S-Ketamine As An Adjuvant in Patient-controlled Intravenous Analgesia for Prevention of Postpartum Depression: A Randomized Controlled Trial

(1) Background: Postpartum depression (PPD) is a common complication after cesarean section. Recent studies have shown that intravenous S-ketamine during surgery could be effective in preventing PPD. However, no evidence shows S-ketamine used in patient-controlled intravenous analgesia (PCIA) could reduce the incidence of PPD. Our aim was to explore the effect of S-ketamine as an adjuvant in patient-controlled intravenous analgesia (PCIA) for prevention of postpartum depression. (2) Methods: In a single center, 375 parturients scheduled to undergo cesarean section were recruited and randomly assigned to two groups: Control group (C group) or S-ketamine group (S group). Parturients in both groups received PCIA, the formula of Group C: sufentanil 2 μg/kg + tropisetron 10 mg, S group was the same as C group except 0.5mg/kg S-ketamine. The primary outcome was the incidence of PPD measured by the Edinburgh Postnatal Depression Scale (EPDS) after surgery. The secondary outcomes were EPDS scores, Visual analogue scale (VAS) scores, and Ramsay Sedation Scale (RSS) scores, and incidence of related adverse events. (3) Results: A total of 275 puerpera were finally included and randomly assigned to two groups. The incidence of depression at postoperative 3, 14, 28days in C group and S group were 17.6%vs8.2%, P<0.05;24.2%vs9.8%, P<0.05, and 19.0%vs 17.2%, P=0.76, respectively). As for EPDS scores, C group and S group at 3,14, and 28 days after cesarean were 7.65±3.14vs6.00±2.47, p<0.05,7.62±3.14vs6.38±2.67, p<0.05, and 7.35±3.17vs6.90±2.78, p=0.15, respectively. Adverse events such as headache and nausea were 3.3% vs 4.1%, p=0.755; 5.9%vs8.2%, p=0.481. (4) Conclusions: 0.01mg/kg/h S-ketamine as an adjuvant in patient-controlled intravenous analgesia can significantly reduce the incidence of postpartum depression within 14 days and relieve postoperative pain within 48h after cesarean section, without increasing the incidence of adverse reactions.Trial registration: ChiCTR, ChiCTR2100050263，retrospectively registered. Registered 24/08/2021.

Comparing the efficacy and safety of Dexmedetomidine/Ketamine with Propofol/Fentanyl for sedation in colonoscopy patients: A double-blinded randomized clinical trial

Background: In this double-blinded randomized clinical trial, we aimed to compare the safety and efficacy of a combination of dexmedetomidine and ketamine [DK] with propofol and fentanyl [PF] for sedation in colonoscopy patients. Methods: In this study, 64 patients who underwent colonoscopy were randomized into two groups: 1) A, which received PF, and 2) B, which received DK for sedation. Among 64 patients, 31 patients were included in PF, and 33 patients were included in the DK group. Both groups were similar in terms of demographics. Patients’ sedation score (based on Ramsay sedation scale) and vital signs were recorded at 2, 5, 10, and 15 minutes. Complications including apnea, hypotension, hypoxia, nausea, and vomiting, along with gastroenterologist satisfaction and patients’ pain score (based on Wong-Baker faces pain assessment scale), were recorded by a checklist. Data were analyzed by SPSS v.18 software, using chi-square, independent t-tests, and repeated measures analysis with p<0.05 as the criterion for significant differences. Results: The mean score of sedation was 4.82±0.49 in the DK group and 5.22±0.45 in the PF group [p value=0.001]. Serious complications, including hypotension [p value=0.005] and apnea [p value=0.10] were significantly higher in the PF group. Satisfaction of gastroenterologist [p value= 0.400] and patients’ pain score [p value = 0.900] were similar among groups. Conclusion: Combination of DK provides sufficient sedation with fewer complications in comparison with PF in colonoscopy patients.

