Dexmedetomidine - Oxycodone Combination for Conscious Sedation During Colonoscopy in Obese Patients: A Randomised Controlled Trial

Background: The objective of this trial was to investigate the effectiveness and safety of dexmedetomidine plus oxycodone for conscious sedation during colonoscopy in obese patients. Methods: A total of 138 patients undergoing colonoscopy were randomly assigned into one of two groups: group Dex+oxy received sedation with dexmedetomidine plus oxycodone; while group Pro+suf received anaesthesia with propofol plus sufentanil. Parameters including blood pressure, heart rate, respiration, blood oxygen saturation, injection pain, and recovery were recorded for both groups. Results: The incidence of hypoxaemia was significantly reduced in group Dex+oxy compared with group Pro+suf (4.9% vs 20.3%, P = 0.011). Blood pressure was significantly increased, and heart rate was reduced in group Dex+oxy compared with group Pro+suf (P < 0.05). Moreover, the caecal insertion time, recovery time to orientation, and recovery time to walking were significantly reduced in group Dex+oxy compared with group Pro+suf (P < 0.05). Endoscopist satisfaction scores were significantly higher in group Dex+oxy compared with group Pro+suf (P = 0.042). Conclusion: Dexmedetomidine plus oxycodone provides effective sedation with minimal adverse effects for obese patients, while also reducing colonoscopy operation difficulty by allowing obese patients to reposition. Thus, dexmedetomidine plus oxycodone could be used safely as a conscious sedation method for colonoscopy in obese patients.Trial registration The protocol was registered at www.chictr.org.cn (ChiCTR1800017283, 21/07/2018)

Assessing intravenous midazolam for conscious sedation during cataract surgery

Background: A large number of geriatric populations above the age of 50 worldwide suffer from cataract. Cataract starts with short-sightedness and gradually worsens resulting in blurring of vision and inability to visualize and distinguish fine details. Surgery is the only available treatment for cataract. Anaesthesia is essential during cataract surgery to minimize pain caused during surgical procedure and to achieve favourable surgical outcome. The current investigation was aimed towards assessing the performance of intravenous midazolam used for conscious sedation during cataract surgery along with retrobulbar block.Methods: Current study is a randomized double blinded study performed for duration of 6 months on 60 patients undergoing cataract surgery at Terna medical college and hospital. Patients were divided in two groups; group M received 0.02 mg/kg midazolam diluted to 5 ml, group N received 5 ml normal saline before cataract surgery. All vital hemodynamic parameters were observed after 5 minutes of sedation, immediately after block administration and after every 15 minutes till the end of the surgery to assess the effect of sedation. Patients and surgeons satisfaction levels were also documented post-surgery.Results: Patients who were sedated with midazolam prior to cataract surgery along with block exhibited a significant decrease in hemodynamic parameters like SAP, DAP and heart rate which indicated effective sedation. Anxiety level also significantly decreased in the patients who received midazolam. No major adverse or intra-operative events were observed in the patients who received midazolam.Conclusions: Sedation with midazolam provides haemodynamic conditions favourable for cataract surgery along with high level of patient and surgeon satisfaction.

Practical Considerations for Dexmedetomidine Sedation in Adult Cataract Surgery Under Local/Regional Anesthesia: A Narrative Review

: Cataract surgery is predominantly performed under local/regional anesthesia, with or without sedation. The practice pattern of sedation is unknown and seems to vary significantly among institutions and countries, routinely administered in some parts of the world to the other extreme of none at all. The selection of sedative agents and techniques varies widely. Currently, there is no ideal sedative agent. Dexmedetomidine has gained recent attention for sedation in ophthalmic local/regional anesthesia due to its alleged advantages of effective sedation with minimal respiratory depression, decreased intraocular pressure, and reduced pain during the local anesthetic injection; however, they are subject to differing interpretations. Published literature also suggests that although dexmedetomidine sedation for cataract surgery under local/regional anesthesia is potentially useful, its role may be limited due to logistical difficulties in administering the recommended dose.

Comparison of the effect of oral diphenhydramine and midazolam on sedation of children

Objectives: The aim of this study was to compare the effect of diphenhydramine and midazolam on sedation of children. Methods: This clinical trial was performed on children aged 1 to 7 years who referred to the emergency department for diagnostic radiology. Patients were randomly divided into two groups of midazolam and diphenhydramine. Then, 30 minutes before the start of the procedure, 0.5 mg /kg was given to the midazolam group and 0.5 cc /kg to the diphenhydramine group. If sedation occurred, the child was separated from the parents and transferred to a diagnostic procedure. After performing the intended diagnostic procedure, the information sheet was completed and the patient's vital signs were checked again. The data were then analyzed by SPSS version 19 software. Results: A total of 74 patients were included in the study. There was no significant difference between the two groups in terms of age and gender (P = 0.89; P = 0.32). The mean sedation in the midazolam and diphenhydramine groups was 1.02 and 1.59 years, respectively. A significant difference was found between the two groups in terms of sedation (P = 0.04), where a greater effect of diphenhydramine on sedation was observed. Conclusion: The findings showed that the use of diphenhydramine resulted in effective sedation for children. Due to the fact that the main problem with midazolam is its bitter taste, which makes children reluctant to eat it, the use of diphenhydramine can be recommended.

