Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit

BackgroundProper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients.MethodsA multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan–do–study–act cycles to develop, test and implement the new sedation protocol.ResultsThere was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target.ConclusionsThe standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.

Systematic Review and Meta-analysis of Efficacy and Safety of Melatonin and Triclofos for Inducing Adequate Sedation for Sleep Electroencephalogram in Children

Introduction Triclofos and melatonin are commonly used oral sedatives in children for obtaining a sleep electroencephalogram (EEG) record. There has been no systematic review till now to compare the efficacy and safety of these two medications. Objectives The review intended to compare the efficacy of oral triclofos and melatonin in children <18 years of age for inducing adequate sedation for obtaining a sleep EEG record. We also attempted to compare the adverse effects, impact on EEG record, the yield of epileptiform abnormalities, and sleep onset latency in both groups. Methods A systematic search was conducted on “MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, and Google Scholar” till November 30, 2020, with the following keywords/the Medical Subject Headings (MESH) terms while searching: “sleep EEG,” “electroencephalogram,” “triclofos,” “melatonin” OR “ramelteon” AND “epilepsy,” “seizure,” OR “convulsion.” ROB 2.0 and ROBINS-I tool was used to determine the risk of bias. To assess heterogeneity in studies, Higgins and Thompson's I 2 method was utilized. When I 2 was more than 50%, a random effects model was utilized and a fixed-effect model was used for other parameters. To assess the presence of publication bias, Egger's test was used. Results For describing the efficacy of triclofos in 1,284 and melatonin in 1,532 children, we selected 16 articles. The indirect comparison between the pooled estimate of all children receiving individual medications revealed comparable efficacy in obtaining successful sleep EEG record with a single dose (90 vs. 76%, p = 0.058) and repeat dose (p = 0.054), detection of epileptiform abnormalities (p = 0.06), and sleep onset latency (p = 0.06), but more proportion of children receiving triclofos had adverse effects (p = 0.001) and duration of sleep was also higher with triclofos (p = 0.001). Conclusion Efficacy of triclofos and melatonin are comparable in inducing sleep for recording EEG in children, although triclofos is more likely to cause adverse effects. However, the level of evidence is low for this conclusion and the weak strength of recommendation for the results of this review is likely to change in the future after completion of controlled trials exploring these two medications.

Comparing the Role of Auditory Soothing Effect and Ketamine on Duration of Sedation and Recovery Time in Procedural Sedation and Analgesia (PSA) Among Pediatric Patients in Emergency Department. A Case-Control Comparative Study from a Tertiary Care Setting of LIC

Introduction: Pediatric pain, is a major concern of anxiety and fear during emergency procedures, to alleviate pediatric pain and distress different mode of sedation is required from local, nasal to parental. Appropriate pain relief with adequate sedation and analgesia different drugs are used, however, most have their side effects. Ketamine alone has been used for procedural sedation and analgesia (PSA), but a higher dose may be required to achieve adequate sedation and pain relief, leading to dose-dependent side effects. In this study, we hypothesize that cartoon music or parental/physicians soothing rhymes/sounds during PSA may reduce the dose and frequency of sedative medications, and reduce the duration of sedation and early recovery.Material and Methods: This is a prospective cross-sectional comparative hospital-based study, we used non-probability consecutive sampling from children below 16 years during 2018-2019, post ethical review board approval from Hospital Ethical Committee (3827-EM-ERC-15 (3827-EM-ERC-15{Emergency Medicine – Ethical Review Committee}), who need PSA in ED settings. The PSA was carried by ED physicians who were credentialed for PSA and advanced airway care, while the procedure will be dealt with by another physician from ED or another subspecialty. The study population was divided into two groups, one with Ketamine alone (control group) with 32 patients, while another (case group) with 60 children, who got a low dose of Ketamine along with either of the soothing auditory stimulus, like cartoon music via mobile, parental/physician rhymes during PSA. Data was entered and analyzed using SPSS version-21 Frequency and the percentage was calculated for qualitative variables. Shapiro-Wilk test was applied to check the hypothesis of normality for age (years), sedation, and recovery time, and descriptive statistics such as mean±SD, median (IQR), maximum and minimum were calculated appropriately. Effect modifiers like age, gender, sedation, and recovery time were addressed through stratification. The post-stratification chi-square test was applied by taking p ≤ 0.05 as significant.Results: Comparing the two major groups (case and control), there was no statistical difference among age, gender, types of procedures done, and recovery time, however LOS in ED (<60 minutes) and sedation time (<30 minutes) in the case group was statistically better than in control group (78% vs 87% and 85% and 78% respectively). Children with oxygen saturation ≤90% were slightly better in the case group 1.7% vs 3.1%, similarly 25% had tachycardia as compared to 28% in the ketamine-only group. Tachypnea was observed in 21.7% vs 28% among the case and control groups. Importantly ketamine repeat dose was observed in 34.4% among control (ketamine only) group and only 21.7 need repeated dose in the case group. Discussion: The goal of PSA was to relieve anxiety and fear of pain during the procedure in chaotic EDs. This will help in gaining child cooperation and parents' satisfaction along with reduced drug dose, minimizing LOS, speedy recovery time, and lessening the anticipated drug-related complications. The significant finding observed was the total sedation time and LOS in ED which was significantly better in the control group. Younger children were better soothed by parental voice (rhymes) as compared to other soothing methods examined, similarly lesser drop in oxygen saturation, minimal tachycardia or tachypnea were observed and fewer repeat doses of Ketamine was used as compared to the control group. Music during PSA demonstrates a reduction in patient anxiety, however, the dose and frequency of sedation required didn't show any such reduced medications.Conclusion: In conclusion, listening to cartoon music or parental sound/rhymes has no significant effect on the hemodynamic variables or the drug consumption among pediatric patients during PSA. By considering the reported beneficial results of previous studies, listening to music can be accepted as an adjunct non-pharmacological method for sedation.

