A comparative study of hemodynamic changes in dexmedetomidine versus midazolam and fentanyl combination during awake fibreoptic intubation

Background: The hemodynamic changes during awake fibreoptic intubation (AFOI) are attributed to patient’s anxiety, poor topicalization of the airway, excessive sedation, lack of expertise, pain, prolonged time to intubation, stimulation of oropharyngeal structures, and jaw thrust to aid intubation. In this study, we compared hemodynamic changes of dexmedetomidine (DEX) with midazolam (MDZ) and fentanyl during AFOI. Aims and Objectives: The objective of the study is to compare the hemodynamic changes in DEX alone versus fentanyl- MDZ combination during AFOI. Materials and Methods: Group-I patients (n=30) received DEX 1 μg/kg bolus infusion over 10 min, followed by infusion of 0.1 μg/kg/h titrated to 0.7 μg/kg/h whereas Group-II patients (n=30) received iv fentanyl 2 μg/kg bolus followed by MDZ infusion of 0.02–0.1 mg/kg/h until they were adequately sedated, i.e. Ramsay Sedation Score (RSS) of 3. Hemodynamics including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), oxygen saturation (SpO2) were recorded when patient is sedated, i.e. at RSS-3, every min of fibrescopy till 5 min and at intubation and every 3rd min post-intubation till 30 min. Results: Measurements of the HRs in the two groups showed significant differences between the two groups at RSS-3, during FOS and post-intubation with the DEX group showing lower mean HRs compared with the MDZ and fentanyl group. SBP and DBP showed a fall in both the groups as compared with the baseline at RSS-3, during FOS and post-intubation; however, no significant differences were noted between the two groups. The mean SpO2values show significant difference between the two groups. (P<0.05) at RSS-3, FOS, post intubation upto 18 min (P<0.05). Conclusion: The use of DEX at 1 mcg/kg bolus slowly over 10 min, with maintenance rates of 0.1–0.7 μg/kg/h, is safe and beneficial for patients undergoing AFOI. Thus, DEX acts like an ideal drug for AFOI. It provides excellent intubating conditions without significant hemodynamic perturbations and risk of hypoxia.

Processed Electroencephalogram-Based Monitoring to Guide Sedation in Critically Ill Patients: A Systematic Review and International Expert Panel-Based Consensus Recommendations

BackgroundThe literature related to the use of processed EEG (pEEG) for depth of sedation (DOS) monitoring is increasing, however it is unclear how to use this type of monitoring for critical care patients within the intensive care unit (ICU).MethodsWe performed a systematic review of the literature according to the Grade of Recommendation assessment, Development, and Evaluation (GRADE) approach. The modified Delphi method was utilised by a team of experts to produce statements and recommendations derived from study questions. Three separate online rounds discussing 89 statements categorized into four domains were formulated. The panelists rated the appropriateness of each statement and were able to suggest modifications or addition of statements. An analysis of anonymised ratings of the statements by part of the panel followed each Delphi round and previously validated criteria were used to define appropriateness and consensus.ResultsLevel of evidence regarding the four domains was very low. Fourteen panelists participated in the Delphi rounds and consensus was reached for 28 out of 89 statements, from which the reccomendations were created. The main findings were that DOS monitoring should be performed in critically ill patients whenever clinical evaluation is not possible, it should be performed by continuous pEEG techniques and the resulting data depicted with graphical tools to facilitate detection of excessive sedation, a potential cause of burst-suppression, and finally, structured training is suggested to achieve a basic pEEG competency.ConclusionsAlthough evidence on using DOS monitors in ICU is scarce and further research is required in order to better define the benefits of using pEEG, the results of this consensus highlight the general agreement that critically-ill patients would benefit from this type of neuromonitoring.

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.

