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PubMed2004

Sedation records: TRACS electronic database.

The volume of data that should be recorded before, during and after a conscious sedation procedure makes accurate and complete manual recording impractical. Unless the data is in a structured electronic format, subsequent analysis is extremely difficult. The TRacking and Analysis of Conscious Sedation electronic database (TRACS) is designed to overcome these problems. The user is guided through the recording procedure, which follows the Guidelines for Conscious Sedation in the Provision of Dental Care. This, together with the 'Audit Trail' of events provided by TRACS could prove invaluable in the event of a legal or technical dispute. Since the information is in an electronic database, immediate analysis can be performed on both individual and groups of patient records. Provision has been made for records from many treatment centres to be consolidated thus enabling serious academic work to be performed on large numbers of records.

Anesthesia, Dental↗
PubMed2001

Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine.

The pediatric sedative combination of meperidine, promethazine, and chlorpromazine (MPC) has been widely used for more than 40 years. Despite its relatively poor efficacy and questionable safety profile, many emergency departments (EDs) continue to stock specially formulated mixtures of these three agents. We report a case of iatrogenic cardiac arrest in a 2-month-old infant in whom a consulting resident administered too much MPC (10 times the expected dose) by the wrong route (intravenous instead of intramuscular). The child was successfully resuscitated with no apparent neurologic deficit. Subsequently, we have removed MPC entirely from our ED and instituted a policy restricting ED procedural sedation privileges to emergency physicians. We urge other EDs to do likewise.

Chlorpromazine↗
PubMedDate not supplied

Applications of bispectral index monitoring in the pediatric intensive care unit.

The bispectral index (BIS) monitor is an electroencephalographic recording device that generates a single numeric value. It has traditionally been used to measure anesthetic depth and avoid awareness in the operating room setting. In this report, the authors present different scenarios in the pediatric intensive care unit that demonstrate the potential applications of the BIS monitor outside of the operating room setting. The scenarios presented include use of the BIS monitor during titration of barbiturate coma, procedural sedation, sedation assessment during mechanical ventilation, and sedation while administering potentially confounding medications. Previous reports regarding the use of the BIS monitor in such scenarios and potential future applications are reviewed

Adolescent↗
PubMed1996

Intramuscular ketamine is superior to meperidine, promethazine, and chlorpromazine for pediatric emergency department sedation.

OBJECTIVE: To compare ketamine hydrochloride (KET) with combined meperidine hydrochloride, promethazine hydrochloride, and chlorpromazine hydrochloride (MPC) for pediatric emergency department sedation with respect to onset, duration, and efficacy. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: Pediatric emergency department in an urban university hospital. PATIENTS: Convenience sample of 29 patients, 6 months to 6 years of age, requiring sedation for suturing, wound or burn debridement, or lumbar puncture. INTERVENTION: Children received intramuscular KET (4 mg/kg) with atropine sulfate (0.01 mg/kg) or MPC (meperidine hydrochloride 2 mg/kg, promethazine hydrochloride 1 mg/kg, chlorpromazine hydrochloride 1 mg/kg). Data collection included demographics, vital signs, and onset of sedation; procedural distress using the Observational Scale of Behavioral Distress; and time to recovery. The operator was questioned on satisfaction with the drug, and parents received follow-up to assess parental satisfaction. RESULTS: Of the 29 patients enrolled in the study, 2 were excluded for protocol violation, 15 received KET, and 12 received MPC. Demographics and baseline vital signs did not differ. Although patients in the 2 groups had a similar duration of sedation (KET, 82 min vs MPC, 97 min, P = .15), patients receiving KET had more rapid onset of sedation (3 min vs 18 min, P < .01) a shorter time to discharge (85 min vs 113 min, P 0 .01) and lower Observational Scale of Behavioral Distress scores (9.9 vs 19.2, P = .003). All 15 physicians using KET would request it again vs 5 of 12 (42%) of the physicians using MPC (P < .001). No serious adverse reactions occurred. There were no differences in parental satisfaction. CONCLUSION: Ketamine has a faster onset and results in more rapid discharge from the pediatric emergency department while providing for less patient distress during procedures. Ketamine is also associated with greater physician satisfaction than MPC.

Child↗
PubMed2006

Anesthesiologist-controlled versus patient-controlled propofol sedation for shockwave lithotripsy.