Effectiveness and safety of intravenous dexmedetomidine sedation for ophthalmic surgery under regional anesthesia

Purpose To assess the effectiveness and safety of intravenous (IV) dexmedetomidine for sedation in ophthalmic surgery. Methods Prospective, observational, uncontrolled, single-center study. Patients were sedated with a continuous dexmedetomidine IV infusion started 15 min before regional anesthesia administration and maintained up to the end of surgery. Effectiveness of dexmedetomidine was assessed by the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) targeted at 5. Safety was assessed by the incidence of patients’ movements/snoring and by the incidence of respiratory and haemodynamic complications. An eleven-point numerical rating scale (NRS) was used to assess the level of satisfaction of both the surgeon and the patient. Results 123 patients (73 males, mean age: 63 ± 13) were included; 81 (81/123; 65.8%) patients reached the requested MOAA/S score of 5. Any intraoperative movement – mostly voluntary – occurred in 34 (34/123; 27.6%) cases with no need for a switch to general anaesthesia; no ocular complications related to the intraoperative movements occurred. Intraoperative snoring occurred in 30 (30/123; 24.4%) patients and it did not affect the surgical manoeuvres. Respiratory drive depression requiring manual or mechanical ventilation never occurred. Bradycardia occurred in 14 (14/123; 11.3%), cases but only 4 (4/123; 3.2%) patients required atropine administration, which was always effective. Intraoperative analgesia was consistently obtained and both the surgeons and the patients reported a high NRS satisfaction score. Conclusion Dexmedetomidine provided adequate sedation in patients undergoing ocular surgery under local anaesthesia and showed a good effectiveness and safety profile. Upper airway obstruction, apnoea and snoring can occur.

THE DIFFERENT TIMING OF ORAL CLONIDINE PREMEDICATION EFFECT ON SEDATION SCORE IN SPINE SURGERY

Background: Premedication is the administration of medication before anaesthesia. It is used to prepare the patient for anaesthesia and to provideoptimal conditions for surgery. Methods: The study of oral premedication dose of clonidine in spinal surgery at different time was conducted on sixty ASA grade-1 patients of eithersex between 20 to 60 years of age undergoing elective spine surgery. This study was performed after approval from ethics committee of the institute.Informed consent was obtained from each patient. Results: Sedation score was recorded preoperatively in both the groups when the patient were shifted to the operation theater according to score givenby American Society of Anaesthesia. In group-1, 25 patients (83.3%) had sedation score of 0 and 5 patients (16.7%) had score of 1. Similarly in group-2, 29 patients (96.7) had a sedation score 0 and only 1 patient (3.3%) had sedation score1. Conclusion: In conclusion this study establishes that the premedication with tab. clonidine 200µg (As tab. clonidine is available in 100µg) 90 minutebefore the surgery or 3.5 hour before the surgery produced adequate sedation Keywords: Clonidine, Sedation, Spine

A comparison of sedation with midazolam–ketamine versus propofol–fentanyl during Endoscopic retrograde cholangiopancreatography in adults

