Sedation

Whipple's operation can be carried out either under general anaesthesia or continuous epidural anaesthesia with sedation. We report three cases that were managed successfully and we found that the combination of lumbar epidural analgesia with sedation is safer and beneficial as compared to those who undergo Whipple's operation under general anaesthesia. For the last three decades epidural analgesia has been the part of anaesthesia practice. Epidural analgesia can be a useful method of pain management various situations. It facilitates early mobilization and also avoids perioperative pulmonary complications especially after major thoracic or upper abdominal surgeries. The combination of continuous epidural analgesia with sedation has many advantages in prolonged major upper abdominal surgeries.

Chemical restraint for wild animals is necessary to perform procedures such as: physical examination, collection of biological material and imaging exams. Little is known about the effects of anesthetics on chelonians, in part, because of the rare studies and investigations. This investigation aimed to demonstrate three techniques of chemical containment for chelonians, in addition, to evaluate latency period, duration of drug effect and the degree of chemical containment. We used 6 animals, 2 of each species: Kinosternon scorpioides, Chelonoidis carbonaria and Phrynops geoffroanus, from services provided by Hovet/UEMA. Three protocols were used: the association of (Ketamine 10mg/Kg and Midazolam 1mg/Kg intramuscularly - Protocol 1), (Propofol at a dose of 35 mg/Kg intracoelomically - Protocol 2) and (Butorphanol 1 mg/kg kg intramuscularly - Protocol 3). The following criteria were evaluated: spontaneous locomotor activity, muscle relaxation and manipulation of limbs, tail, head and mouth. Protocol 1 had a mean latency period of 5 minutes and the duration of the drug's effect lasted for 95 minutes. The species Phrynops geoffroanus was more sensitive to this protocol, showing marked signs of sedation. In protocol 2, the species Chelonoidis carbonaria had more intense signs of sedation. The latency period was 3 minutes on average and the duration of the effect lasted for 80 minutes. Protocol 3 did not cause signs of chemical containment.

The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at end-of-life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia, and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.

Pain is a major problem in intensive care and is the primary problem for intensive care patients. The high-quality pain management and pain, palliative treatment should be targeted for every patient. Palliation, evaluation, and monitoring of the pain begin with the use of effective strategies. Pain management includes both pharmacological and nonpharmacological treatments. Analgesia has positive effects on morbidity and prevents pulmonary complications such as atelectasis and pneumonia, and self-extubation after agitation. In this review, assessment, monitoring, results, and method of the pain management in intensive care unit (ICU) were explained.

Materials and Methods This retrospective study was approved by the Institutional Review Board of the Faculty Medicine Siriraj Hospital, Mahidol University. Between January 2006 and June 2008, data were collected prospectively on all children younger than aged 18 ...

Objectives: To evaluate dexmedetomidine as adjunctive therapy to
lorazepam for severe alcohol withdrawal.
Design: Prospective, randomized, double-blind, placebo-controlled
trial.
Setting: Single center; medical ICU.
Patients: Twenty-four adult patients with a Clinical Institute Withdrawal
Assessment score greater than or equal to 15 despite
greater than or equal to 16 mg of lorazepam over a 4-hour period.
Interventions: Patients received a symptom-triggered Clinical
Institute Withdrawal Assessment protocol with lorazepam and
were randomized to dexmedetomidine 1.2 μg/kg/hr (high dose),
0.4 μg/kg/hr (low dose), or placebo as adjunctive therapy for up
to 5 days or resolution of withdrawal symptoms.
Measurement and Main Results: High-dose and low-dose groups
were combined as a single dexmedetomidine group for primary
analysis with secondary analysis exploring a dose-response relationship.
The difference in 24-hour lorazepam requirements after
versus before study drug was greater in the dexmedetomidine
group compared with the placebo group (–56 mg vs –8 mg,
p = 0.037). Median differences were similar for high dose and low
dose. The 7-day cumulative lorazepam requirements were not statistically
different between dexmedetomidine and placebo (159 mg
vs 181 mg). Clinical Institute Withdrawal Assessment or Riker
sedation-agitation scale scores representing severe agitation (13%
vs 25%) or moderate agitation (27% vs 22%) within 24 hours of
initiating study drug were similar for dexmedetomidine and placebo
groups, respectively. Bradycardia occurred more frequently
in the dexmedetomidine group versus placebo group (25% vs 0%,
p = not significant), with the majority of bradycardia occurring in the
high-dose group (37.5%). Study drug rate adjustments occurred
more often in the dexmedetomidine group compared with the placebo
group (50% vs 0%, p = 0.02). Neither endotracheal intubation
nor seizure occurred in any group while on study drug.
Conclusions: Adjunctive dexmedetomidine for severe alcohol
withdrawal maintains symptom control and reduces lorazepam
exposure in the short term, but not long term, when using a symptom-
triggered protocol. Monitoring for bradycardia is needed with
dexmedetomidine but the occurrence may be lessened with low
dose. Further study is needed to evaluate the clinical impact of
dexmedetomidine. (Crit Care Med 2014; 42:1131–1139)
Key Words: alcohol withdrawal; benzodiazepine; critical care;
dexmedetomidine; intensive care