PURPOSE: To compare anesthesiologist-controlled sedation (ACS) with patient-controlled sedation (PCS), with respect to propofol requirements, sedation, and recovery, in patients undergoing extracorporeal shockwave lithotripsy for urinary calculi. METHODS: Sixty-four patients were randomized, in this double-blind study, to receive propofol sedation according to one of two regimens: infusion of 200 microg.kg(-1) .min(-1) for ten minutes reduced thereafter to 50-150 microg.kg(-1) .min(-1) titrated by an anesthesiologist, according to patient response (group ACS), or propofol administered by patient-controlled analgesia (bolus dose 300 microg.kg(-1), lockout interval three minutes, no basal infusion), (group PCS). All patients received midazolam 10 microg.kg(-1) iv and fentanyl 1 microg.kg(-1) iv preoperatively, followed by fentanyl infused at a rate of 0.5 microg.kg(-1) .hr(-1) throughout the procedure. Sedation and analgesia were assessed using the A-line ARX index and visual analogue scale, respectively. Psychomotor recovery and readiness for recovery room discharge were assessed using the Trieger dot test and postanesthesia discharge score, respectively. Patient satisfaction was assessed on a seven-point scale (1-7). RESULTS: In comparison to group PCS, patients in group ACS received more propofol (398 +/- 162 mg vs 199 +/- 68 mg, P < 0.001), were more sedated (A-line ARX index: 35 +/- 16 vs 73 +/- 16, P < 0.001), experienced less pain (visual analogue scale: 0 +/- 0 vs 3 +/- 1, P < 0.001), and were more satisfied (median [Q1, Q3]: 7 [7, 7] vs 6 [6, 7], P < 0.001). In contrast, patients in group PCS had faster psychomotor recovery (Trieger dot test median [Q1, Q3]: 8 [4, 16] vs 16 [12, 26] dots missed, P = 0.002) and achieved postanesthesia discharge score >/=9 earlier (median [Q1, Q3]: 40 [35, 60] vs 88 [75, 100] min, P < 0.001) compared with group ACS. CONCLUSION: In comparison to PCS for patients undergoing extracorporeal shockwave lithotripsy, propofol/fentanyl ACS is associated with increased propofol administration, deeper sedation levels, and greater patient comfort. However, ACS is associated with slower recovery and a longer time to meet discharge criteria, when compared to PCS.

Adjuvants, Anesthesia↗
PubMed1999

A randomized double-blind placebo-controlled trial evaluating the cost-effectiveness of droperidol as a sedative premedication for EUS.

BACKGROUND: Droperidol is a neuroleptic agent with anti-emetic properties that produces mild sedation, reduced anxiety, and a state of mental detachment and indifference to one's surroundings. Routine premedication with droperidol has been shown to improve sedation during esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography. The purpose of this randomized double-blind placebo-controlled study was to determine whether premedication with droperidol improves sedation during routine upper endoscopic ultrasound (EUS) in a cost-effective manner. METHODS: One hundred consecutive patients referred for EUS were randomly assigned to receive either 2.5 mg or 5 mg of droperidol or placebo before the procedure. After EUS, the physician, nurse, and recovered patient scored various parameters of procedural sedation. RESULTS: In the group receiving 5 mg of droperidol there was significantly less gagging at intubation, less retching during the procedure, better patient cooperation, less need for physical restraint, and improved nurses' and physician's impression of sedation. Significantly less meperidine and less midazolam were required for sedation, making medication costs significantly lower in the group receiving 5 mg droperidol. CONCLUSIONS: A 5 mg dose of droperidol given as premedication for routine upper EUS improves sedation during the procedure while significantly decreasing the overall cost of sedation.

Adjuvants, Anesthesia↗
PubMed2000

Effect of flumazenil on electroencephalographic patterns induced by midazolam.

BACKGROUND: Flumazenil is a competitive benzodiazepine receptor antagonist, reverts the sedation effects of benzodiazepines and its effect on electroencephalographic (EEG) patterns is controversial. The purpose of this study was to describe flumazenil's effect on EEG patterns of patients undergoing conscious sedation. METHODS: Ten voluntary patients, aged 16-23, at elective oral surgery had conscious sedation with midazolam and local anesthesia. After the procedure, sedation was reversed with flumazenil. Each patient had 4 EEGs of 4 minutes each: baseline, 5 minutes after midazolam, prior to flumazenil, and 8 minutes after flumazenil. A clinical neurophysiologist interpreted EEGs blinded to time. RESULTS: Eight patients had an awake and 2 had an awake and drowsy normal EEG. After midazolam all developed a diffuse beta wave and alpha wave attenuation or dropout. Prior to flumazenil 7 presented diffuse beta and scattered theta waves, and 3 an awake pattern (procedure required > 30 minutes). After flumazenil, reversal of beta and theta waves and appearance of alpha waves was noted; no changes occurred when procedure lasted more than 30 minutes. One patient presented with diffuse theta waves, 6 Hz. CONCLUSIONS: Flumazenil reverts midazolam EEG changes if administered < 30 minutes after midazolam administration, midazolam-induced EEG changes revert spontaneously after 30 minutes, and flumazenil may precipitate theta activity.

