Palliative Sedation for Children at End of Life: a Retrospective Cohort Study

Background: Palliative sedation is consciously reducing the patient's consciousness to alleviate the refractory symptoms. However, studies on palliative sedation for children are scarce. We aimed to survey the symptom control and risks for children with sedative therapy in end of life.Method: This study was a single center retrospective cohort study. Children who died in the Department of Palliative Medicine were divided into palliative sedation (Group A) and non-palliative sedation group (Group B). The symptoms relief, survival time, and last hospitalization time were compared between two groups. Results: From January 2012 to November 2019, 41 children died in department of palliative care. 24 children were sedated (Group A), meanwhile 17 children were not (Group B). The symptoms in Group A were more complex than Group B (p =0.013). Overall symptom relief in Group A was higher than that in Group B (24/24, 10/15 p =0.041). Pain relief rates（7/7, 20/21 p =0.714）, maximum/pre-death opioid dose [30(20, 77.5), 18(9, 45) p =0.175, 30(20, 60), 18(9, 45) p =0.208]and pain intensity difference [5(4,6.5), 4(2,6) p =0.315] were not statistically significant difference in both group. After diagnosis, the survival time of the Group A was longer than the Group B (p =0.047). However, the length of hospitalization before death was similar in two groups (p =0.385).Conclusion: Palliative sedation controls complicated, painful symptoms at the end of life and does not shorten the hospitalization time in children.

Anesthesiologic management of elective endovascular stenting of coronary artery

Introduction. Ischemic heart disease is the most common cause of death in the Russian Federation and in the world. One of the main methods of surgical treatment is endovascular stenting of the coronary arteries. Despite the minimally invasive method, there is a need to ensure sedation of the patient during the intervention. The main type of anesthetic aid for this procedure is monitored sedation.The aim of the study was to conduct a comparative analysis of the two most frequently used regimens of monitored sedation for elective endovascular interventions in world practice.Materials and methods. From January to July 2021, a prospective cohort study was conducted that included 70 patients. A comparison was made between the sedation group using phenazepam (n = 38) with the analgosedation group (n = 32) — a combination of sibazone and fentanyl. The comparison was made by the level of sedation (RASS scale), the severity of anginal pain at the stage of stenting of the coronary arteries according to the VAS; vital indicators of patients (sBP, dBP, avgBP, HR, SpO2).Results. The use of a monitored sedation regimen (sibazone + fentanyl) leads to deeper sedation according to the RASS and a more significant decrease in heart rate in patients at the stage of coronary artery stenting compared with the use of benzodiazepine (phenazepam) alone. Despite this, the incidence of anginal pain during the intervention did not differ statistically significantly between the comparison groups.Discussion. In this work, we compared two approaches to anesthetic protection when performing planned endovascular stenting of coronary arteries, which are most often used in foreign and domestic interventional practice.Conclusions. The use of analgosedation (sibazone + fentanyl) for elective endovascular stenting of coronary arteries has no significant advantages over sedation with benzodiazepines (phenozepam) for these types of interventions. It becomes obvious that it is necessary to continue the search for more effective and safer schemes of anesthetic management during planned endovascular stenting of coronary arteries.

Comparison of variants of anesthesia for left atrial appendage occlusion in patients with atrial fbrillation

Objective: comparison of general anesthesia (GA) and intravenous conscious sedation during left atrial appendage occlusion (LAAO).Materials and Methods. The study included 120 patients from LAAO Register at the National Medical Research Center of Cardiology, who were divided into GA (n = 100) and intravenous sedation (n = 20) groups. In-hospital outcomes were assessed, as well as outcomes and data of transesophageal echocardiography (TEE) at 45 days and 6 months.Results. 3 patients required intraoperative conversion of the anesthetic method to GA. The duration of the procedure, the time of fluoroscopy, the amount of contrast medium, and the technical success did not differ signifcantly between the two groups. The incidence of in-hospital complications in the GA group was 10%, and 15% in the intravenous sedation group (p = 0.453). There were no statistically signifcant differences between the groups in long-term outcomes and TEE data after 45 days and 6 months.Conclusion. Combined intravenous sedation with local anesthesia is an effective and fairly safe method of anesthesiological support for implantation of the occluder of the left atrial auricle. It can be used in patients with a high risk of GA, with predictable difculties of tracheal intubation, as well as if the patient wishes accordingly. The limitations of the use of intravenous sedation in combination with local anesthesia are anatomical variants of SFM that are difcult for occluder implantation, as well as the patient's low tolerance to ECG in consciousness.