Problem Excess sedation, inadequate analgesia, or sedation in lieu of analgesia in the mechanically ventilated patient can contribute to delirium, poorer outcomes, increased time of mechanical ventilation, weakness, and other secondary complications [1-6]. The Pain, Agitation, and Delirium guidelines published in 2013 have further educated the critical care community on the importance of responsibly using sedative hypnotics, analgesics, and neuroleptics in the mechanically ventilated patient [7]. There is also considerable evidence to support that protocol driven sedation minimizes complications and over sedation. Trials such as ABC and ABCDE have demonstrated that a coordinated, standardized method of addressing sedation, analgesia, and mobility in the ICU can improve outcomes [8-12]. However, there is no clear evidence-based guidance for clinicians describing how to develop a customized, reliable, and consistent sedation plan for bedside providers to use Abstract Purpose: Inadequate analgesia and excess sedation in mechanically ventilated patients leads to delirium or respiratory suppression prolonging ventilation time and hospital length of stay (LOS). Intensive care units (ICUs) are challenged with designing, implementing, and educating providers' on protocols which consistently guide the practitioner to provide safe and effective sedation and analgesia. This case study evaluates a method of sedation and analgesia for mechanical ventilation from the perspectives of protocol content, education, implementation, and outcomes. Summary: This is a single-centered retrospective analysis of the implementation of a sedation and analgesia protocol in a 35 bed ICU with a focus on implementation and education. All mechanically ventilated patients were placed on the protocol and included in the assessment except patients who were; neurologically impaired, chronically ventilated, intubated for open-heart surgery, or whose condition required off-protocol sedatives. The protocol was presented so as to accommodate for differing staff learning styles. Education included nursing and respiratory therapy in-services, education through multidisciplinary rounds, and letters to or personal discussions with intensivists. Our initiative resulted in a 40.8% decrease in average days requiring mechanical ventilation (p < 0.003); a 37.6% reduced ICU LOS (p < 0.04); and a 34.5% decrease in hospital LOS (p < 0.01). Lorazepam use decreased by 67% (p = 0.037). Conclusions: This case study describes a method of sedation and analgesia for the mechanically ventilated patient and our approach to education and application, resulting in a paradigm shift in how these drugs are utilized in the ICU, thereby decreasing the average days requiring mechanical ventilation and LOS.

Partir des hommes tels qu’ils sont, pour penser une éthique de vie à la mesure des soignants et des patients. C’est l’exigence que nous nous sommes fixée pour mettre en place une anthropologie éthique. Cela revient ainsi à porter une attention toute particulière aux affects et représentations en jeu dans le soin, à réinscrire les pratiques de soins dans leur contexte (celui de la recherche, celui de la clinique, celui des demandes sociétales, celui des contraintes organisationnelles, celui des imaginaires, …) et à ancrer l’éthique du quotidien dans une autre conception de l’humain sans pour autant l’y réduire ou renoncer à cheminer et à faire cheminer. Après ces trois années de relecture de l’éthique en santé à la lumière d’une anthropologie spinoziste, nous nous proposons pour les trois années à venir de rester dans cette tonalité spinoziste à l’œuvre dans notre travail en milieu hospitalier, mais en l’enrichissant d’une approche plurielle (celle de la géographie, celle de l’ergonomie, celle de la psychologie du travail, …) avec en prisme des pratiques de soins toujours à repenser et à réfléchir – au sens du miroir comme de l’approche réflexive. C’est ainsi une approche systémique du patient, mais aussi des soignants et des chercheurs, que nous cherchons à mettre en place et en œuvre progressivement. Dans le même mouvement, cette approche plurielle sera alimentée de retours pratiques et réflexifs sur les projets en cours dans un Centre de lutte contre le cancer, dans un CHU et dans deux centres hospitaliers périphériques, avec un ancrage territorial (cœur d’une grande ville, espace montagnard et rural, …) et de spécialités (oncologie médicale, réanimation, soins palliatifs, rééducation fonctionnelle, hématologie, …) varié, venant enrichir et pluraliser la réflexion. Ce séminaire vise ainsi une compréhension plus adéquate de la situation dans laquelle se trouvent les patients, les familles, le personnel soignant, l’encadrement et les chercheurs, au sein des pratiques de soins qui sont autant d’interfaces entre les différents acteurs. Notre exigence est de nous prémunir de tout jugement de valeur tout en gardant à l’esprit qu’un cheminement éthique est toujours possible, mais doit aussi être toujours en cours de réactivation.