Adolescent↗
PubMed2002

Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial.

STUDY OBJECTIVE: We determine whether patients with acute, anterior shoulder dislocation undergoing emergency department procedural sedation and analgesia (PSA) with intravenous etomidate would experience a reduced time of impaired consciousness when compared with a group of patients receiving intravenous midazolam. METHODS: This study was a prospective, double-blinded, randomized, institutional review board-approved trial of ED patients with anterior shoulder dislocation. Patients were randomized to receive intravenous boluses of etomidate (0.1 mg/kg) or midazolam (0.033 mg/kg) during PSA. The primary outcome for comparison was PSA duration. RESULTS: Forty-six patients with anterior shoulder dislocation were enrolled: 22 in the etomidate group and 24 in the midazolam group. Three patients sustained reduction without physician or sedative intervention. Two patients were excluded from protocol because of unavailable study drug or fracture dislocation. The median lowest modified postanesthetic recovery score observed during PSA was 5 (95% confidence interval [CI] 4 to 7) in the etomidate group and 6 (95% CI 6 to 7) in the midazolam group. The median time of PSA for patients receiving etomidate was 10 minutes (95% CI 8 to 15) compared with 23 minutes (95% CI 16 to 30) for patients receiving midazolam, with a difference between the group medians of 13 minutes (95% CI 5 to 22). Reduction success was achieved in 37 (90%) of 41 patients: 2 did not experience reduction with etomidate and 2 did not experience reduction with midazolam. There were 15 PSA complications reported. CONCLUSION: Etomidate provides effective PSA for reduction of ED patients with anterior shoulder dislocation. When compared with midazolam, etomidate use confers a significantly shorter period of PSA.

Adult↗
PubMed2004

Evolving treatment in a decade of pediatric burn care.

BACKGROUND: Over the last decade, an ambulatory burn care (ABC) and procedural sedation (PS) program was instituted at St Louis Children's Hospital (SLCH). This study assessed the effect of these interventions on resource utilization. METHODS: The authors reviewed the hospital experience comparing 1993 with 2002 data regarding gender, age, burn depth, patient admissions, inpatient days, and ABC visits. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges. RESULTS: Gender, age, and burn depth were similar; 192 patients were admitted in 1993. In 2002, there were 167 admissions and 118 patients treated solely on an ABC basis resulting in a total of 285 burn patients treated (+48%). Hospital days decreased from 2,041 (1993) to 963 (2002 [-53%]). LOS declined from 10.4 +/- 8.3 days (1993) to 5.8 +/- 14.2 days (2002 [-44%; P <.05]). PS was used sporadically in 1993, and increased to 71% in patients in 2002. There were no ABC visits in 1993 and 501 visits in 2002. The incidence of infection was 5.2% in 1993 versus 3.0% in 2002 (P <.05) Average charge per patient fell 45% from 13,286 dollars (1993) to 7,372 dollars (2002), adjusted to 1993 dollars using medical care price index. CONCLUSIONS: Over a 10-year period, the program achieved a significant reduction in resource utilization while increasing the number of patients treated and maintaining a low incidence of infection. This was due in large part to a shift to ABC and the use of PS.

Adolescent↗
PubMed1995

Analgesia and sedation in interventional radiological procedures.

The use of intravenous analgesia and anxiolytics in interventional radiology improves the patient's tolerance of potentially painful and prolonged procedures and allows the radiologist better control of the course of the procedure being undertaken. Monitoring of the patient's oxygen saturation, pulse rate, respiration, blood pressure and cardiac rhythm during a procedure is essential. Fentanyl and midazolam is a combination that is effective and convenient to use because both agents are relatively short acting, have little cardiovascular depression and are easily reversible (with naloxone and flumazenil). They are a better alternative to pethidine and diazepam because they can be more tightly titrated and controlled and are safer and more suitable for use in outpatients. Monitoring for respiratory depression is important and special care must be taken in the elderly and patients with hepatic, renal or chronic airways disease. General anaesthesia may be unavoidable in patients who are unstable, unco-operative or who have raised intracranial pressure.

Aged↗
PubMed2006

Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?

