Outpatient conscious sedation with titrated nitrous oxide/oxygen, alone or combined with midazolam, enabled the successful completion of all planned complex dental and minor oral surgical procedures in selected uncooperative pediatric and special needs patients.
Abstract
Highlights What are the main findings? Outpatient conscious sedation with titrated nitrous oxide/oxygen, alone or combined with midazolam, enabled the successful completion of all planned complex dental and minor oral surgical procedures in selected uncooperative pediatric and special needs patients. No procedure required conversion to deep intravenous sedation or general anesthesia, and no major adverse events or airway emergencies were observed. What are the implications of the main findings? Appropriate patient selection, behavioral management and clinician expertise may allow complex pediatric dental procedures to be completed under conscious sedation in selected patients. Dedicated outpatient Conscious Sedation Units may provide an additional treatment pathway for selected pediatric patients; however, their effect on access to care, hospital-resource utilization, and costs requires dedicated comparative evaluation. Abstract Aim: This two-center retrospective observational study evaluated whether outpatient conscious sedation protocols based on titrated nitrous oxide/oxygen, midazolam, or their combination enabled complex dental and minor oral surgical procedures to be completed in uncooperative pediatric and special needs patients, without escalation to deep intravenous sedation or general anesthesia. Materials and Methods: Forty pediatric and special needs patients treated at the Conscious Sedation Units of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Milan, Italy) and Policlinico of Bari (Bari, Italy) were included. Overall, 60 complex dental or minor oral surgical procedures were performed. Procedures were classified according to the sedation protocol administered: Protocol A, nitrous oxide/oxygen inhalation sedation alone; Protocol B, midazolam alone; and Protocol C, combined midazolam and nitrous oxide/oxygen sedation. Vital signs were monitored before, during, and after treatment. The primary outcome was successful procedural completion, defined as completion of the planned procedure without premature termination, escalation to deep intravenous sedation or general anesthesia, or the need for unplanned airway or emergency medical intervention. Results: Forty patients underwent 60 procedures. The mean age was 8.7 ± 2.3 years (range, 4–14 years). Protocol A was used in 24 procedures (40%), Protocol B in 6 procedures (10%), and Protocol C in 30 procedures (50%). All procedures were completed successfully, with no conversion to general anesthesia, no airway crises, and no medical emergencies. Transient elevations in heart rate and blood pressure during local anesthesia occurred in 11/60 procedures (18.3%), and mild self-limiting nausea or fatigue occurred in 5/60 procedures (8.3%). Conclusions: The evaluated protocols were associated with successful procedural completion and few recorded adverse events in this selected cohort. Combined behavioral and pharmacological management was associated with completion of the planned procedures without conversion to deep intravenous sedation or general anesthesia. Comparative studies are required to determine whether these protocols reduce general-anesthesia utilization.
Intravenous sedation is optimal for profound anxiolysis in complex cases, while nitrous oxide is ideal for routine procedures, prioritizing rapid recovery and fewer side effects.
M. Nahar, Md Toufiqur Rahman, Mohammad Ataul Hasan et al.· Community Based Medical Jour...· 0 citations
Aim: Advanced endoscopic procedures such as endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) require deep sedation, during which respiratory complications remain a major concern. This study aimed to compare the effects of propofol and a ketamine–propofol combination (ketofol) on hypoxemia and airway intervention.Material and Methods: This retrospective, single-center observational study included 125 adult participants who underwent EUS or ERCP and received either propofol (n=63) or ketofol (n=62) sedation. The primary outcome was hypoxemia, defined as peripheral oxygen saturation (SpO₂) <90% sustained for at least 10 seconds, and the secondary outcome was the requirement for an airway intervention. Clinical, procedural, and sedation-related variables were analyzed.Results: Hypoxemia occurred in 18 (28.6%) participants in the propofol group and 9 (14.5%) participants in the ketofol group (p=0.056). The lowest recorded SpO₂ was lower in the propofol group than in the ketofol group (91.2±4.8% vs 93.6±3.9%, p=0.003). Airway intervention was required in 14 (22.2%) and 6 (9.7%) participants, respectively (p=0.056). Ketofol sedation was independently associated with a lower risk of hypoxemia (adjusted odds ratio: 0.42, 95% confidence interval: 0.18-0.98, p=0.044). Older age, higher body mass index, American Society of Anesthesiologists physical status class III-IV, and longer procedure duration were independently associated with an increased risk of hypoxemia.Conclusion: Ketofol sedation was independently associated with a lower risk of hypoxemia than propofol alone in patients undergoing advanced endoscopic procedures. These findings suggest that ketofol may offer a potential respiratory safety advantage, although prospective randomized studies are needed to confirm this association.