Penelitian ini bertujuan mengamati pengaruh diabetes melitus terhadap onset dan lama sedasi pada tikus putih (Rattus norvegicus) yang diinjeksi dengan propofol. Dalam penelitian ini digunakan 8 ekor tikus putih betina strain Wistar berumur 2-3 bulan dengan bobot badan 150-200 g. Semua tikus putih diberi pakan standar dan air minum secara ad libitum dan selanjutnya dibagi menjadi 2 kelompok perlakuan. Kelompok I (KI) diinjeksikan dengan pelarut aloksan, sedangkan kelompok II (KII) diinjeksikan aloksan dengan dosis 150 mg/kg bobot badan dalam NaCl 0,9%. Semua perlakuan diberikan secara intraperitoneum sebanyak 0,5 ml. Sepuluh hari setelah induksi aloksan, dilakukan pemeriksaan kadar glukosa darah puasa pada tikus putih KII. Propofol 1% dengan dosis 10 mg/kg bobot badan sebagai anestesi umum diinjeksikan pada semua tikus putih melalui vena lateralis ekor. Parameter penelitian ini adalah onset dan lama sedasi pada masing-masing kelompok. Onset dan lama sedasi antara KI dan KII masing-masing adalah 1,39±0,49 dan 8,64±1,23 detik dan 12,12±1,47 dan 7,62±1,61 menit (P<0,01). Dari hasil penelitian dapat disimpulkan bahwa kondisi diabetes melitus pada tikus putih galur Wistar berpengaruh terhadap onset dan lama sedasi anestesi propofol.

Background Septic shock is associated with decreased vasopressor responsiveness. Experimental data suggest that central alpha2-agonists like dexmedetomidine (DEX) increase vasopressor responsiveness and reduce catecholamine requirements in septic shock. However, DEX may also cause hypotension and bradycardia. Thus, it remains unclear whether DEX is hemodynamically safe or helpful in this setting. Methods In this post hoc subgroup analysis of the Sedation Practice in Intensive Care Evaluation (SPICE III) trial, an international randomized trial comparing early sedation with dexmedetomidine to usual care in critically patients receiving mechanical ventilation, we studied patients with septic shock admitted to two tertiary ICUs in Australia and Switzerland. The primary outcome was vasopressor requirements in the first 48 h after randomization, expressed as noradrenaline equivalent dose (NEq [μg/kg/min] = noradrenaline + adrenaline + vasopressin/0.4). Results Between November 2013 and F...

Objective: To identify utilisation rates of prn (pro re nata) sedation in children and adolescents receiving inpatient psychiatric treatment, and to compare correlates of prn pre- scribing and administration. Method A retrospective chart re- view examined 122 medical charts from a child and youth mental health inpatient service. Results 71.3% of patients were prescribed prn sedation and 50.8% were administered prn sedation. Pa- tients received an average of 8.0 doses of prn sedation, with 9.8% receiving 10 or more doses. Chlorpromazine and diazepam were the most commonly utilised agents. Prescribing of prn seda- tion was only related to use of regular medications (p < 0.01), and non-parent carers (p < 0.01). In contrast, administration of prn
sedation was associated with multiple diagnoses (p < 0.01), pervasive development disorder (p < 0.01), mental retardation (p < 0.01) ADHD (p < 0.01), longer hospital admission (p < 0.01), use of atypical antipsychotics (p < 0.01) and polypharmacy (p < 0.01). Conclusions Despite lack of data to inform practice, prn sedation is widely utilised, especially in complex patients. Future research in this area needs to incorporate nurses and examine whether patients benefit from prn sedation, which drugs and dosing patterns optimise safety and efficacy, and what is the role of prn sedation in the context of other medication.

This study was designed to investigate the difference in CNS effects of Santalum album L. administered via oral route and inhalational route. The aqueous extract (4 ml) and fragrance of paste was administered to rats for continuous period of 7 days. The pharmacological activities assessed were spontaneous behaviour using autotrack instrument and analgesic activity using hot plate analgesia meter. Diazepam (4mg/kg) and Pentazocine (5 mg/kg) served as standard drugs. Statistical analysis of the obtained results was carried using one way ANOVA followed by Dunnett's test. Both the extracts expressed significant sedative action as indicated by reduction in mobility of rats as compared to control groups. The aqueous extract produced better sedation and the effect was seen to be cumulative. Analgesic effect was not clear from the obtained results. It can be concluded from the study that Santalum album Linn. administered by oral route had more prominent central nervous system effect.