A Randomized Controlled Study of Caudal Dexmedetomidine for the Prevention of Postoperative Agitation in Children Undergoing Urethroplasty

Background: Postoperative agitation is a common complication in children undergoing general anesthesia. This study aimed to investigate the effect of caudal dexmedetomidine for the prevention of postoperative agitation in children undergoing urethroplasty.Materials and Methods: Eighty children were prospectively recruited to this study and randomized to two groups (40 cases in each group), specifically, a dexmedetomidine group (group D) who received 0.2% ropivacaine + 0.5 μg/kg dexmedetomidine for caudal block, and a control group who received 0.2% ropivacaine alone. The time to wake up, the time to discharge from the postanesthesia care unit (PACU), the duration of the caudal block, and the Ramsay sedation scale (RSS) were evaluated in the patients. Adverse events such as postoperative agitation, respiratory depression, bradycardia, hypotension, excessive sedation, nausea, and vomiting were also recorded during the first postoperative 24 h.Results: The incidence of postoperative agitation was lower in group D compared with patients in the control group (2.5 vs. 22.5%, p = 0.007). The time to wake up and the time to discharge from PACU were longer in group D than in the control group (15.2 ± 2.6 vs. 13.4 ± 1.3 min, 48.2 ± 7.7 vs. 41.5 ± 8.0 min, respectively, p &lt; 0.001). However, the extubation times were similar between the two groups. The duration of the caudal block was longer in group D compared with the control group (8.8 ± 1.6 vs. 4.6 ± 0.7 h, p &lt; 0.001).Conclusions: Caudal dexmedetomidine prolongs the duration of caudal block and decreases the incidence of postoperative agitation in children undergoing urethroplasty.Clinical Trial Registration: ChiCTR1800016828.

THE USE OF DEXMEDETOMIDINE IN PUNCTURE TECHNIQUES FOR DEGENERATIVE DISEASES OF THE LUMBAR SPINE

ABSTRACT Objective To analyze the results of the use of dexmedetomidine (D) in the treatment of patients with degenerative diseases of the lumbar spine using puncture techniques. Methods The study included 77 patients who underwent surgical puncture for degenerative diseases of the lumbar spine with the use of alpha-2-adrenomimetic D: percutaneous laser denervation of the facet joints (n = 46) and posterolateral transforaminal endoscopic discectomy (n = 31). We assessed: the level of sedation using the Ramsay Sedation Scale (RSS) and the Richmond Agitation Sedation Scale (RASS); intraoperative dynamics of the cardiovascular and respiratory system parameters; the level of pain syndrome according to VAS. Results A high intraoperative level of sedation was determined, with RASS -2, -3 and Ramsay III, IV; when transferring a patient to a department (in 90 minutes) this parameter was RASS 0 and Ramsay II. There were no significant changes in central hemodynamics and respiratory depression. The minimum level of pain was determined immediately after surgery, at 30 and 60 minutes after surgery, and before transfer to the department (90 minutes): 6 (4;9); 10 (8;12); 12 (9;13); 16 (13;19) respectively. The absence of the need for additional analgesia on the first postoperative day was verified. Conclusion The use of D significantly reduces the level of pain, while maintaining the necessary verbal contact with the patient, and provides the necessary neurovegetative protection without respiratory depression or lowered hemodynamic parameters during the perioperative period. Level of evidence II; Prognostic Studies - Investigating the Effect of a Patient Characteristic on Disease Outcome. Case series, retrospective study.

Intravenous versus perineural dexmedetomidine in prolongation of analgesia with regional anesthesia: a meta-analysis and systematic review

Background and Objective. It is unclear whether perineural administration offers advantages when compared to intravenous dexmedetomidine in local anesthesia. To compare the efficacy of perineural versus intravenous dexmedetomidine as local anesthetic adjuvant, we conducted the meta analysis and systematic review. Materials and Methods. Two researchers searched MEDLINE, OVID, PubMed, Embase, Cochrane Central, Web of Science and Wanfang data for randomized controlled trials comparing the effect of intravenous versus perineural dexmedetomidine as local anesthetic adjuvant without any language restrictions. Results. We identified 14 randomized controlled trials (801 patients). The results revealed that the duration of analgesia (SMD: -1.76, 95 % CI, [-2.7, -0.83] P = 0.000, I2 = 96 %), the duration of sensory block (SMD:- 3.99, 95 % CI, [-5.88, -2.0], P = 0.000, I2 = 97.6 %), the duration of motor block (SMD: -1.6, 95 % CI, [-2.78, -0.41] P = 0.008, I 2 = 95.5 %) were significantly longer in the perineural group, when compared to systematic dexmedetomidine. The onset time of sensory block (SMD: 1.55, 95 % CI, [0.16, 2.94] P = 0.028, I2 = 96.7 %) and the onset time of motor block (SMD: 0.84, 95 % CI, [0.17, 1.5] P = 0.013, I2 = 88.3 %) were shorter in perineural group compared to intrave nous dexmedetomidine. Meanwhile, analgesic consumption in 24 hours (SMD: 0.37, 95 % CI, [0.05, 0.69] P = 0.023, I 2 = 55.6 %) and the incidence of patients of Ramsay Sedation Scale > 3 (RR: 3.8, 95 % CI, [1.45, 9.97] P = 0.000, I 2 = 26.9 %), hypotension (RR: 1.74, 95 % CI, [1.15, 2.65] P= 0.009, I2 = 32.7 %) and bradycardia (RR: 3.71, 95 % CI, [1.27, 10.86] P = 0.017, I2 = 0 %) were lower in perineural dexmedetomidine compared to the intravenous group. Conclusions. Our meta-analysis generates the evidence that perineural dexmedetomidine is a superior adminstration for prolonging the duration of analgesia. Perineural dexmedetomidine also shows the advantages in duration of sensory block and the onset time of sensory and motor block, when compared to the intravenous administration. Simultaneously, dexmedetomidine as a local anesthetic adjuvant for perineural injection may be much safer than intravenous application because of the lower incidence of patients of Ramsay Sedation Scale > 3 and lower incidence of hypotension and bradycardia.

