Deep sedation

SummaryThe aim of this study was to evaluate the feasibility of the double pelvic osteotomy (DPO) (osteotomy of the ilium and pubis) to treat clinical cases of hip dyplasia in young dogs instead of performing a triple pelvic osteotomy (TPO) (osteotomy of the ilium, pubis, and ischium). Candidates for DPO were 4.5- to nine-month-old dogs with coxofemoral joint subluxation and laxity, indicative of susceptibility to future development of severe hip dysplasia. The angle of reduction (AR) and angle of subluxation (AS) with Ortolani's sign, Norberg angle (NA), percentage of femoral head (PC) covered by the acetabulum, and the pelvic diameters and their relationships were measured clinically and radiographically before and after surgery. The surgical technique was similar to the TPO technique, but excluded ischiatic osteotomy. A DPO was carried out in 53 joints of 34 dogs AR and AS values immediately postoperatively and at the oneand two-month follow-up examinations were significantly...

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidenc...

Continuous sedation at the end of life is a practice that has attracted a great deal of attention. An increasing number of guidelines on the proposed correct performance of the practice have been drafted. All of the guidelines stress the importance of using sedation in proportion to the severity of the patient's symptoms, thus to reduce the patient's consciousness no more than is absolutely necessary. As different patients can have different experiences of suffering, the amount of suffering should, ideally, be assessed subjectively; that is, via communication with the patient. Continuously sedated patients are often unable to communicate, however, making subjective methods of pain assessment unusable. For these patients, the degree of consciousness is the sole available measure. It therefore seems important to adequately measure how deeply the patient is sedated, thereby allowing sedation to be increased when it is too light and decreased when it is too heavy. This is in accordance with the idea that reducing consciousness is not an ethically neutral act. Although consciousness measuring techniques are a hot topic in anesthesiology, almost no research exists on the use of such techniques in the context of continuous sedation at the end of life. This article aims to review existing techniques to measure consciousness and to evaluate their applicability, efficiency, and invasiveness for patients who are continuously sedated until death. Techniques commonly used to assess the depth of sedation in continuously sedated patients are basic clinical assessment and sedation scales, as they are often considered reliable and non-invasive. These techniques might not be very reliable, however, since it is known that some patients are nonresponsive and yet aware. Moreover, sedation scales require stimulation of the patient (for example prodding, shaking, or providing painful stimuli), and can thus be considered invasive of one's bodily integrity or dignity. Other techniques, such as EEG (electroencephalography) derivatives, may score better on reliability and invasiveness. Yet these have so far never been compared to sedation scale scores for patients receiving continuous sedation at the end of life. Therefore, we conclude that, for both clinical and ethical reasons, research into the efficiency and applicability of other techniques, such as derivatives of EEG, are urgently needed.

Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this 'paradigm case' was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation.

Background: According to various guidelines about continuous sedation until death, this practice can and should be clearly distinguished from euthanasia, which is legalized in Belgium. Aim: To explore professional caregivers’ perceptions of the similarities and differences between continuous sedation until death and euthanasia. Design: Qualitative data were gathered through focus groups. Questions pertained to participants’ perceptions of continuous sedation. The focus groups were recorded and transcribed verbatim. Analyses were conducted by a multidisciplinary research team using constant comparison analyses. Setting/Participants: We did four focus groups at Ghent University Hospital: two with physicians (n = 4 and n = 4) and two with nurses (n = 4 and n = 9). The participants could participate if they were ever involved in the use of continuous sedation until death. Results: Although the differences and similarities between continuous sedation until death and euthanasia were not s...

Continuous sedation at the end of life is an end-of-life practice that has gained considerable attention in the international literature. Nevertheless, significant confusion persists, even on how to label or define the practice. Several different terms and definitions exist, and these are often non-neutral and indicative of one's normative position on sedation at the end of life. This is problematic for two reasons. First, the use of such value-laden terms or definitions of continuous sedation may make it difficult, if not impossible, to agree on the facts surrounding continuous sedation. Second, including normative criteria in a definition can lead one to make disguised circular or tautological statements. This paper identifies commonly used terms and definitions and demonstrates how particular elements present in these are value-laden and can influence the ethical evaluation of continuous sedation at the end of life. Two commonly used terms, 'palliative sedation' and 'terminal sedation', have been strongly criticized. We propose to use another, more descriptive term, namely 'continuous sedation at the end of life'. As regards the different definitions of sedation, some are general, but most contain very specific elements, thereby clearly limiting the number of cases that are covered by the definition. Some definitions of sedation include the intention one should (not) have, the possible indications for the practice, and the type of patients the practice should be reserved for. Including value-laden elements in the very definition of a clinical practice runs the risk of pre-empting a proper normative debate about the practice. We explain why this is the case and why it is problematic, and we propose an alternative, descriptive, definition that seeks to avoid these problems.

Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. Qualitative case studies using interviews. Hospitals, the domestic home and hospices or palliative care units. In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consc...