Transesophageal echocardiography (TEE), being a displeasing intervention, usually entails se.dation. We aimed to compare the effects of hypnosis and midazolam for sedation in TEE. A prospective single-blinded study conducted on patients scheduled for TEE between April 2011 and July 2011 at a university in Istanbul, Turkey. A total of 41 patients underwent sedation using midazolam and 45 patients underwent hypnosis. Patients were given the State-Trait Anxiety Inventory (STAI) test for anxiety and continuous performance test (CPT) for alertness before and after the procedure. The difficulty of probing and the overall procedure rated by the cardiologist and satisfaction scores of the patients were also documented. Anxiety was found to be less and attention more in the hypnosis group, as revealed by STAI and CPT test scores (P &lt; .05 and P &lt; .001, respectively). Hypnosis proved to be associated with positive therapeutic outcomes for TEE with regard to alleviation of anxiety and mai...

Introduction: Ketamine is an agent used broadly for pediatric procedural sedation and analgesia in emergency departments. It has been found to be safe and with a low risk of complications. As choosing between intravenous (IV) and intramuscular (IM) injections is a matter of concern, we did comparison between two methods in terms of their efficacy and the rate of complications. Methods: This single-blind clinical trial study recruited 240 children (age: three months to 15 years, weight > 5 kg), who underwent short and painful procedures at the emergency departments. They were randomly allocated in to two groups of 120 patients to receive either IV or IM ketamine with doses of 1.5 and 4 mg/kg, respectively. Indications for use, dose, side effects, and efficacy of the medications as well as duration of the procedure and time to recovery were compared between two groups. Results: The mean age of the IV and IM groups were 6.5 ± 3.6 and 3.05 ± 2.6 years, respectively (p < 0.001). The onset of action of ketamine was 1.7 ± 1.1 minutes in the IV group and 8.6 ± 3.1 in the IM ones (p < 0.001). Patients of the IV and IM groups remained in optimal sedation for 20.6±12.0 and 37.2±11.8 minutes, respectively (P < 0.001). Time until emergency department discharge was 65.3 ± 36.9 minutes in the IV group and 72.2 ± 14.5 in the IM group (P = 0.40). Ketamine had excellent and moderate efficacy in 66.7% and 32.5% of the IV group and 70.0% and 25.0%  in the IM group, respectively (p = 0.02). Totally, 60.0% of IV group patients and 40.0% of IM group experienced drug side effects (p = 0.21). Need to rescue dose was significantly higher in IV group (26.7% vs. 10.0%; p < 0.001). Finally, recovery was tranquil and comfortable in 88 patients (73.3%) of the IV group and 108 patients (90.0%) of the IM group (p = 0.06). Conclusion: We found that although the sedative and analgesic effects of IM and IV ketamine are not significantly different, duration of effect and onset of action are more desirable in the IV group for suturing, fracture reduction, and foreign body removal. Meanwhile, the IM method can lead to lesser need of rescue doses.

Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been
established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians.
Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (>86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger (<86 years old)
Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE
procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic
personnel in the endoscopy room. The cohort was divided into three groups, <65 years old (group 1), 65-85 years
old (group 2), and >86 years old (group 3).
Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in 2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups. Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p <0.001). Mean procedure time in group 3 was longer than in group 1 or 2 (p=0.010). Adverse events in group 3 occurred more frequently when compared to group 1 or 2 (p <0.001). Transient hypotension was the main complication across all aged groups.
Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

To report the largest study on the safety and effectiveness of sedation in paediatric ophthalmology in a nurse-led outpatient sedation unit. Retrospective cohort study reviewing all children who underwent sedation from January 2006 to December 2010. Patients were sedated with 80 mg/kg of chloral hydrate (CH) given orally with top up dose given at half dose as required. All demographic data, sedation and procedure duration, sedation success and adverse events were recorded. Univariate and multiple regression analyses were performed to assess factors associated with success and complications. Data was collected for 1509 sedation episodes. More boys were sedated compared with girls (56.3% vs 43.7% p=0.0003) with an average age of 23.86 months and weight of 11.76 kg. A higher proportion of patients had an American Society of Anaesthesiologists status of II than I (58.5%:41.5%, p=0.0001). Successful sedation was obtained in 96.69% of children with 4.77% requiring a top up dose to achieve this. The average sedation duration was 53.4 min (SD=21.5) with an average of 1.7 procedures performed; the most common being a detailed examination (93.5%) and electroretinogram (45.1%). Adverse events included paradoxical reaction (1.33%), oxygen desaturation (0.99%) and vomiting (0.53%). There were no serious complications or hospital admission. Multiple logistic regression analysis found weight greater than 15 kg and needing a top up dose to be significant risk factors for Failure (OR=2.49 and 8.69, respectively) and Adverse events (OR=2.1 and 3.97, respectively). Sex and American Society of Anesthesiologists Physical Status score did not significantly affect outcomes. CH sedation allows detailed examination and investigations in the majority of children with few side effects. Patients over 15 kg and need for a top up dose are risk factors for failure and adverse events. This is the largest study in the current literature looking at the use of CH sedation in ophthalmology and confirms its safety and effectiveness.