A comparative study of dexmedetomidine and propofol infusion during monitored anesthesia care (MAC) in endoscopic retrograde cholangiopancreatography (ERCP): a randomized controlled trial

Background Endoscopic retrograde cholangio-pancreatography (ERCP) is an invasive procedure and hence is distressing for awake patients, requiring adequate level of sedation and analgesia. Recent advancements have encouraged use of monitored anesthesia care (MAC), that allows the patient to tolerate unpleasant procedures while maintaining cardio-respiratory function. The main aim is to compare the effect of dexmedetomidine and propofol on the hemodynamics during ERCP, quality of sedation, recovery profile, and any side effects. A total of 100 patients were randomized by a computer-generated random number table into two groups of 30 patients each. The group P received continuous propofol infusion at a rate of 25-75 mcg/kg/min to achieve a Ramsay sedation scale (RSS) of 3-4 before starting the procedure. Group D received dexmedetomidine at loading dose of 1 μg/kg i.v. over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4. Results The present study shows significant decrease in heart rate in group D (65.27 ± 4. 3 vs.77.27 ± 9.3) with more stable blood pressure values throughout than group P. There were episodes of transient desaturation in few patients in group P while no patient showed any signs of respiratory depression or desaturation in group D. The time to achieve Ramsay sedation score (RSS) 3-4 is significantly more in group D (11.4 ± 1.37 vs. 7.93 ± 1.32) with increased tendency to use rescue drug but shows better and early recovery. Conclusion Dexmedetomidine is a better substitute to propofol for patients undergoing ERCP; however, use of adjunct may be necessary to decrease the need for rescue drug.

Efficacy and Safety of Butorphanol Use in Patient-Controlled Analgesia: A Meta-Analysis

Objective. This meta-analysis evaluates the efficacy and safety regarding usage of butorphanol in patient-controlled analgesia (PCA). Methods. Several databases such as PubMed, Cochrane Library, Embase, CNKI, and VIP were explored with the help of computer search and manual retrieval. Randomized controlled trial (RCT) was selected, and the meta-analysis was conducted using RevMan 5.1. The primary efficacy endpoint was the postoperative visual analog scale score, postoperative Ramsay sedation scale (RSS), and adverse events. Results. Nine RCTs met the inclusion criteria and were included in this meta-analysis. No significant differences were found between the butorphanol group and nonbutorphanol group at 12 h and 48 h. The postoperative RSS score at 12 h, 24 h, and 48 h was representative of the calming effect of butorphanol. No significant difference was found on the endpoint of the postoperative RSS score at 12 h, 48 h, and 24 h. The RSS score was lower in the butorphanol group in comparison to the nonbutorphanol group. The butorphanol group was also associated with lower rate of nausea, vomiting, itching, and dizziness compared to the nonbutorphanol group. Conclusion. Butorphanol may be used in PCA as a successful postoperative analgesia and is also associated with lower side effects. Further research is needed to verify the efficacy and safety of butorphanol.