Objective:Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide.Method:Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective.Results:The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated t...

The Small Ubiquitin-like Modifier (SUMO) is as a regulator of many cellular functions by reversible conjugation to a broad number of substrates. Under endogenous or exogenous perturbations, the SUMO network becomes a fine sensor of stress conditions by alterations in the expression level of SUMO enzymes and consequently changing the status of SUMOylated proteins. The diaphragm is the major inspiratory muscle, which is continuously active under physiological conditions, but its structure and function is severely affected when passively displaced for long extents during mechanical ventilation (MV). An iatrogenic condition called Ventilator-Induced Diaphragm Dysfunction (VIDD) is a major cause of failure to wean patients from ventilator support but the molecular mechanisms underlying this dysfunction are not fully understood. Using a unique experimental Intensive Care Unit (ICU) rat model allowing long-term MV, diaphragm muscles were collected in rats control and exposed to controlled ...

Oxygen-induced CSF hyperintensity on FLAIR MR imaging is often observed in sedated children. This phenomenon can mimic leptomeningeal pathology and lead to a misdiagnosis. The purpose of this study was to investigate whether magnetization-prepared FLAIR MR imaging can reduce oxygen-induced CSF hyperintensity and improve image quality compared with conventional (non-magnetization-prepared) FLAIR MR imaging. Bloch simulation for magnetization-prepared and non-magnetization-prepared FLAIR sequences was performed for tissue contrast. We retrospectively reviewed 85 children with epilepsy who underwent MR imaging under general anesthesia with supplemental oxygen (41 with non-magnetization-prepared FLAIR and 44 with magnetization-prepared FLAIR). CSF hyperintensity was scored from 0 to 3 points according to the degree of CSF signal intensity and was compared between the 2 sequences. The contrast-to-noise ratios among GM, WM, and CSF were evaluated to assess general image quality from both ...

Death from cancer is often painful. Usually, the pain can be relieved in ways that allow patients to remain awake and alert until the end. Sometimes, however, the only way to relieve pain is to sedate patients until they are unconscious. This method has been called palliative sedation therapy. Palliative sedation therapy is controversial because it can be misunderstood as euthanasia. We present a case in which an adolescent who is dying of leukemia has intractable pain. Experts in oncology, ethics, pain management, and palliative care discuss the trade-offs associated with different treatment strategies.

Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. Qualitative case studies using interviews. Hospitals, the domestic home and hospices or palliative care units. In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consc...

The application of ethically controversial medical procedures may differ from one place to another. Drawing on a keyword and text-mining analysis of 156 interviews with doctors and nurses involved in end-of-life care ('care providers'), differences between countries in care providers' ethical rationales for the use of sedation are reported. In the United Kingdom, an emphasis on titrating doses proportionately against symptoms is more likely, maintaining consciousness where possible. The potential harms of sedation are perceived to be the potential hastening of social as well as biological death. In Belgium and the Netherlands, although there is concern to distinguish the practice from euthanasia, rapid inducement of deep unconsciousness is more acceptable to care providers. This is often perceived to be a proportionate response to unbearable suffering in a context where there is also greater pressure to hasten dying from relatives and others. This means that sedation is ...

Editor – We thank Schildman and colleagues for their comments regarding our study of continuous sedation (CS) in end-of-life care. We agree that more work needs to be done in the development of high-quality international guidance to aid sound clinical decision-making and also concur with their observations that guidelines alone are insufficient: too much emphasis on guidelines risks encouraging routinisation and obscuring the vital importance of case by case-based consideration of decisions about CS and the need for clinical staff to have the necessary time and repeated opportunities to refine this area of their practice. The role of nurses is often neglected, yet they have been shown to suffer emotional and moral distress in CS practice.1 It is interesting to note, in line with the observation of Schildman et al., that a Dutch study of the general public suggests that there are likely to be some individuals who express a preference to end their life at one point in time without any compromise to their level of consciousness.2 Research by Steinhauser et al.3 also suggests that not all patients associate deep ‘sleep’ with a good death. We agree with Schildman and colleagues that decisions regarding the initiation of CS need to be clearly distinguished from decisions regarding clinically assisted nutrition and hydration (CANH). Justifying the withholding or withdrawing of CANH on the basis of the argument that, since the patient is no longer conscious, CANH is ‘futile’, fails to make the necessary distinction between the two decisions and is a misuse of the concept of futility.4 Yours sincerely

A reduction in portal pressure gradient (PPG) to below 12 mmHg after placement of a transjugular intrahepatic porto-systemic shunt (TIPS) correlates with the absence of further bleeding or ascites at follow-up examinations of patients with cirrhosis. The PPG is usually measured immediately after placement of the TIPS, when different circumstances can affect PPG values - this could affect determination of risk for decompensation. We investigated variations in PPG measurements collected at different time points after TIPS, aiming to identify a time point after which PPG values were best maintained. We performed a retrospective study of 155 consecutive patients with severe complications of portal hypertension who received placement of TIPS from January through October 2015; patients were followed until March 2016. We compared PPG values measured at different time points and under different conditions: immediate following placement of TIPS (immediate PPG); at least 24 hrs after placemen...

