COMPARATIVE CHARACTERISTICS OF EFFECTIVENESS AND SAFETY OF ADJUVANT SEDATION OF PATIENTS WITH ALCOHOLIC DELIRIUM

Chronic alcoholism is one of the factors of early mortality in the world. The most formidable complication of this addiction is the state of alcohol withdrawal with delirium. It is based on a long-term imbalance of the GABA and glutamatergic systems in the brain. Today, the search for an optimal sedation regimen that would be effective on the one hand, and, on the other hand, would have a sufficient safety profile, remains relevant. Three sedation regimens with the addition of ketamine, sodium oxybutyrate and dexmedetomidine were investigated. All were compared with the traditional sedation (control) regimen and with each other. The control points of the study were the following parameters: the duration of the episode of delirium, hemodynamics, plasma cortisol and serotonin, laboratory parameters of the state of the kidneys and liver. As a result of the study, we found that all of the proposed schemes had a shorter duration of delirium compared to the control. The shortest episodes of delirium were observed in the dexmedetomidine group. None of the proposed groups could adequately normalize hemodynamic parameters. We believe that the reason for this is both the peculiarities of the mechanism of action of the drugs we have chosen, and electrolyte imbalance, in particular, hypomagnesemia. The safety of our proposed sedation regimens requires further comprehensive research

Dexmedetomidine versus Ketamine-Propofol for Sedation of Obese Patients Undergoing Upper Gastrointestinal Endoscopy

Background Gastrointestinal endoscopy is an uncomfortable and stressful procedure for most patients. Conscious sedation is a common strategy for improving patient comfort during this procedure. Benzodiazepines (gamma-aminobutyric acid (GABA) agonists) such as midazolam have been used for sedation of patients undergoing gastrointestinal endoscopy. The effective dose ranges of such agents differ considerably among patients, making it difficult to achieve stable sedation. Also obesity is a significant health problem that has assumed epidemic proportions. As a result, the number of obese patients requiring endoscopy is increasing. It is relatively unknown how safe the current practices of sedation for endoscopic procedures are in bariatric patients. Therefore, special consideration should be given to these patients Aim of the Work To compare the sedative properties and haemodynamic and respiratory effects of Dexmedetomidine and a Ketamine-Propofol combination (ketofol) in obese patients undergoing Upper GI Endoscopy. Patients and Methods This study was conducted in the endoscopy unit of Ain Shams University Hospital after obtaining approval from the Research Ethical Committee of Ain Shams University. A prospective, randomized controlled clinical trial was found to be the most suitable design in order to achieve the study objectives. Cases were divided into 2 groups using computer generated random list of numbers in sealed opaque envelopes. Results We found that ketamine-propofol infusion (1:3) is a better sedation regimen for upper gastrointestinal endoscopy compared to dexmedetomidine as lesser time is taken to achieve optimal sedation, with no hemodynamic unstability or postprocedure complications. Conclusion In this study, we compared a group of 40 upper GIT endoscopy obese patients (BMI 30-40) who received procedural sedation with either Dexmedetomidine or propofolketamine combination, we found that ketamine-propofol infusion (1:3) is a better sedation regimen for upper gastrointestinal endoscopy compared to dexmedetomidine as lesser time is taken to achieve optimal sedation, with no hemodynamic unstability or post procedure complications.

Comparative characteristics of ketamine and sodium oxybutyrate as adjuvant sedation in patients with alcoholic delirium