Effect of bronchoscopy on intracranial hypertension during different regimen of sedation by optic nerve sheath diameter

Objectives: Fiberoptic bronchoscopy (FOB) is a useful method for ventilator-associated pneumonia (VAP), aspiration, and atelectasis, especially in intensive care units. (ICU) We aimed to investigate the effect of FOB on intracranial pressure by ultrasonographic optic nerve sheath diameter (uONSD) during different sedation protocols in a tertiary ICU. Methods: Prospective randomized study included the patients with two groups as superficial (Group M; midazolam) and deep sedation (Group P; propofol). FOB was performed for VAP or aspiration and intracranial hypertension (ICH) was measured with uONSD, noninvasively. The values of uONSD were noted pre-procedure, on sedation, 1st – 5th, and 15th minute of the procedure. In addition, mean arterial pressures (MAP), oxygen saturation, and heart rate values were recorded from the monitor. Results: The mean age and indications of FOB for 33 patients as Group M (n=17) and Group P (n=16) were similar to each other. ONSD was increased with the procedure in both groups but in group P it was stabilized from the 5th minutes of FOB whereas became higher progressively in group M (p<0,001). Postoperative MAP values that may have an important role for ICH were also increased in Group M (MAP was 70.65 ± 16.18 at time of sedation in Group P and 75.63 ± 13.76 in Group M). Conclusion: This study showed that bronchoscopy results as a significant increase for OSND in both groups but that was less high in patients who had deep sedation with propofol and it returned to baseline after the procedure.

Implementation of the Feed and Swaddle Technique as a Non-Pharmacological Strategy to Conduct Brain Magnetic Resonance Imaging in Very Low Birth Weight Infants

Purpose: Magnetic resonance imaging (MRI) is a useful tool for evaluating brain injury and maturation in preterm infants and often requires sedation to acquire images of sufficient quality. Infant sedation is often associated with adverse events, despite extreme precautions. In this study, the swaddling technique was investigated as an alternative non-pharmacological strategy to obtain brain MRIs of sufficient quality.Methods: We applied the feed and swaddle technique during routine brain MRI as a quality improvement project and compared its morbidity with that of sedation in a historic age-matched group. Seventy-nine very low birth weight infants in the neonatal intensive care unit of Ajou University Hospital (Suwon, Korea) were enrolled. Thirty-two (40.5%) infants were in the feed and swaddling group, and 47 (59.5%) were in the sedation group.Results: The morbidity associated with the cardiopulmonary system (swaddling group vs. sedation group: 53.13% [n=17] vs. 63.83% [n=30], P=0.723) and central nervous system (40.63% [n=13] vs. 29.79% [n=14], P=0.217) were not significantly different between groups. The MRI failure rate was not significantly different (swaddling group vs. sedation group: 12.5% [n=4] vs. 4.3% [n=2], P=0.174). The MRI scanning time was longer in the swaddling group than in the sedation group (76.5±20.3 minutes vs. 61.5±13.6 minutes, P=0.001). Cardiopulmonary adverse events were significantly less common in the swaddling group than in the sedation group (3.13% [n=1] vs. 34.04% [n=16], P=0.002).Conclusion: The success rate of MRI was comparable between the swaddling technique and sedation. Furthermore, despite the drawback of prolonged scan time, cardiopulmonary adverse events are fewer with swaddling than with sedative agents. Therefore, swaddling can be an alternative to sedation or anesthesia when performing neonatal MRI scans.

Manipulation under anaesthesia after primary total knee arthroplasty

Aims Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m2 (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130.

900 An Audit of Effectiveness of Inhaled Methoxyflurane (Penthrox) Use for Reduction of Shoulder Dislocation

Introduction Shoulder dislocation is a painful injury best treated by early closed reduction. Patients often require intravenous sedation, with airway monitoring in a safe setting. We implemented methoxyflurane inhalational analgesia (Penthrox) to aid shoulder dislocation reduction without the need for sedation and evaluated the effectiveness and adverse events. Method Patients presenting to the minor injury’s unit at Wrexham Maelor Hospital between 01/04/2020 and 26/05/2020 with only shoulder dislocation were included. Patients had Penthrox and underwent closed reduction. Pre and post reduction shoulder radiographs were reviewed to determine reduction success and time between radiographs was evaluated. Adverse events were recorded. Reduction success and times between radiographs were compared to a consecutive retrospective cohort of patients who underwent closed shoulder dislocation reduction with sedation before implementing Penthrox. Results 22 patients were included. Mean patient age was 44.6 years. Majority were male (72%). Penthrox was used in 11 patients. All patients had their shoulder dislocation reduced successfully. Mean time between reduction radiographs for the Penthrox group was 40.8 min (95%CI 27.4 to 54.3). This was shorter than the intravenous sedation group mean 157.7 minutes (95%CI 92.3 to 223.2, p = 0.0026). No documented adverse events with Penthrox. Conclusions Simple shoulder dislocations can be reduced safely, quickly, and effectively using Penthrox.