Midazolam for sedation before procedures in adults and children: a systematic review update

Background Midazolam is used for sedation before diagnostic and therapeutic medical procedures by several routes including oral, intravenous, intranasal and intramuscular. This is an update of a Cochrane review published in 2016, which aimed to determine the evidence on the effectiveness of midazolam for sedation when administered before a diagnostic or therapeutic procedure in adults and children. Methods We searched CENTRAL, MEDLINE, Embase and two trials registers up to May 2020 together with reference checking to identify additional studies. We imposed no language restrictions. Randomized controlled trials of midazolam in comparison with placebo or other medications used for sedation were included. Two authors independently extracted data and assessed risk of bias for each included study. Results Eight new trials were included in this update, which resulted in changed conclusions for the intravenous midazolam versus placebo, oral midazolam versus chloral hydrate and oral midazolam versus placebo comparisons. Effect estimates for all outcomes within the intravenous midazolam versus placebo (7 trials; 633 adults and 32 children) are uncertain due to concerns about imprecision and risk of bias. Midazolam resulted in a higher level of sedation than placebo (mean difference (MD) 1.05; 95% confidence interval (95% CI) 0.69 to 1.41; 1 study; 100 adults). There was no difference in anxiety (RR 0.43, 95% CI 0.09 to 1.99; I2 = 75%; 2 studies; 123 adults). Risk of difficulty performing procedures was lower in the midazolam group (RR 0.5; 95% CI 0.29 to 0.86; I2 = 45%; 3 studies; 191 adults and 32 children). There was no difference in discomfort (RR 0.51; 95% CI 0.25 to 1.04; I2 = 0%; 2 studies; 190 adults). Five trials with 336 children were included in the oral midazolam versus chloral hydrate comparison. Midazolam was less likely to result in moderate sedation (RR 0.30, 95% CI 0.11 to 0.82; I2 = 64%; 2 studies, 228 participants). This effect estimate is highly uncertain due to concerns about the risk of bias, imprecision and inconsistency. There was no difference in ratings of anxiety (SMD − 0.26; 95% CI − 0.75 to 0.23; I2 = 0%; 2 studies; 68 participants). Midazolam increased risk of incomplete procedures (RR 4.01; 95% CI 1.92 to 8.40; I2 = 0%; 4 studies, 268 participants). This effect estimate is uncertain due to concerns about the risk of bias. There were four trials with 359 adults and 77 children included in the oral midazolam versus placebo comparison. Midazolam reduced ratings of anxiety (SMD − 1.01; 95% CI − 1.86 to − 0.16; I2 = 92%; 4 studies; 436 participants). It is unclear if midazolam has an effect on difficulty performing procedures. Meta-analysis was not performed because there was only one incomplete procedure in the midazolam group in one of the trials. Midazolam reduced pain in one study with 99 adults (MD − 2; 95% CI − 2.5 to − 1.6; moderate quality). The effect estimate is uncertain due to concerns about the risk of bias. Conclusion The additional evidence arising from inclusion of new studies in this updated review has not produced sufficient high-quality evidence to determine whether midazolam produces more effective sedation than other medications or placebo in any specific population included in this review. For adults, there was low-quality evidence that intravenous midazolam did not reduce the risk of anxiety or discomfort/pain in comparison to placebo, but the sedation level was higher. By combining results from adults and children, there was low-quality evidence of a large reduction in the risk of procedures being difficult to perform with midazolam in comparison to placebo. The effect estimates for this comparison are uncertain because there was concern about risk of bias and imprecision. There is moderate-quality evidence suggesting that oral midazolam produces less-effective sedation than chloral hydrate for completion of procedures for children undergoing non-invasive diagnostic procedures. Ratings of anxiety were not different between oral midazolam and chloral hydrate. The extent to which giving oral midazolam to adults or children decreases anxiety during procedures compared with placebo is uncertain due to concerns about risk of bias and imprecision. There was moderate-quality evidence from one study that oral midazolam reduced the severity of discomfort/pain for adults during a brief diagnostic procedure in comparison with placebo.