A. Eşbah, Serkan Torun· Düzce Tıp Fakültesi Dergisi· 0 citations
This study aims to compare intranasal dexmedetomidine with inhaled nitrous oxide for procedural pain relief and sedation during intra-articular injections in a pediatric rheumatology outpatient clinic. Patients from 1 to 18 years-of-age requiring 1–5 intra-articular injections were randomized to receive 2 µg/kg intranasal dexmedetomidine or inhaled nitrous oxide in the first visit. When the patient required subsequent treatment visit, the other sedative was administered. The primary outcome was patient-reported pain immediately after recovery from sedation. Hemodynamic and respiratory parameters, level of sedation and patient’s pain assessed by the parent, rheumatologist, and nurse were secondary outcomes. Out of 119 eligible patients, 68 were included, and 43 received both medications at two separate visits. Overall pain experience was mild and did not differ between dexmedetomidine and nitrous oxide in patient-reported pain immediately after the procedure (difference, 0.2; 95% CI − 0.7 to 1.2, p = 0.65) but the patients recalled milder pain after nitrous oxide in the follow-up survey (difference, − 1.3; 95% CI − 2.3 to − 0.3; p = 0.01). Milder pain was reported during the second visit compared to the first visit regardless of the sedative used (difference, − 1.2; 95% CI − 2.1 to − 0.2; p = 0.02). In the follow-up survey, majority (69%) of patients would prefer nitrous oxide to dexmedetomidine for sedation in future. Conclusions: Both intranasal dexmedetomidine and inhaled nitrous oxide offered effective analgosedation for intra-articular injections in children. Nitrous oxide resulted in better patient experience and became their preference for future sedation. Trial registration: ClinicalTrials.gov TRN: NCT03069638. https://clinicaltrials.gov/study/NCT03069638. The date of registration 2016–12-20. What is known: • Children suffering juvenile idiopathic arthritis often require repeated intra-articular injections. • Procedural sedation is being used during these procedures. What is New: • When intranasal dexmedetomidine and nitrous oxide was compared in a crossover design both agents provided effective analgosedation without difference in patient-reported pain immediately after the procedure. • Despite this, most patients favored nitrous oxide for future sedation. What is known: • Children suffering juvenile idiopathic arthritis often require repeated intra-articular injections. • Procedural sedation is being used during these procedures. What is New: • When intranasal dexmedetomidine and nitrous oxide was compared in a crossover design both agents provided effective analgosedation without difference in patient-reported pain immediately after the procedure. • Despite this, most patients favored nitrous oxide for future sedation.
Miikka Tervonen, O. Peltoniemi, P. Vähäsalo et al.· European Journal of Pediatri...· 0 citations
Importance
Older adults undergoing major noncardiac surgery experience substantial postoperative morbidity and health care use. The comparative effectiveness of total intravenous anesthesia (TIVA) vs volatile-based inhalational anesthesia on recovery and safety remains uncertain.
Objectives
To determine whether TIVA improves days alive and at home at 30 days compared with inhalational anesthesia and to evaluate differences in patient-centered outcomes and recovery.
Design, Setting, and Participants
Pragmatic, multicenter, open-label randomized clinical trial conducted in 49 UK National Health Service hospitals from January 2022 to April 2024 (final follow-up, October 2024) among patients aged 50 years or older scheduled for elective major noncardiac surgery.
Interventions
Participants were randomized 1:1 to receive maintenance of general anesthesia with either TIVA (propofol infusion) (n = 1254) or volatile-based inhalational agents (n = 1254). All other perioperative care was at clinician discretion.
Main Outcomes and Measures
The primary outcome was days alive and at home at 30 days. Secondary outcomes included days alive and at home at 90 days; mortality at 30 days, 90 days, and 6 months; Quality of Recovery-15 score at day 3; patient satisfaction (Bauer Patient Satisfaction Questionnaire) at day 1; delirium (4 As Test [4AT]) at day 3; unintentional awareness under anesthesia; and major postoperative complications within 30 days.