OBJECTIVES: The value of ventilation monitoring with end-tidal carbon dioxide (ETCO2) to anticipate acute respiratory events during emergency department (ED) procedural sedation and analgesia (PSA) is unclear. The authors sought to determine if ETCO2 monitoring would reveal findings indicating an acute respiratory event earlier than indicated by current monitoring practices. METHODS: The study included a prospective convenience sample of ED patients undergoing PSA. Clinicians performed ED PSA procedures with generally accepted patient monitoring, including oxygen saturation (SpO2), and clinical ventilation assessment. A study investigator recorded ETCO2 levels and respiratory events during each PSA procedure, with clinical providers blinded to ETCO(2) levels. Acute respiratory events were defined as SpO2 < or =92%, increases in the amount of supplemental oxygen provided, use of bag-valve mask or oral/nasal airway for ventilatory assistance, repositioning or airway alignment maneuvers, and use of physical or verbal means to stimulate patients with depressed ventilation or apnea, and reversal agent administration. RESULTS: Enrollment was stopped after independent review of 20 acute respiratory events in 60 patient sedation encounters (33%). Abnormal ETCO2 findings were documented in 36 patients (60%). Seventeen patients (85%) with acute respiratory events demonstrated ETCO2 findings indicative of hypoventilation or apnea during PSA. Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events. CONCLUSIONS: Abnormal ETCO2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO2 abnormalities that occurred before oxygen desaturation or observed hypoventilation.

Acute Disease↗
PubMedDate not supplied

Effect of submucosal midazolam on behavior and physiologic response when combined with oral chloral hydrate and nitrous oxide sedation.

PURPOSE: This study was designed to examine the efficacy and safety of submucosal (SM) midazolam and oral chloral hydrate (CH) when used for pediatric conscious sedation in a clinical dental environment. METHODS: Twenty children ages 32 to 63 months participated in this institutionally approved study. Selection criteria included good health (ASA I), 2 to 5 years of age, uncooperative behavior, and the need for multiple restorative visits. In a double-blind crossover design, patients were randomly assigned to receive either oral CH (50 mg/kg) and SM midazolam (0.2 mg/kg), or oral CH (50 mg/kg) and SM saline placebo on their first sedation visit. On the second sedation visit, the patient received the opposite drug regimen than the first visit. Nitrous oxide (50%) was used during each sedation visit. Behavior response was rated as quiet (Q), crying (C), movement (M), or struggling (S) every 2.5 minutes through 40 minutes of operative procedures. Sedations were monitored using a capnograph, pulse oximeter, an automated blood pressure cuff, and precordial stethoscope. Respiratory rate (RR), heart rate (HR), and blood pressure (BP) were evaluated for each procedure. Data was analyzed using ANOVA and multinomial repeated-measures logistic regression. RESULTS: Analysis showed a significant difference in behavior during sedation across drug regimen (chi-square = 55.6, df = 3, P < .0001). Patients given SM midazolam in addition to oral CH showed increased Q rating and decreased C, M, and S ratings. RR, BP, and HR for both groups remained within the normal values for 2- to 5-year-olds. CONCLUSIONS: SM midazolam improved the quality of sedation without compromising safety. Quiet behavior was increased and struggling behavior was decreased. In addition, mean HR, RR, and BP analysis did not deviate from the norm for this age group.

Anesthesia, Dental↗
PubMed2000

Routine droperidol pre-medication improves sedation for ERCP.

BACKGROUND: Pre-medication with droperidol has been used to improve sedation during endoscopy, especially in patients with a history of alcohol or narcotic abuse. We studied whether routine use of droperidol pre-endoscopic retrograde cholangiopancreatography (ERCP) could improve patient and physician satisfaction with sedation. METHODS: Sixty-seven patients undergoing routine ERCP were enrolled in this double-blind placebo-controlled study. Patients were given either parenteral normal saline solution or 5 mg of droperidol 15 minutes before the procedure. After the ERCP, several parameters of procedural sedation were scored on an ordinal scale by the endoscopist, the endoscopy nurse, and the recovered patient. In addition, a follow-up telephone call was made to the patient after 24 hours. RESULTS: The mean procedural room time was similar in the two groups. Nearly 25% less meperidine and diazepam was used in the droperidol-treated patients, making the overall medication cost similar in both groups. The mean recovery room time was 113 minutes for the placebo group and 106 minutes for the droperidol group. Droperidol premedication significantly decreased post-procedure nausea and vomiting, reduced gagging at intubation, and decreased retching during the procedure. Droperidol also improved physician (p = 0.001), nurse (p = 0.001), and patient (p = 0.0001) impressions of overall sedation and decreased the need for physical restraint during the procedure. Droperidol significantly increased the number of patients with no memory of the procedure. CONCLUSION: Droperidol improved overall patient, physician, and nurse satisfaction with sedation during ERCP. It also reduced post-ERCP nausea and vomiting without increasing recovery time or medication cost. Droperidol is recommended for routine pre-ERCP sedation. (Gastrointest Endosc 2000;52:362-6).

Adolescent↗