Responsiveness Index versus the RASS-Based Method for Adjusting Sedation in Critically Ill Patients

Background. Sedation of intensive care patients is needed for patient safety, but deep sedation is associated with adverse outcomes. Frontal electromyogram-based Responsiveness Index (RI) aims to quantify the level of sedation and is scaled 0–100 (low index indicates deep sedation). We compared RI-based sedation to Richmond Agitation-Sedation Scale- (RASS-) based sedation. Our hypothesis was that RI-controlled sedation would be associated with increased total time alive without mechanical ventilation at 30 days without an increased number of adverse events. Methods. 32 critically ill adult patients with mechanical ventilation and administration of sedation were randomized to either RI- or RASS-guided sedation. Patients received propofol and oxycodone, if possible. The following standardized sedation protocol was utilized in both groups to achieve the predetermined target sedation level: either RI 40–80 (RI group) or RASS −3 to 0 (RASS group). RI measurement was blinded in the RASS group, and the RI group was blinded to RASS assessments. State Entropy (SE) values were registered in both groups. Results. RI and RASS groups did not differ in total time alive in 30 days without mechanical ventilation ( p = 0.72 ). The incidence of at least one sedation-related adverse event did not differ between the groups. Hypertension was more common in the RI group ( p = 0.01 ). RI group patients were in the target RI level 22% of the time and RASS group patients had 57% of scores within the target RASS level. The RI group spent significantly more time in their target sedation level than the RASS group spent in the corresponding RI level ( p = 0.03 ). No difference was observed between the groups ( p = 0.13 ) in the corresponding analysis for RASS. Propofol and oxycodone were administered at higher RI and SE values and lower RASS values in the RI group than in the RASS group. Conclusion. Further studies with a larger sample size are warranted to scrutinize the optimal RI level during different phases of critical illness.

Comparative Study of Hemodynamic Infusion of Dexmedetomidine With Alternative Sufentanil-Midazolam Injection for Sedation of Patients Undergoing Cataract Surgery

In order to induce sedation during cataract surgery, various medications with different side effects are used in separation or in combination. Dexmedetomidine has no effect on the respiratory system, but being dependent on dosage, it may cause cardiovascular disorders. The present study aims to compare the hemodynamic and sedative effects of dexmedetomidine and the combination of sufentanil-midazolam on patients undergoing cataract surgery. In a randomized clinical trial study, 60 patients were randomly divided into two dexmedetomidine and sufentanil-midazolam groups. In sufentanil-midazolam group, dexmedetomidine (DEX infusion at 0.5 μg/ kg for 10 minutes, then adjusted to 0.2 µg/kg/h) was prescribed. In the sufentanil-midazolam group, sufentanil (0.1 μg/kg for 5 minutes) and midazolam (0.2 µg/kg) were injected five minutes before the operation. Hemodynamic variables (Systolic blood pressure, diastolic blood pressure, heart rate), complications (nausea, vomiting, hypoxia), sedation level, and pain intensity were recorded (at the beginning of the study, 5, 10 minutes after anesthesia, at the start of surgery, 5, 10, 15 minutes after the surgery) as well as patient’s satisfaction, surgeon's satisfaction, and complications. Results suggest that apart from gender, other primary characteristics of patients, including age, history of blood pressure, diabetes history, ASA score, mean of systolic, diastolic blood pressure, heart rate, and SPO2 levels, were similar in both groups (P>0.05). Systolic blood pressure patients receiving dexmedetomidine declined significantly more than that of patients receiving sufentanil-midazolam (P>0.5). Diastolic blood pressure suddenly fell 5 minutes after the infusion of sufentanil-midazolam (P>0.05), but then a relative increase and finally a relative decrease occurred, while diastolic blood pressure in patients receiving dexmedetomidine decreased steadily. The mean heart rate in patients receiving dexmedetomidine and sufentanil-midazolam declined gently (P>0.05). SPO2 was reduced significantly in the sufentanil-midazolam group (P<0.05). Drugs used in both groups reduced pain intensity equally (P>0.05). From the beginning of the study, dexmedetomidine produced a relatively stable sedation level (score 2) based on Ramsay's criteria, while the combination of sufentanil-midazolam-medications causes deeper sedation (score 3) in patients (P<0.05). Despite this fact, 23.33% of the patient receiving sufentanil-midazolam could have movements during the surgery, which was 6.66% higher in patients receiving dexmedetomidine (P=0.071). The satisfaction of patients receiving dexmedetomidine was significantly higher (P=0.044), while the surgeon's satisfaction was almost identical in both anesthesia procedures (P=0.94). In the end, the results of the present study showed that although dexmedetomidine is associated with few respiratory problems and higher satisfaction of patients, it decreases blood pressure and heart rate progressively. However, it seems that this medicine is more effective than a combination of midazolam-sufentanil because of more patient satisfaction, lack of hypoxia, fewer complications, and more suitable immobility.

