrees of sedation but did not discriminate mild-to-moderate sedation or moderate-to-deep sedation, as measured by the Ramsay Sedation Scale score for the patients undergoing procedural sedation and analgesia in our ED.

Adolescent↗