Sedatives can impair the swallowing process. We assessed the incidence and severity of swallowing impairment in patients sedated with propofol at clinically relevant doses. We also identified factors that were predictive of swallowing impairment. In 80 patients scheduled to undergo elective gastrointestinal endoscopy under target-controlled infusion (TCI) propofol sedation, swallowing was evaluated by glottis videoendoscopy, using the Dysphagia Severity Score (DSS) and the Penetration and Aspiration Scale (PAS). The level of sedation was assessed with the Observer's Assessment of Alertness/Sedation (OAAS) scale. Evaluations were obtained within each patient at 3 target effect-site propofol concentrations of 2, 3, and 4 μg/mL (Marsh model). At 2 μg/mL TCI, the OAAS score was 2 in 21 (26.25%) patients and 1 in 59 (73.75%). The OAAS score was 1 in all patients at 3 and 4 μg/mL TCI target. At 3 μg/mL TCI target, 19 (24.36%) patients had a DSS = 3 and 18 patients (23.08%) had a PAS =...

Children with acute lymphoblastic leukemia (ALL) undergo multiple lumbar punctures (LPs) during their course of treatment for diagnostic and therapeutic purposes. LP is a stressful and painful procedure, affecting the quality of life of these children. Procedural analgo-sedation might improve the child's comfort and prevent the child's movements, reducing the risk of traumatic lumbar puncture with blasts (TLP+), mainly at diagnosis, when higher numbers of blast cells are circulating in the peripheral blood. The aim of this study was to evaluate the safety and efficacy of procedural analgo-sedation in children with ALL. From September 2006 to November 2008, we performed a total of 252 lumbar punctures under deep sedation with propofol and ketamine in 25 children with ALL treated at our division. During the procedures, vital parameters were monitored and side effects were recorded. The efficacy of deep sedation was evaluated using Ramsay and Children's Hospital Eastern Ontario Pain scales. Cerebrospinal fluid was collected for chemical and cytological examinations. In all patients a satisfactory sedation and analgesia were achieved. The evaluation of vital parameters did not show any significant variation compared to baseline values. No side effects were recorded. Only 3 (1.2 %) of 252 lumbar punctures resulted in traumatic effects. To strongly improve comfort and quality of life of children with ALL and reduce the risk of TLP+ mainly at diagnosis, we recommend performing the lumbar punctures under analgo-sedation because it is a safe and effective procedure.

After reading this article, the participant should be able to: 1. Describe the basic fundamentals of conscious sedation and deep sedation techniques. 2. Describe the basic principles of effective local anesthesia, as well as the "wide awake approach" and monitored anesthesia care. 3. Describe current methods for achieving postoperative pain control. 4. Evaluate and manage postoperative nausea and vomiting. This article reviews the basic fundamentals of sedational anesthetic techniques. In addition, current concepts on local anesthesia administration are reviewed, including a description of newer techniques to allow for wide awake surgery. A brief review of postoperative pain management, and the management of postoperative nausea and vomiting, is also included.

To compare the impact of carbon dioxide (CO₂) and air insufflation on patient tolerance/safety in deeply sedated patients undergoing colonoscopy. Patients referred for colonoscopy were randomized to receive either CO₂ or air insufflation during the procedure. Both the colonoscopist and patient were blinded to the type of gas used. During the procedure, insertion and withdrawal times, caecal intubation rates, total sedation given and capnography readings were recorded. The level of sedation and magnitude of patient discomfort during the procedure was assessed by a nurse using a visual analogue scale (VAS) (0-3). Patients then graded their level of discomfort and abdominal bloating using a similar VAS. Complications during and after the procedure were recorded. A total of 142 patients were randomized with 72 in the air arm and 70 in the CO₂ arm. Mean age between the two study groups were similar. Insertion time to the caecum was quicker in the CO₂ group at 7.3 min vs 9.9 min with air ...

Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. Qualitative case studies using interviews. Hospitals, the domestic home and hospices or palliative care units. In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consc...

Deep sedation with Propofol has become popular in recent years. The safety of this technique when administered by non-anaesthesiologists has created much controversy which at times is masked in a contentious debate on the economic sustainability of the health system. In 2011, the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy, along with 20 other organisations from European countries, revoked the recommendations of the European Society of Gastrointestinal Endoscopy on the administration of Propofol by non-anaesthesiologists, citing that it is "extremely dangerous for the safety and quality of endoscopic procedures". The FDA in 2005 had already rejected the use of Propofol by non-anaesthesiologists in the United States, a prohibition which was reiterated in 2010 and is still in force, basing its evidence, among others, on the recommendations and guidelines of the Joint Commission and the Declaration of Helsinki. In Spain, the data sheet of Propofol restr...