Oral Transmucosal or Intramuscular Administration of Dexmedetomidine–Methadone Combination in Dogs: Sedative and Physiological Effects

The aim of this study was to compare the sedative and physiological effects following either oral transmucosal (OTM) or intramuscular administration of dexmedetomidine–methadone combination in healthy dogs. Thirty dogs were randomly assigned to receive a dexmedetomidine–methadone combination either by the OTM (n = 15) or intramuscular (n = 15) route. Sedation was scored 10, 20, and 30 min after drugs administration. Heart rate (HR), non-invasive blood pressure (NIBP), respiratory rate (fR), and body rectal temperature were recorded before drugs administration and then every 10 min for 30 min. Propofol dose required for orotracheal intubation was recorded. Sedation scores increased over time within both groups with higher values in intramuscular group (p < 0.05). Within each group, HR decreased significantly compared with baseline (p < 0.001) and was significantly lower in intramuscular group compared with the OTM group (p < 0.001). In both groups, NIBP increased significantly compared with baseline (p < 0.05). In the intramuscular group, fR was lower compared with the OTM group at all the observational time points (p < 0.001). Propofol dose was lower in the intramuscular group (p < 0.05). Compared to intramuscular dexmedetomidine–methadone, OTM combination produced lower but effective sedation in healthy dogs.

Comparative study between intranasal dexmedetomidine and intranasal ketamine as a premedication for anxiolysis and sedation before pediatric general anesthesia

Background This study compared dexmedetomidine versus ketamine as regard sedation and anxiolysis produced by giving them through intranasal route to pediatric patients undergoing adenotonsillectomy. This study was double-blinded randomized comparative prospective interventional clinical study done in Ain Shams University Hospital (El Demerdash Hospital) on 76 pediatric patients who underwent adenotonsillectomy, and they were randomly allocated equally into two main groups; group D received 2 μg/kg intranasal dexmedetomidine and group K received 5 μg/Kg intranasal ketamine 30 min before the operation, and the aim of this study was to compare the efficacy of intranasal dexmedetomidine versus intranasal ketamine for anxiolysis and sedation to alleviate stress, agitation, and anxiety in children before general anesthesia and for promoting good level of sedation for them. Results Results of this study as regards sedation level that was assessed by modified Ramsay sedation score showed that there was statistically significant difference between both groups at 10, 20, and 30 min from intranasal application of the drug (P value < 0.05), the median (IQR) of sedation score at 10, 20, and 30 min preoperative in group D was (2 (2 – 2)), (3 (3 – 4)), (4 (4 – 5)) compared to (2 (2 – 3)), (3 (2 – 3)), (4 (3 – 4)) in group K respectively which revealed that there was better and effective sedation in group D more than in group K, this difference was statistically significant but clinically insignificant as both drugs produced an acceptable level of sedation and decreased the level of anxiety in children. Conclusion Both drugs produce effective and favorable sedation level with superiority to dexmedetomidine in sedation scores and time of onset of sedation, and also there was little decrease in heart rate and mean arterial pressure which is favorable during such surgeries; also, there was accepted level of cannulation and parental separation scores, and the parents were highly satisfied with the procedure and were grateful for us due to alleviating stress and anxiety from them and from their children.

A contemporary approach to sedation during regional anaesthesia in gynaecology

Safe and adequate sedation during regional anesthesia is one of the issues at the current time. According to the basic principles of modern anesthesiology, safe and effective sedation should protect the patient’s psycho-emotional sphere, provide absence of awareness, pain and fear during surgery as well as nausea and vomiting in the postoperative period. At the same time, it should neither cause respiratory depression and haemodynamics changes, nor be accompanied by a slow recovery of psychomotor function.After studying modern literature and analyzing our own observations, we reached the point that sedation with dexmedetomidine rather than propofol is more preferred during regional anaesthesia. Sedation with dexmedetomidine decreases frequency of cognitive impairment in the early postoperative period, intensity of the pain syndrome, and has beneficial effect on recovery and activation after surgery. Additionally, it is associated with lower risk of hypoxemia and arterial hypotension during surgery.

Propofol for endotracheal intubation in neonates: a dose-finding trial

ObjectiveTo find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA).Design and settingProspective multicentere dose-finding study in 3 neonatal intensive care units.PatientsNeonates with a PNA <28 days requiring non-emergency endotracheal intubation.InterventionsNeonates were stratified into 8 groups based on GA and PNA. The first 5 neonates in every group received a dose of 1.0 mg/kg propofol. Based on sedative effect and side effects, the dose was increased or decreased in the next 5 patients until the optimal dose was found.Main outcome measuresThe primary outcome was the optimal single propofol starting dose that provides effective sedation without side effects in each age group.ResultsAfter inclusion of 91 patients, the study was prematurely terminated because the primary outcome was only reached in 13% of patients. Dose-finding was completed in 2 groups, but no optimal propofol dose was found. Effective sedation without side effects was achieved more often after a starting dose of 2.0 mg/kg (28%) than after 1.0 mg/kg (3%) and 1.5 mg/kg (9%). Propofol-induced hypotension occurred in 59% of patients. Logistic regression analyses showed that GA and PNA did not predict effective sedation or the occurrence of hypotension.ConclusionsEffective sedation without side effects is difficult to achieve with propofol and the optimal dose in different age groups of neonates could not be determined. The sedative effect of propofol and the occurrence of hypotension are unpredictable and show large inter-individual variability in the neonatal population.