Objective To perform a cross-cultural adaptation of the Richmond Agitation-Sedation Scale (RASS) to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care. Methods Cross-cultural adaptation process including the conceptual, item, semantic and operational equivalence stages according to current recommendations. Results Pretests, divided into two stages, included 30 professionals from the pediatric intensive care unit of a university hospital, who administered the translated RASS to patients aged 29 days to 18 years. The pretests showed a content validity index above 0.90 for all items: 0.97 in the first stage of pretests and 0.99 in the second. Conclusion The cross-cultural adaptation of RASS to Brazilian Portuguese resulted in a version with excellent comprehensibility and acceptability in a pediatric intensive care setting. Reliability and validity studies should be performed to evaluate the psychometric properties of the Brazilian Portuguese version of the...

Background and aim: Pain assessment in pediatric intensive care unit (PICU) is a demanding challenge. The COMFORT-B scale is recognized as the gold standard in such patients. However, the use of this instrument in PICU setting is disputed. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. The BPS has been validated in Italian, requires a short observation time compared to the COMFORT-B and does not increase workloads. A first evaluation of BPS was made in PICU with good results regarding face validity and content validity, however suggesting further studies given the small sample on which it was tested. The aim of this study was the validation of the BPS in sedated, intubated, and mechanically ventilated pediatric patients. Methods: A descriptive, comparative design was used. A convenience sample of 84 non-verbal, sedated and mechanically ventilated critical care pediatric patients was included. Patient pain was assessed concurrently with three observational scales (BPS, COMFORT-B, NRS) before, during and after routine procedures that are considered painful and non-painful. Results: Internal consistency was α = .86. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the BPS. T test and assessment of ROC curves demonstrated a good discriminant validity of the BPS. Conclusions: The BPS proved to be valid and reliable for the assessment of pain also in the use with pediatric patients.

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the &quot;Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care&quot;. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidenc...

be divided into a 'background' pain and a 'breakthrough' pain associated with painful procedures. While background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/or less potent oral opioids, breakthrough pain may be treated with a variety of interventions. The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium. This review summarizes recent developments and current techniques in sedation and analgesia in non-intubated adult burn patients during painful procedures

La SPCMJD est utilisée pour contrôler des symptômes physiques réfractaires comme la dyspnée, la nausée, le vomissement, la douleur physique, mais aussi pour les symptômes psychologiques comme l’anxiété, l’angoisse, le délirium, etc. En certains cas, cette intervention se pose aussi pour contrôler la souffrance existentielle, une forme de souffrance qui dérive d’une perte ou interruption du sens, du propos, ou de l’espérance dans la vie. Des dizaines d’études qualitatives, quantitatives et mixtes sur la SPCMJD-SE ne sont pas parvenues à établir une « évidence » sur les aspects cliniques et éthiques de cette intervention. Par rapport aux aspects éthiques, une récente revue systématique de la littérature en bioéthique [2] a mis en évidence la diversité d’arguments et de principes éthiques invoqués dans les discussions, qui manifestent une absence de consensus, aussi bien parmi les cliniciens que parmi les éthiciens, concernant la SPCMJD-SE. Pour rendre accessibles ces résultats au public francophone, cet article propose un état de la question sur la SPCMJD-SE en articulant les perspectives cliniques (1.) et éthiques (2.) qui renvoient finalement à des interrogations philosophiques (3.).