Dexmedetomidine in modern anesthesiology and intensive care

Background. Sedation is a controlled medical depression of consciousness with the preservation of protective reflexes, independent effective breathing and response to physical stimulation and verbal commands. Sedation is indicated for patients in the intensive care unit in presence of agitation, delirium, withdrawal syndrome of alcohol, drugs or other potent medications and the need to protect the brain (blunt traumatic brain injury, posthypoxic encephalopathy). In addition, at the request of the patient, sedation can be used during invasive diagnostic and treatment procedures. Objective. To describe the role of dexmedetomidine in modern anesthesiology and intensive care. Materials and methods. Analysis of literature data on this issue. Results and discussion. When performing sedation, one should balance between the excessive sedation and its absence. Excessive sedation is accompanied by the lack of contact with the patient, inability to assess the neurological status of the patient, and respiratory depression. If the patient is optimally sedated, he is calm and able to cooperate; he is also adapted to mechanical lung ventilation and other procedures. The target level of sedation according to the Richmond excitation-sedation scale is from 0 to -1. Drugs such as benzodiazepines (diazepam, midazolam, lorazepam), barbiturates (sodium thiopental), propofol, ketamine, inhaled anesthetics (sevoflurane, dexflurane), dexmedetomidine, opioids (morphine, fentanyl, remifentanyl) are used for sedation. Dexmedetomidine is a highly selective α2-adrenoagonist, so it has anxiolytic, sedative, antinociceptive, sympatholytic, and hypothermic actions. In addition, this drug reduces heart rate, suppresses tremor and increases diuresis. The sedative effect of dexmedetomidine is due to the inhibition of neuronal activity in the locus coeruleus of the brain stem. The condition caused by dexmedetomidine is similar to the natural sleep. The use of dexmedetomidine allows to achieve the target level of sedation in a higher percentage of cases than the use of other drugs (propofol, midazolam) (Jacub S.M. et al., 2012). Cooperative sedation is a sedation with the possibility of interaction of the patient with the medical staff. Compared to other drugs, dexmedetomidine increases the patient’s ability to wake up and quickly orient, after which the patient can quickly return to a state of sedation. One of the major complications of critically serious diseases and their treatment is the deterioration of cognitive abilities. Dexmedetomidine has been shown to improve the patient’s cognitive performance by 6.8 points on the John Hopkins scale. In contrast, propofol reduces cognitive function by an average of 12.4 points (Mirski M.A. et al., 2010). Dexmedetomidine has no respiratory depressant effect. Patients on mechanical ventilation do not require discontinuation of dexmedetomidine prior to extubation. Importantly, dexmedetomidine increases coronary blood flow, reduces the incidence of perioperative myocardial ischemia and the risk of perioperative cardiac death. Dexmedetomidine reduces the intensity of pain in the postoperative period and the need for opioids, the incidence of delirium, and the duration of mechanical ventilation. The financial and economic reasonability of dexmedetomidine use has been proved. Conclusions. 1. Sedation is indicated for patients in the intensive care unit in presence of agitation, delirium, withdrawal syndrome and the need to protect the brain, as well as during invasive diagnostic and treatment procedures. 2. The target level of sedation is from 0 to -1 on the Richmond excitation-sedation scale. 3. Dexmedetomidine is a highly selective α2-adrenoagonist, which has anxiolytic, sedative, antinociceptive, sympatholytic, and hypothermic action. 4. Dexmedetomidine increases coronary blood flow and reduces the incidence of perioperative myocardial ischemia, the risk of perioperative cardiac death, pain, delirium incidence and the duration of mechanical ventilation.

Sedation of children in the intensive care unit: what’s new in the field?