Effects of Preoperative Low-Dose Gabapentin on Postoperative Pain and Sedation of Patients Undergoing General Anesthesia

Objective: To study the drug interaction between gabapentin and morphine in surgical patients under general anesthesia. Materials and Methods: Two hundred sixty patients undergoing surgery under general anesthesia were randomized into two groups, A with 130 patients receiving gabapentin 2.0 to 3.5 mg/kg orally for premedication add-on, and B with 130 patients getting morphine 0.1 to 0.2 mg/kg intravenously. After surgery, a co-researcher assessed patients using Ramsay sedation scale (RSS) and pain numeric rating scale (NRS) at 2, 4, 8, 12, 16, and 24-hour intervals. Results: Two hundred thirty-two patients were included the present study without procedural adverse events. There were 120 and 112 patients in gabapentin and morphine group, respectively. The administration dosage of gabapentin and morphine between the two groups showed statistically significant differences (p=0.031). During the emergence, the RSS on the sedation, agitation, drowsiness, and pain scores of gabapentin (1.8±0.4) and morphine (1.7±0.5) appeared statistically significant differences (p=0.032); however, the RSS on that in the post-anesthetic care unit (PACU) were 2.0±0.1and 2.0±0.2, respectively, which showed insignificant differences (p-value 0.283). Conclusion: A small, single oral dose of gabapentin as premedication showed a synergistic effect on intraoperative morphine administration. However, this additive effect was not long lasting through the PACU and might not be suitable for an extended surgery. Keywords: Drug interaction; Gabapentin; Morphine; Anesthesia

Comparison of Hemodynamic and Sedative Effects of Midazolam-Fentanyl and Midazolam-Ketamine Combinations Used in Cardioersion Sedation

Objective: The aim of the study is to compare the hemodynamic and sedation results of patients who underwent anesthesia for electrical cardioversion (EC) during a one-year period in the coronary intensive care unit, retrospectively. Methods: 60 patients who were administered ketamine or fentanyl in addition to midazolam, which was administered EC for the correction of atrial fibrillation rhythm, were evaluated in terms of the study. According to the sedation applied to the patients, they were divided into two groups as Group F (midazolam-fentanyl) and Group K (midazolam-ketamine). The hemodynamic parameters of the groups before and after the procedure and the sedation data during and after the procedure were compared. Results: The pre-intervention heart rate of the patients was found to be high in Group-F (p<0.05). There was no significant difference between the two groups in terms of systolic and diastolic blood pressures (p>0.05). While heart rate was observed to be statistically higher after the intervention in midazolam-fentanil applied patients, a statistically significant decrease was found in diastolic blood pressures (p<0.05). When Ramsay sedation scale was evaluated; There was no significant difference between the two groups at the 5th, 10th and 15th minutes (p>0.05). Conclusion: It was determined that the combination of midazolam + fentanyl or midzolam + ketamine provided adequate sedation at standard doses and had no adverse effects on hemodynamic and sedation parameters. These results made us think that both protocols can be safely applied for electrical cardioversion sedation in intensive care units.

How to measure the effects and potential adverse events of palliative sedation? An integrative review

Background: Palliative sedation is the monitored use of medications intended to relieve refractory suffering. The assessment of palliative sedation has been focused on the assess of the level of consciousness but a more comprehensive approach to assessment is needed. Aim: To understand how the potential effects and possible adverse events of palliative sedation in Palliative Care patients are measured. Design: Integrative review of most recent empirical research. Data sources: Cochrane Library, Embase, Medline, PubMed, and CINAHL were searched (2010–2020) using the terms sedation, palliative care, terminal care, assessment. Limits included studies in English and adults. Inclusion criteria were: scientific assessment papers, effects and complications of palliative sedation; patients with incurable illness. Results: Out of 588 titles, 26 fulfilled inclusion criteria. The Discomfort Scale-Dementia of Alzheimer Type and Patient Comfort Score were used to assess comfort. The Richmond Agitation-Sedation Scale and The Ramsay Sedation Scale are the most used to measure its effect. Refractory symptoms were assessed through multi-symptom or specific scales; except for psychological or existential distress. Delirium was assessed using the Memorial Delirium Assessment Scale and pain through the Critical Care Pain Observation Tool. The use of technical approaches to monitor effects is upcoming. There is lack of measurement of possible adverse events and variability in timing measurement. Conclusions: There are palliative care validated instruments to assess the sedation effect but this review shows the need for a more standardized approach when assessing it. Instruments should be used within an experienced and trained expert, providing a holistic assessment.