Efficacy and Safety of Inhalation Sedation during Office Probing for Congenital Nasolacrimal Duct Obstruction

We compared the effectiveness of inhaled sevoflurane versus physical restraint during probing in children with congenital nasolacrimal duct obstruction (CNLDO). We performed a retrospective review of children with CNLDO who underwent office probing procedures by a single surgeon under sedation or restraint. Patients’ characteristics at the time of probing, including age, sex, laterality, previous non-surgical treatment, presence of dacryocystitis, outcomes of probing, and complications were compared between the sedation and restraint groups. A multivariable logistic regression analysis was performed to investigate the prognostic factors associated with the success of probing. A subgroup analysis by 12 months of age was also conducted. The overall success rate was 88.6% in 202 eyes of 180 consecutive children (mean age, 15.1 ± 7.7 months). The sedation group had a marginally higher success rates than the restraint group (93.8% vs. 85.1%, p = 0.056). The success rate was not significantly different between the two groups in children aged <12 months (90.9% vs. 93.1%, p = 0.739), but it was significantly higher in the sedation group (94.7% vs. 77.8%. p = 0.006) in children aged ≥12 months. Inhalation sedation was the most potent factor associated with success (adjusted odds ratio = 5.56, 95% confidence interval = 1.33–23.13, p = 0.018) in children aged ≥12 months. There were no surgical or sedation-related complications intra- and postoperatively. Inhaled sevoflurane sedation resulted in more successful, controlled, painless probing, particularly in children aged ≥12 months. It represents a safe, efficient alternative to general anesthesia.

Isoflurane sedation in patients undergoing VA-ECMO treatment for cardiogenic shock

Funding Acknowledgements Type of funding sources: None. Objectives (Background): The feasibility and hemodynamic effects of isoflurane sedation in cardiogenic shock in the presence of extracorporeal membrane oxygenation (VA-ECMO) treatment is currently unknown. Design Retrospective single-center study Patients/subjects: Cardiogenic shock patients with VA-ECMO treatment under sedation with volatile isoflurane between November 2018 and October 2019 have been enrolled in this study and were matched by propensity score in a 1:1 ratio with intravenously (IV) sedated patients treated between January 2013 and November 2018 from the cardiogenic shock registry of our university hospital. Measurements and Main Results: Isoflurane sedation was used in 32 patients with cardiogenic shock and VA-ECMO treatment. The mean age of conventionally sedated patients was 58.4 ± 13.8 years and 56.3 ± 11.5 years for patients with isoflurane sedation (p = 0.51). Administration of isoflurane was associated with lower IV sedative drug use during VA-ECMO treatment (86% vs. 32%, p = 0.01). Mean systolic arterial pressure was similar (94.3 ± 12.6 mmHg versus 92.9 ± 10.5 mmHg, p = 0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared to the isoflurane group (85.2 ± 20.5 /min vs. 74.7 ± 15.0 /min; p = 0.02). Catecholamine doses, VA-ECMO blood and gas flow, ventilation time (304 ± 143 h vs. 398 ± 272 h,p = 0.16), bleeding complications BARC3a or higher (59.3% vs. 65.3%, p = 0.76) and 30 day-mortality (59.2% vs. 63.4%, p = 0.80) were similar in both groups. The overall sedation costs per patient were significantly lower in the conventional group, when compared to the isoflurane group (537 ± 624 € vs. 1280 ± 837 €, p &lt; 0.001). Conclusions Volatile sedation with isoflurane is feasible – albeit at higher costs - in patients with cardiogenic shock and VA-ECMO treatment and was not associated with higher catecholamine dosage or ECMO flow rate compared to IV sedation.

Inased (inhaled sedation in ICU) trial protocol: a multicentre randomised open-label trial

IntroductionThe use of sedation in intensive care units (ICUs) is necessary and ubiquitous. The impact of sedation strategy on outcome, particularly when delivered early after initiation of mechanical ventilation, is unknown. Evidence is increasing that volatile anaesthetic agents could be associated with better outcome. Their use in delirium prevention is unknown.Methods and analysisThis study is an investigator-initiated, prospective, multicentre, two-arm, randomised, control, open-trial comparing inhaled sedation strategy versus intravenous sedation strategy in mechanically ventilated patients in ICU. Two hundred and fifty patients will be randomly assigned to the intravenous sedation group or inhaled sedation group, with a 1:1 ratio in two groups according to the sedation strategy. The primary outcome is the occurrence of delirium assessed using two times a day confusion assessment method for the ICU (CAM-ICU). Secondary outcomes include cognitive and functional outcomes at 3 and 12 months.Ethics and disseminationThe study has been approved by the Regional Ethics Committee (CPP Ouest) and national authorities (ANSM). The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04341350