The effects of naloxone, diazepam, and quercetin on seizure and sedation in acute on chronic tramadol administration: an experimental study

Background Tramadol is a widely used synthetic opioid. Substantial research has previously focused on the neurological effects of this drug, while the efficacy of various treatments to reduce the associated side effects has not been well studied. This study aimed to evaluate the protective effects of naloxone, diazepam, and quercetin on tramadol overdose-induced seizure and sedation level in male rats. Methods The project was performed with 72 male Wistar rats with an average weight of 200–250 g. The rats were randomly assigned to eight groups. Tramadol was administered intraperitoneally at an initial dose of 25 mg/kg/day. On the 14th day, tramadol was injected at 75 mg/kg, either alone or together with naloxone, diazepam, and quercetin (acute and chronic) individually or in combination. The rats were monitored for 6 h on the last day, and the number, the duration, and the severity of seizures (using the criteria of Racine) were measured over a 6-h observation period. The sedation level was also assessed based on a 4-point criterion, ranging from 0 to 3. Data were analyzed in SPSS software using Kruskal–Wallis, Chi-square, regression analysis, and generalized estimating equation (GEE) tests. The significance level was set at P < 0.05. Results The naloxone-diazepam combination reduced the number, severity, and cumulative duration of seizures compared to tramadol use alone and reduced the number of higher-intensity seizures (level 3, 4) to a greater extent than other treatments. Naloxone alone reduced the number and duration of seizures but increased the number of mild seizures (level 2). Diazepam decreased the severity and duration of seizures. However, it increased the number of mild seizures (level 2). In comparison with the tramadol alone group, the acute quercetin group exhibited higher numbers of mild (level 2) and moderate (level 3) seizures. Chronic quercetin administration significantly increased the number of mild seizures. In the GEE model, all groups had higher sedation levels than the saline only group (P < 0.001). None of the protocols had a significant effect on sedation levels compared to the tramadol group. Conclusion The combined administration of naloxone and diazepam in acute-on-chronic tramadol poisoning can effectively reduce most seizure variables compared to tramadol use alone. However, none of the treatments improved sedation levels.

A comparison of propofol with ketofol for sedation quality and side effects in patients undergoing colonoscopy.

Colonoscopy is an endoscopic method and ıt is better to perform this procedure under sedoanalgesia in order to eliminate patients’ anxiety, the colic-like pain and discomfort that occur during the procedure [1]. The aim of this study was to compare the effects of propofol and propofol+ketamine (ketofol) on sedation and side effects in patients undergoing colonoscopy. Material-Method: 50 patients with ASA I-II that are between the ages of 18-65. The patients in the propofol group and Ketofol group were given 0.1mL/kg of drug and/or combination of drugs. The vital parameters, injection pain, spontaneous time of opening eyes, the time of Modified Aldrete Score (MAS) ≥ 9 and the amount of medication used during the procedure and in the recovery room were recorded. Results: There was no significant difference between the two groups during the procedure and in the recovery room (p<0.05). It was shown that the ketamine reduces the amount of propofol by 50% and propofol induced injection pain. Ketofol had no positive effects on hemodynamic and respiratory parameters. Conclusion: We assert that the ratio of combinations will vary depending on the necessary sedation level and analgesic need of the procedure to be performed and depending on the frequency of the administration of additional doses. Although ketofol is being used in different procedures and different age groups in the recent years, there is still need for studies conducted with different drug dosages of this combination.