Background: Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) require adequate sedation or general anesthesia. This prospective clinical study investigated the safety and efficacy of midazolam -Ketamine versus propofol-fentanyl during ERCP procedures. patients and Methods: The study included 80 patients who underwent ERCP following anesthesiologist-administered sedation with fentanyl-propofol and other group midazolam-Ketamine. Procedural data, oxygen saturation, blood pressure, heart rate, recovery time, discharge times the effectiveness of sedation during the procedure was assess according to Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scores. Results: Sedation related complications occurred in 13 of 40 patients in group Ketamine – midazolam and 5 of 40 patients in group fentanyl-propofol included nausea / vomiting, agitation and headache. Most events were minor and did not necessitate discontinuation of the procedure. Successful cannulation was performed in all patients. the time of recovery was significantly lower in group MK with 5.15 ± 1.3 min compared to 6.15 ± 2 in group FP, and discharge was significantly. lower in group FP with 20.35 ± 0.7 min, compared to 24.15 ± 3.4 min in group MK. this occurred due to the number of patients who had side effects in midazolam-Ketamine group was more than the other group. Conclusion: We concluded that FP, more suitable for sedation and less complications rather than MK. Although no significant complications were seen.

Anesthetic management of super-elderly patients with remimazolam: a report of two cases

Background Remimazolam is a newly developed benzodiazepine with more rapid onset and offset of sedation effects than midazolam. We report elderly patients in whom a small dose of remimazolam was successfully used for general anesthesia. Case presentation Two elderly women (patients 1 and 2, aged 95 and 103 years, respectively) underwent hip fracture surgery under general anesthesia guided by bispectral index (BIS). Anesthesia was induced with 1.2 and 1.0 mg/kg/h and maintained with 0.2 and 0.1 mg/kg/h remimazolam, combined with fentanyl and remifentanil in patients 1 and 2, respectively. Their hemodynamics were stable with a small dose of vasopressor, and they awoke soon after the discontinuation of remimazolam without flumazenil reversal. Their postoperative courses were uneventful without any complications. Conversely, the remimazolam dose required to achieve adequate sedation were much lower than expected. Conclusion Remimazolam could be useful in general anesthesia, particularly for super-elderly patients. However, the appropriate dose for induction and maintenance of anesthesia should be carefully considered based on BIS or vital signs.

“CON: TIVA versus Inhalational Agents for Pediatric Cardiac Intensive Care”.

The field of pediatric intensive care has come a long way, especially with the recognition that adequate sedation and analgesia form an imperative cornerstone of patient management. With various drugs available for the same, the debate continues as to which is the better: total intravenous anesthesia (TIVA) or inhalational agents. While each have their own advantages and disadvantages, in the present era of balance toward the IV agents, we should not forget the edge our volatile agents (VAs) might have in special scenarios. And ultimately as anesthesiologists, let us not forget that be it knob and dial, or syringe and plunger, our aim is to put pain to sleep and awaken a new faith to breathe.

Effect of dexmedetomidine on hemodynamic and recovery responses during tracheal extubation

Endotracheal extubation is associated with cardiovascular and airway responses leading to tachycardia, hypertension, arrhythmias, myocardial ischemia, coughing, agitation, bronchospasm, increased bleeding, raised intracranial and intraocular pressure which may be life threatening especially in vulnerable patients. Dexmedetomidine, a highly selective α2-adrenoreceptor agonist is found to attenuate these effects and provide a smooth extubation. To assess the effect of dexmedetomidine on hemodynamic and ventilatory recovery during tracheal extubation. This comparative study was done in 42 patients who fulfilled the inclusion and exclusion criteria between the age group of 20 to 45 years from both sexes were randomly allocated in to two groups of 21 each. One group received 0.5mg Dexmedetomidine and the other group received 100 ml NS. Both groups were compared for the hemodynamic parameters at different time intervals during the whole procedure and were compared for differences if any. In the study group, parameters like Mean arterial pressure, Systolic Blood Pressure, Diastolic Blood Pressure and Heart Rate were under control than the control group. The extubation quality score between controls and dexmedetomidine group (2.14 vs. 1.24) is statistically significant (P&#60;0.001). 14.28% of study group had cough compared to 52.39% in the control group. Bradycardia and Hypertension were significantly higher in the study population. Justbefore extubation, administration of dexmedetomidine ensures the smooth extubation of the trachea and reduces the cardiovascular responses. It also provides adequate sedation postoperatively.