Results
Among the 2508 randomized participants, the mean age was 67 (SD, 8.9) years, and 55% were male. Characteristics were balanced across randomized groups. Days alive and at home at 30 days were similar between groups (mean, 22.5 [SD, 6.8] days vs 22.4 [SD, 6.6] days for TIVA vs inhalational anesthesia, respectively; incidence rate ratio, 1.00; 95% CI, 0.99-1.02; adjusted P = .68). There were no differences in days alive and at home at 90 days; mortality at 30 days, 90 days, or 6 months; or Quality of Recovery-15 score at day 3. Lower rates of thirst, hoarseness, and nausea and vomiting were reported in the TIVA group. Levels of delirium were similar between groups, with the majority (87.6%) having no delirium at day 3. Major complications occurred in 12.4% of patients overall, with no significant between-group differences. Two cases of certain or probable unintentional awareness under anesthesia were reported, both in the TIVA group.
Conclusions and Relevance
Among older adults undergoing major noncardiac surgery, TIVA did not improve days alive and at home at 30 days compared with inhalational anesthesia.
Trial Registration
ISRCTN.org Identifier: ISRCTN62903453.
S. Jhanji, Katie Booth, Louise Hiller et al.· Journal of the American Medi...· 1 citation
OBJECTIVES
Propofol is used sparingly in pediatrics owing to the risk of propofol-related infusion syndrome (PRIS). The objective of this study is to evaluate the safety of propofol in pediatrics and describe its effectiveness at facilitating extubation and decreasing concomitant sedation.
METHODS
This retrospective, descriptive study evaluated critically ill children who received continuous propofol infusions for at least 12 consecutive hours while admitted to pediatric, congenital cardiac, or neonatal intensive care units. The primary outcome was PRIS incidence. Secondary outcomes included change from baseline in laboratory parameters, discontinuation due to adverse effects, change in sedative requirements following sedation washout, and successful extubation.
RESULTS
From January 1, 2019, to November 1, 2023, a total of 100 children received 120 courses of propofol infusions. The median infusion rate was 106 mcg/kg/min (IQR, 68-149) and 27.5% of courses exceeded 48 hours in duration. No PRIS events were identified. Patients experienced a moderate, non-duration-dependent increase in triglycerides, with no impact on aspartate aminotransferase (AST)/alanine aminotransferase (ALT) concentrations; 11.7% of infusions were discontinued for adverse effects. No children self-extubated while on propofol when used for peri-extubation (N = 49). Opioid and benzodiazepine requirements were decreased by 17% and 26% from baseline, respectively, during a 24-hour period following sedation washout (N = 26).
CONCLUSIONS
Propofol was tolerated by most patients at doses commonly exceeding guideline-recommended maximum rate and duration. Propofol was safely used to facilitate extubation and decreased baseline sedative exposure when used for sedation washout in a complex critically ill pediatric population.
Benjamin Colwell, Ferras Bashqoy, Maria Spilios et al.· The Journal of Pediatric Pha...· 0 citations
Objectives: The objective of the study was to assess the effectiveness and safety of dexmedetomidine versus midazolam for sedation during regional anesthesia surgery.
Methods: This prospective randomized comparative interventional study was conducted in the Department of Anesthesiology at a tertiary care hospital from January 2025 to January 2026. 100 adult patients undergoing elective surgeries under regional anesthesia were randomly divided into two groups: Group D (dexmedetomidine, n=50) and Group M (midazolam, n=50). Richmond agitation sedation scale (RASS) was used to evaluate sedation. Intraoperative monitoring of hemodynamic parameters, such as mean arterial pressure and heart rate, was performed. Recovery characteristics, patient satisfaction, requirement for rescue sedation and adverse effects were also assessed.
Results: The mean intraoperative RASS score was significantly lower in the Group D than in the Group M (−2.8±0.5 vs. −2.5±0.7; p=0.02). The time required to reach the target sedation level was significantly greater in Group D (9.4±2.6 min vs. 7.8±2.4 min; p=0.003). The scores of patient satisfaction with dexmedetomidine use were significantly greater than with midazolam use (8.5±1.0 vs. 7.9±1.2; p=0.01). Dexmedetomidine was associated with more adverse effects of bradycardia (p=0.08) and hypotension (p=0.46), whereas midazolam was associated with more adverse effects of excessive sedation (p=0.14) and restlessness (p=0.09).
Conclusion: Dexmedetomidine and midazolam were both found to be effective sedatives for patients undergoing regional anesthetic. Dexmedetomidine was found to be a more effective sedative, well tolerated, more patient-satisfying and more stable for intraoperative hemodynamic despite its comparatively slower onset of sedation than midazolam.
AVINASH KAREKAL, SRINIVAS KURAHATTI, Rashmi C· Asian Journal of Pharmaceuti...· 0 citations