Background: Anxiety can complicate any outpatient procedure by causing elevation in blood pressure and heart rate with resultant increase in intraoperative and postoperative bleeding. Anxiety may also reduce patient satisfaction with the surgical experience. Midazolam is an efficacious short-acting benzodiazepine with an excellent safety record. However, little experience is documented on the use of midazolam in outpatient dermatologic surgery. Objective: To establish the safety and efficacy of oral midazolam in healthy patients undergoing Mohs micrographic surgery. Methods: Patients undergoing outpatient Mohs surgery were randomized in a double-blind, placebo-controlled study of single-dose midazolam for efficacy and safety in producing anxiolysis of short duration. A subpopulation of patients was evaluated prospectively in a nonrandomized arm of the study. Data on vital signs, anxiety, adverse events, and overall satisfaction were collected and compared using analysis of covariance model. Results: Forty-four patients were randomized and 31 patients were enrolled in the prospective arm. Socioeconomic and surgical characteristics were similar among the groups. At 60 minutes, there was a clinically and statistically significant reduction in anxiety and alertness in both randomized and prospective arms. There were no major adverse events. Patients in all 3 groups were equally satisfied with their experience. Limitations: Few patients with high perioperative anxiety were willing to participate in a randomized controlled trial of anxiolytic medication. Conclusions: Midazolam is safe and efficacious in perioperative anxiolysis for healthy patients undergoing outpatient Mohs micrographic surgery. Midazolam offers the benefits of amnesia, reduced alertness, and reduced blood pressure with no clinically significant adverse effects. (J Am Acad Dermatol 2011;64:310-22.)

La fin de vie est l’une des grandes thématiques contemporaines de l’éthique en santé : d’un côté, les progrès de la médecine permettent de maintenir les personnes en vie plus longtemps, mais parfois dans un état général très dégradé ; d’un autre côté, le mourir est devenu tabou dans l’intimité, et on délègue à la société sa prise en charge institutionnalisée, voire on demande à la médecine de nous redonner une maîtrise sur la mort, quand on semble avoir perdu la maîtrise de sa vie. Entre soins palliatifs, sédation, suicide assisté et euthanasie, les connotations et enjeux s’entrechoquent, et les représentations sociales s’entremêlent, au point que l’on se sait plus de quoi l’on parle et que les débats dits éthiques se transforment en opposition de valeurs en apparence irréconciliable : c’est à celui qui parlera le plus fort, le dernier, ou qui aura le plus de charisme, et on perd de vue ce qu’il y a d’éthique et de réflexif dans la discussion.

The California poppy (Eschscholzia californica Cham.) contains a variety of natural compounds including several alkaloids found exclusively in this plant. Because of the sedative, anxiolytic, and analgesic effects, this herb is currently sold in pharmacies in many countries. However, our understanding of these biological effects at the molecular level is still lacking. Alkaloids detected in E. californica could be hypothesized to act at GABA A receptors, which are widely expressed in the brain mainly at the inhibitory interneurons. Electrophysiological studies on a recombinant 1 2 2 GABA A receptor showed no effect of N-methyllaurotetanine at concentrations lower than 30 M. However, ( )-reticuline behaved as positive allosteric modulator at the 3 , 5 , and 6 isoforms of GABA A receptors. The depressant properties of aerial parts of E. californica are assigned to chloride-current modulation by ( )reticuline at the 3 2 2 and 5 2 2 GABA A receptors. Interestingly, 1 , 3 , and 5 were not significantly affected by ( )-reticuline, 1,2-tetrahydroreticuline, codeine, and morphine-suspected ( )-reticuline metabolites in the rodent brain.

Colonoscopy has become an essential modality for evaluation and treatment of lower gastrointestinal tract. This endoscopic procedure is complex and may be unsafe if special concerns are not considered. It is well accepted that children undergoing colonoscopy should receive sedation for the procedure. Nevertheless, considerable practice variation prevails. The goal of procedural sedation is the
safe and effective control of pain, anxiety and motion as well as to provide an appropriate degree of memory loss or decreased awareness. Regardless of regimen used, the safe administration of sedation to children requires an awareness of the particular needs of this population. Although colonoscopy is considered safe, the procedure has a potential for complications. Procedure and sedation-related complications can more easily occur in pediatric patients. Increased awareness of the complications associated with sedation during colonoscopy in children and involving the anesthesiologists in caring for these children may be optimal for safety. Proper patient preparation, endoscopic personnel and endoscopic unit are imperative
to successful sedation and procedure. Additionally, postprocedural monitoring is important to insure that children have fully recovered from sedation.

Introduction: The quality of interventions in children is largely dependent on their control. Hence, this study compared the sedative effects of subcutaneous (SC) and intravenous (IV) Midazolam in pediatric sedation induction.
Methods: This randomized clinical trial was conducted on children aged 1-6 years presenting to emergency departments of Shahid Sadoughi and Shahid Rahnemoon Hospitals, Yazd, Iran. Participants were randomly assigned to IV or SC midazolam using a jet injector and success rate, degree of sedation, and satisfaction of parents and physician were compared between groups.
Results: 60 cases with the mean age of 3.15±1.43 (1-6) years were randomly assigned to the SC (30 cases) or IV (30 cases) groups (56.7% female). SC and IV groups were similar regarding the mean age (p = 0.165) and sex (p = 0.121).
Depth of sedation (p=0.900), control of child (p=0.711), in-charge physician’s satisfaction (p=0.467), successful sedation and need for rescue dose (p=0.519) were not different between groups. IV midazolam group had a significantly shorter recovery time (about 10 minutes; p=0.040) and SC midazolam group had a significantly higher level of parent satisfaction (p=0.001).
Conclusion: The findings indicate no significant difference in depth of sedation, control of child, in-charge physician’s satisfaction, successful sedation (reaching stage 1 of sedation or higher), and need for rescue dose of SC and IV midazolam. Parents’ satisfaction was significantly greater with SC administration and IV injection had shorter recovery time.