Background. The purpose of sedation is to reduce anxiety, create amnesia, reduce motor activity when performing invasive procedures, and provide the synchronization with the respirator. The ideal sedative drug should be characterized by minimal toxicity and minimal depressant effects on the cardiovascular system, the possibility of rapid awakening, the absence of withdrawal syndrome. Objective. To describe the sedation of children in the intensive care unit. Materials and methods. Analysis of literature sources on this topic. Results and discussion. A meta-analysis of 25 studies found that sedation is often suboptimal and rarely regularly evaluated. Excessive sedation can increase the duration of hospitalization, cause tolerance and withdrawal syndrome (Nienke J. Vet et al., 2013). In turn, insufficient sedation increases distress and the frequency of complications, including infectious ones. Frequent problems of sedation also include the choice of suboptimal drug, prolonged infusion, limited use of propofol and dexmedetomidine, lack of routine practice of earplugs and face masks, insufficient frequency of delirium assessment. In a significant proportion of cases, benzodiazepines, primarily midazolam, are used for sedation. In hepatic insufficiency, lorazepam is preferred. Disadvantages of benzodiazepines are respiratory depression, vasoplegia, cardiopression, withdrawal syndrome. Midazolam is often combined with fentanyl or morphine, however, there is little evidence of such a combination. Propofol infusions can cause metabolic acidosis, hyperkalemia, hyperlipidemia, rhabdomyolysis, and even heart failure. The so-called propofol infusion syndrome develops at a dose >4 mg/kg/h in case of infusion for >48 hours. Analysis of sedation with propofol (at a dose 0.3-6.5 g/kg/h) in 174 children aged from 2 months to 16 years revealed that 8 children exceeded the threshold level of lactate; one child died (Svensson M., Lindberg L., 2012). According to the authors of another study, propofol is safe at a dose of 1-4 mg/kg/h. Clonidine and dexmedetomidine are centrally acting α2a-agonists that exert their effects in the locus coeruleus of the brainstem. Dexmedetomidine does not cause respiratory depression and withdrawal syndrome. Children receiving dexmedetomidine required significantly less morphine than ones receiving midazolam. Dexmedetomidine has been shown to reduce the number of inadequately sedated patients (Tobias J.D. et al., 2004). The pharmacokinetics of this drug in children older than 4 years corresponds to the pharmacokinetics in adults. At a dose of 0.1-0.25 μg/kg/h dexmedetomidine reduces the need for benzodiazepines and opioids, as a monosedation at a dose 0.25 μg/kg/h it is comparable to midazolam, and at a dose of 0.5 μg/kg/h – exceeds the latter in efficiency. Meta-analysis of M. Plambech and A. Afshari (2014) found that dexmedetomidine is convenient and safe for use in children with various pathological conditions. In order to prevent complications, non-pharmacological techniques should be used (reduction of light and sound stress, formation of normal biorhythms, swaddling of young children) and switch to oral forms of necessary drugs as soon as possible. Conclusions. 1. Frequent problems of sedation include insufficient/excessive sedation, choice of suboptimal drugs, prolonged infusion, limited use of propofol and dexmedetomidine, lack of routine practice of earplugs and face masks, insufficient frequency of delirium assessment. 2. It is necessary to form sedation protocols in children. 3. For optimal sedation, it is important to implement modern techniques and drugs, regularly assess the level of sedation and treat the underlying pathological condition.

Excessive sedation as a risk factor for delirium: a comparison between two cohorts of critically-ill patients with and without COVID-19

Background: Excessive sedation has been associated with poor outcome in critically-ill patients with acute respiratory Distress Syndrome (ARDS). The on-going pandemic has seen many critically-ill COVID-19 with ARDS, yet the incidence of excessive sedation and its association to delirium in these patients has to date not been assessed. We aimed at comparing the incidence and outcome of excessive sedation and delirium in two cohorts of critically-ill patients. Methods: This was an international, dual center retrospective analysis of prospectively collected data from two cohorts of critically ill patients, with and without COVID-19 disease, pertaining to two different hospital settings. Depth of sedation was monitored through processed EEG and delirium through the Confusion Assessment Method for the ICU(CAM-ICU). The main outcomes were the incidence of excessive sedation and delirium between the two cohorts, and secondary outcomes were length of ICU and hospital stay and mechanical ventilation duration.Results: Fifty-seven non-COVID-19 and 21 COVID-19 patients were included, 38(49%) of whom had ARDS. Twenty-seven(47.3%) non-COVID-19 and 11(52.3%) COVID-19 patients fulfilled the criteria for excessive sedation. Excessively sedated patients were older(p=0.034) and had delirium more frequently(p<0.001). There was a trend in excessive sedation in ARDS patients, while there was no correlation between excessive sedation and COVID-19 diagnosis. COVID-19 with ARDS was related to delirium at the limit of significance. On adjusted analysis excessive sedation was independently related to delirium(p=0.008). Patients with delirium had longer MV duration, ICU-LOS and H-LOS. In the adjusted analysis, delirium was an independent predictor of ICU-LOS(p=0.005) and MV duration(p=0.039). SAPS II was higher in the non-COVID-19 patients when compared to COVID-19 patients. Despite this, COVID-19 patients remained ventilated for a longer period of time, had a longer ICU and H-LOS. Conclusion: Besides age, excessive sedation might represent an important risk factor for delirium in COVID-19 and non-COVID-19 critically ill patients, which may lead to an increased ICU-LOS, H-LOS and MV duration. The use of continuous EEG-based monitoring for quantification of sedation depth, along with frequent delirium assessment in critically-ill COVID-19 patients is warranted along with larger prospective trials aimed at verifying weather the use of EEG-based monitoring leads to improved outcome.