The Use of Middle Latency Auditory Evoked Potentials (MLAEP) as Methodology for Evaluating Sedation Level in Propofol-Drug Induced Sleep Endoscopy (DISE) Procedure

To analyze the middle latency auditory evoked potential index (MLAEPi), compared to the standard bispectral index (BIS), as a method for evaluating the sedation level in drug-induced sleep endoscopy (DISE). In this controlled clinical study on a sample of 99 obstructive sleep apnea (OSA) or snoring patients, we compared the MLAEPi with the BIS after propofol infusion during the standard DISE technique in order to define the MLAEPi values within the observational window of the procedure. The DISE procedure was divided into eight steps, and we collected both MLAEPi and BIS data values from the same patient in every step. The MLAEPi showed a faster response than the BIS after propofol infusion during DISE. Therefore, the clinical use of the MLAEPi in evaluating the sedation level seems to be a good alternative to the current technological standards.

The effects of naloxone, diazepam, and quercetin on seizure and sedation in acute on chronic tramadol administration: An experimental study

Background: Tramadol is a widely used synthetic opioid. Substantial research has previously focused on the neurological effects of this drug, while the efficacy of various treatments to reduce the associated side effects has not been well studied. This study aimed to evaluate the protective effects of naloxone, diazepam, and quercetin on tramadol induced seizure and sedation level in male rats. Methods: The project was performed with 72 male Wistar rats with an average weight of 200-250 g. The rats were randomly assigned to 8 groups. Tramadol was administered intraperitoneally at an initial dose of 25 mg/kg/day. On the 14th day, tramadol was injected at 75 mg/kg, either alone or together with naloxone, diazepam, and quercetin (acute and chronic) in different combinations. The rats were monitored for 6 hours on the last day, and the number, the duration, and the severity of seizures (using the criteria of Racine) were measured at different times. The sedation level was also assessed based on a 4-point criterion, ranging from 0 to 3, at different times after injection. Data were analyzed in SPSS software using Kruskal-Wallis, Chi-square, multivariate regression, and generalized estimating equation (GEE) tests. The significance level was set at P <0.05.Results: The naloxone-diazepam combination reduced the number of seizures, severity, and duration of seizures compared to the tramadol use alone and reduced the number of higher-intensity seizures to a greater extent than other treatments. Naloxone alone reduced the number and duration of seizures, as well as the duration of mild seizures. Diazepam decreased the severity and duration of seizures. However, it increased the number of mild seizures. In comparison with the tramadol alone group, the acute quercetin group had a lower duration of mild and severe seizures, and higher numbers of mild and moderate seizures. Chronic quercetin administration decreased the duration of seizures and significantly increased the number of mild seizures. Naloxone-Quercetin also reduced the duration of mild and severe seizures significantly. In the GEE model, all groups had higher sedation levels than the saline only group (P <0.001). None of the protocols had a significant effect on sedation levels compared to the other groups.Conclusion: The combined administration of naloxone and diazepam in acute on chronic tramadol poisoning can effectively reduce most seizure variables, compared to the tramadol use alone. However, none of the treatments can improve sedation levels.

The effects of buccal administration of azaperone on the sedation level and biochemical variables of weaned piglets

The aim of the study was to compare the efficacy of buccal and parenteral administration of azaperone in order to achieve pig sedation. The type of study was prospective randomized and double blinded. A total of 40 weaned piglets were divided into 4 groups (10 each) and monitored. Group A was injected intramuscularly (i.m.) with azaperone (Stresnil®, 40 mg/ml inj., Elanco Animal Health) at a dose of 2 mg/kg body weight (b.w.). Group B (control) was given 1 ml of saline buccally. Group C received a dose of 2 mg/kg b.w. of azaperone buccally. Group D was given azaperone buccally at a dose of 4 mg/kg b.w. The response to defined stimulus (a blunt blow of a metal rod into the metal edge of the pen), degree of salivation, movement level, blood plasma azaperone concentration, and the haematological and biochemical variables were included in the study. We found that the buccal administration of azaperone is effective, however, a dose of 4 mg/kg b.w. is required to induce a sedation level comparable to the standard 2 mg/kg b.w. i.m. administration.