Annotation. Today, the number of benzodiazepine-resistant alcoholic deliriums is growing. It is actually to search for an optimal scheme of sedation with a combination of two sedatives. The aim of the study was to compare efficacy of standard sedation with added barbiturates and the schemes with using ketamine and sodium oxybutyrate. We tested 60 cases of delirium tremens which were randomized into three groups. In the control group we conducted the traditional sedation with added sodium thiopental. In the first research group we combined the infusion of ketamine with diazepam. In the second one we gave sodium oxybutyrate with diazepam. We evaluated the duration of delirium, hemodynamics parameters, serum cortisol and serotonin, laboratory indicators of kidneys and liver condition. We used such statistical methods as Mann-Whitney test, Wilcoxon T-criterion and Kruskal-Wallis H-criterion. The duration of delirium was significantly lower in research groups in comparison with the control one. There was no difference of the duration of delirium between research groups. It indicates a comparable effect of using either ketamine, or sodium oxybutyrate. All groups showed significant reduction of hemodynamics parameters in the process of the treatment, however we observed more cases of hypertension and tachycardia on the third day of the treatment in the research groups than in the control one. These data suggest an insufficient effect of the combination of diazepam with both ketamine and sodium oxybutyrate on the sympatho-adrenal system. Serum cortisol was significantly reduced in all the groups, there was no difference between control and research groups. Serotonin was equally increased in all the groups on the third day. The obtained results indicate that the effectiveness of the combination of benzodiazepines with both ketamine and sodium oxybutyrate is comparable to the standard sedation regimen and does not differ in the reaction of these biomarkers. The laboratory indicators of kidneys condition on the third day increased only in the research groups, which indicates more negative influence on kidneys by both ketamine and sodium oxybutyrate. The indicators of liver condition were significantly reduced only in the group of ketamine, there were no difference in the rest groups. The use of ketamine and sodium oxybutyrate as adjuvant sedation may reduce the duration of a delirium episode, but has insufficient effect on hemodynamics and may adversely affect renal function.

High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

Background Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). Methods We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. Results In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. Conclusion The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.

Anaesthetic Considerations in Gastrointestinal Endoscopies

Gastrointestinal endoscopy has become fundamental procedure for diagnosis and treatment of gastrointestinal tract diseases. Generally, the gastrointestinal endoscopy is minimally invasive procedure. However, it can cause considerable amount of discomfort and pain which make the procedure unsafe, complicated and refusal of follow up procedures if done without safe sedation. The sedation is required to alleviate anxiety, provide analgesia, amnesia and to improve endoscopic performance specifically in therapeutic procedures. The safe administration of sedative and analgesic medications, irrespective of the regimen used, requires knowledge of the individual needs of patients. The combination of benzodiazepines and opioids is now the most widely used sedation regimen for sedation in gastrointestinal endoscopic procedures. Generally, sedation for gastrointestinal endoscopy is considered safe, however, it has the potential for serious complications. Therefore, endoscopist should assess the patients properly before the endoscopy as well as should be aware of all possible complications and the risk factors. Furthermore, skilled staff and emergency equipment should be available in endoscopy suit. This chapter discuss in details all the aspects of safe procedural sedation during GI endoscopies.

Lack of recall after sedation for cataract surgery and its effect on the validity of measuring patient satisfaction

Background: We evaluated the validity of assessing patient satisfaction with the sedation regimen among patients being discharged 45 min after receiving midazolam. If most patients do not have recall, then the sedation cannot be considered complete at the time of evaluation.Methods: In this prospective cohort study, 20 patients underwent cataract surgery with nurse-administered midazolam and fentanyl. The 11-item Iowa Satisfaction with Anesthesia Scale was administered  30 min after sedation in the recovery room. Recalled items were evaluated the next morning.Results: Eleven patients recalled 0 themes, 4 recalled 1, 4 recalled 2, and 1 recalled 3 themes. Thus, 15/20 patients (75%) recalled 0 or 1 of the 11 themes (P = 0.021 versus half the patients). The 95% one-sided lower confidence limit for 0, 1, or 2 themes was 80% of patients (P < 0.001 versus half). Patients who received less midazolam recalled more themes (Kendall’s τb = 0.43, P = 0.039).Conclusions: Evaluating patient satisfaction with sedation shortly after admission to the post-anesthesia care unit is invalid because of a lack of recall; the sedation/amnesia is ongoing. Patient comfort may be assessed, but comfort is not synonymous with satisfaction; ‘satisfaction’ implies presence of recall. Because we studied sedation with low doses of midazolam and fentanyl, the same conclusion reliably would apply to larger doses of anxiolytics administered intraoperatively. The results match previous findings that when patients receive preoperative midazolam prior to meeting the anesthesiologist, even if the patient fully answers questions, they may have negligible recall of having met the anesthesiologist.