¿Son los videolaringoscopios una alternativa al fibrobroncoscopio en la intubación del paciente despierto?

La intubación del paciente despierto con fibrobroncoscopio es la técnica más ampliamente utilizada ante la presencia de una vía aérea difícil conocida. Sin embargo, hay varias razones que limitan su ejecución. La mayoría de los anestesiólogos están de acuerdo en que el fibrobroncoscopio constituye un reto en cuanto a su aprendizaje. Además, una vez aprendida esta habilidad, requiere una práctica regular para su mantenimiento. La hiperreactividad de la vía aérea por una anestesia tópica inadecuada, el exceso de sedación y agitación, la hemorragia nasal, y en algunos casos, la progresión de una obstrucción parcial existente la vía aérea hasta una total, han sido comunicados como riesgos de la técnica. Los videolaringoscopios pueden ser una solución ante una vía aérea difícil prevista. Su uso se está extendiendo ampliamente porque son dispositivos fáciles de manejar, económicos y versátiles, permitiendo su utilización en un mayor número y variedad de pacientes. ABSTRACT Are videolaryngoscopy an alternative option to fibreoptic bronchoscopy in awake patient intubation? Awake fiberoptic intubation is the most widely used approach in the management of the known difficult airway. However, there are several problems that limit this technique. Most anesthesiologists agree on the challenging nature of fiberoptic intubation training. The maintenance of this skill requires regular practice. Among the known risks of this technique are airway hiperreactivity due to inadequate topic anesthesia, excessive sedation or agitation, nasal hemorrhage and, in some cases, progression from partial to complete airway obstruction. Vídeolaryngoscopy can be an alternate option in the management of known difficult airway. These devices are becoming widely used because they are easy to use, inexpensive and versatile, and thus they can be used in a wider variety and number of patients.

Ziprasidone, haloperidol and clonazepam intramuscular administration in the treatment of agitation symptoms in Chinese patients with schizophrenia: A network meta-analysis

BackgroundAgitation is very common in patients with acute stage schizophrenia, and injection of antipsychotics and clonazepam is widely used. Network meta-analysis of these comparisons among three injection treatments has been seldom reported.AimTo compare the efficacy and safety of various injections for agitation symptoms in Chinese patients with schizophrenia.MethodsSearches were made in PubMed, Embase and Web of Knowledge, Cochrane Library, Wanfang data, CNKI, SinoMed and VIP databases up to 18 February 2018. Standard search strategies were performed by two reviewers according to the Cochrane Review Group. The Consolidated Standards of Reporting Trials statement was used to assess the methodological quality of the studies. STATA was used to perform meta-analysis. The Cochrane Grades of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the strength of evidence.ResultsA total of 15 studies were included in the network meta-analysis. There were 11 studies comparing ziprasidone with haloperidol, and four studies comparing haloperidol with clonazepam. The results showed that ziprasidone is more effective than haloperidol and clonazepam (sucra: 77.2, 72.8 and 0) in the treatment of agitation symptoms. There was the effect size (standardised mean difference (SMD)) in the three groups: haloperidol: SMD=2.278, 95% CI 1.836 to 2.719; ziprasidone: SMD=2.536, 95% CI 2.082 to 2.990; and clonazepam: SMD=1.360, 95% CI 0.127 to 2.593. The acceptability was assessed by the incidence of excessive sedation, which showed that ziprasidone and haloperidol were similar with both being superior to clonazepam (sucra: 0.3, 0.7 and 99.0). Ziprasidone had significantly less adverse effects than haloperidol in effects of extrapyramidal system (EPS) (z=5.01, p<0.001). There were no statistically significant differences between haloperidol and ziprasidone in tachycardia and abnormal ECG (z=1.69, p=0.091; z=0.87, p=0.386; respectively). Based on GRADE, the strength of the evidence for primary outcome was ‘medium’.ConclusionOur results suggested that ziprasidone was more suitable than haloperidol and clonazepam in the treatment of agitation symptoms in Chinese patients with schizophrenia, according to the efficacy and acceptability of these three intramuscular injection medications.