ABSTRACT: In feline veterinary practice sedation is often needed to perform diagnostic or minimally invasive procedures, minimize stress, and facilitate handling. The mortality rate of cats undergoing sedation is significantly higher than dogs, so it is fundamental that the sedatives provide good cardiovascular stability. Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist utilized in cats to provide sedation and analgesia, although studies have been utilized high doses, and markedly hemodynamic impairments were reported. The aim of this study was to prospectively investigate how the sedative and electrocardiographic effects of a low dose of DEX performing in cats. Eleven healthy cats were recruited; baseline sedative score, systolic arterial pressure, electrocardiography, and vasovagal tonus index (VVTI) were assessed, and repeated after ten minutes of DEX 5μg/kg intramuscularly (IM). A smooth sedation was noticed, and emesis and sialorrhea were common adverse effects, obser...

Betty Basan
Reflections on Last Newsletter

Jerusalem

Bloody Friday – March 30, 2018
Bloody Friday2 – April 6, 2018
Yasser Murtaja
Bloody Friday3 – April, 13, 2018
Bloody Friday4 – April 20, 2018

Israel Reaches Landmark Deal with UN to Resettle African Migrants. But then Retracts. 

David Grossman: Voice of moderation, of sanity, of wisdom
 
Spin Doctoring

British Labour and Antisemitism
Israeli Labour Party Suspends Relations with UK Labour Party

Millicent Fawcett

Zuckerberg’s Testimony in Congress

My New Article - Raphael Cohen-Almagor and E. Wesley Ely, “Euthanasia and Palliative Sedation in Belgium”, BMJ Supportive and Palliative Care (2018).

Wes Ely’s CNN Article

New Books – Amos N. Guiora, Earl Warren, Ernesto Miranda and Terrorism

Gem of the Month – Royal Philharmonic Orchestra Playing Rachmaninoff Piano Concerto No. 2

Spring Please
Guess
Monthly Poems
Light Side

Introduction: Sedation makes it convenient for the patient, the anaesthesiologist and the surgeon during surgeries under regional anaesthesia. Midazolam in doses of 0.05mg/Kg produces good sedation and excellent amnesia but has no specific analgesic properties and causes depression of upper airway muscle tone in the elderly, resulting in a higher incidence of airway obstruction. Midazolam is commonly used drug for sedation during regional anaesthesia, which produces good sedation and excellent amnesia but causes upper airway obstruction and respiratory depression. Dexmedetomidine has been used as a sedative for various surgical and medical procedures, but loading dose of 1μg/kg has been associated with higher incidences of bradycardia, whereas lower doses produce inadequate sedation.
Aim: To evaluate the effect of low dose midazolam on bradycardia and sedation during low dose dexmedetomidine infusion after spinal block.
Methodology: In this prospective case control study, 80 patients undergoing surgeries under spinal anaesthesia were studied under two groups, Group D (n=40) who received 1mcg/kg dexmedetomidine as loading dose and Group DM (n=40) who received inj.midazolam 0.025mg/kg along with 0.5mcg/kg dexmedetomidine as loading dose. Both the groups were maintained by continuous infusion of dexmedetomidine at 0.04mcg/kg//hr. All patients were monitored for heart rate, mean arterial pressure, respiratory rate, oxygen saturation, Observer’s Assessment of Alertness/Sedation Scale (OAA/S) and complications.
Results: Mean heart rate was significantly lower in group D compared to group DM after 5 and 10 min of loading (P < 0.0001). Incidence of bradycardia requiring Atropine was significantly higher (P=0.0011)in group D (22/40) than group DM (7/40). OAA/S score was significantly lower in group DM at 5 minutes (P=0.0049) and 10 minutes (P=0.0004). Other hemodynamic variables were comparable in both groups.
Conclusion: Low dose Midazolam with low dose Dexmedetomidine offered better results for bradycardia and sedation compared to routine dose of Dexmedetomidine alone.

— Aims: The aim of this study was to probe the relationship between the subjective effects of alcohol and impulsive behavior in social drinkers. Methods: Fifty social drinkers performed a response-inhibition task before consuming alcohol. A 0.8-g/kg dose of alcohol was administered in a binge-like fashion (0.2 g/kg every 30 min) to the participants over a 2-h time period. Participants then completed questionnaires measuring stimulation, sedation and mood following consumption of alcohol. Linear regression analyses were performed by examining the relationship between performance on the response inhibition impulsivity task and subjective responses to alcohol (i.e. stimulation, sedation and arousal). Results: There was a significant positive relationship found between impulsive responding and self-reported sedation following alcohol consumption. Additionally, there was a significant negative relationship between behavioral impulsivity and self-reported stimulation and arousal following alcohol consumption. Conclusion: These results suggest that higher levels of impulsivity are associated with experiencing greater sedating than stimulating effects of alcohol. Individuals with high levels of impulsivity may be less sensitive to the stimulating effects of a specified dose of alcohol, which could lead to these individuals consuming more alcohol to experience the stimulating effects of alcohol.

Introduction:The aim of this study was to evaluate and compare the clinical efficacy of propofol-based deep sedation (PBDS) for endoscopic retrograde cholangiopancreatography (ERCP) procedure in sick (American Society of Anesthesiologists [ASA] physical status III–IV) and nonsick (ASA physical status I–II) elderly patients in a teaching hospital in Thailand.Methods:We undertook a retrospective review of the anesthesia or sedation service records of elderly patients who underwent ERCP procedures from October 2007 to September 2008. All patients were classified into two groups according to the ASA physical status. In group A, the patients had ASA physical status I–II, while in group B, the patients had ASA physical status III–IV. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were sedation-related adverse events during and immediately after the procedure.Results:There were 158 elderly patients who underwent ERCP procedure by using PBDS during the study period. Of these, 109 patients were in group A and 49 patients were in group B. There were no significant differences in age, gender, weight, duration of ERCP, indication of procedure, and the mean dose of fentanyl, propofol, and midazolam between the two groups. All patients in both groups successfully completed the procedure except eight patients in group A and three patients in group B (P = 0.781). Overall, respiratory and cardiovascular adverse events in both groups were not significantly different. All adverse events were easily treated, with no adverse sequelae.Conclusion:In the setting of a developing country, PBDS for ERCP procedure in sick elderly patients by trained anesthetic personnel with appropriate monitoring was safe and effective. The clinical efficacy of this technique in sick elderly patients was not different or worse than in nonsick elderly patients. Serious adverse events were rare in our population.

Th e experience of pain during a severe burn is multifactorial, both in the typology of the burn and in the circumstances of its occurrence.
Third-degree burns are painless as the dermis and its nociception sensors are damaged. After a severe burn, from initial management, to home care, to a long hospital stay, pain evolves with its etiology and requires specific management.
L’expérience de la douleur lors d’une brûlure grave est multifactorielle, autant dans la typologie de la brûlure que dans les circonstances de survenue. Les brûlures de troisième degré sont non douloureuses par destruction du derme et de ses capteurs de nociception. Après une brûlure grave, depuis la prise en charge initiale jusqu’aux soins à domicile, en passant par un long séjour hospitalier, la douleur évolue selon son étiologie et nécessite une prise en charge spécifique.

Caffeine has been shown to enhance the speed of recovery from general anesthesia in murine models, though data in human patients is lacking. This is a retrospective review of intravenous caffeine administration (median dose 150 [125, 250] mg) to 151 heavily sedated patients in the post-anesthesia recovery area, to determine the association between caffeine administration and changes in sedation score, respiratory rate, and oxyhemoglobin saturation. Richmond Agitation-Sedation Scale (RASS) score, respiratory rate, and oxyhemoglobin saturation values were obtained during the 90-minute period prior to and following caffeine administration. Generalized estimating equations (GEE) with explanatory variables of time, caffeine, and the time-by-caffeine interaction were created to assess changes in the variables of interest after caffeine administration. Following the administration of caffeine, the RASS scores increased (estimate = 0.57, SE = 0.14, p < 0.001) but a trend over time or in the interaction effect was not observed, suggesting that the changes in RASS were not solely due to the recovery from anesthesia over time. No association was found between caffeine administration and changes in respiratory parameters. No adverse cardiac events were observed. Our data suggests that intravenous caffeine may enhance the speed of recovery following general anesthesia, though future prospective trials are necessary to define the optimal dose and timing of administration.

Clarification of the problem: Evidence is amassing that non-anesthesiologist-directed propofol (NAAP) sedation has a security and feasibility profile comparative or superior to anything that outfitted by benzodiazepines with or without opioids. The guidelines starting at now open underline the essentialness of appropriate patient decision, staff getting ready, checking, and low-estimation sedation traditions for use security.