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Journal articles on the topic 'Continuous and deep sedation'

Author: Grafiati

Published: 5 April 2025

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1

Yokomichi, Naosuke, Takuhiro Yamaguchi, Isseki Maeda, Masanori Mori, Kengo Imai, Akemi Shirado Naito, Takashi Yamaguchi, et al. "Effect of continuous deep sedation on survival in the last days of life of cancer patients: A multicenter prospective cohort study." Palliative Medicine 36, no. 1 (January 2022): 189–99. http://dx.doi.org/10.1177/02692163211057754.

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Background: Continuous deep sedation is ethically controversial with respect to whether it shortens a patient’s life. Aim: To examine whether continuous deep sedation shortens patient survival from the day of Palliative Performance Scale decline to 20 (PPS20). Design: A part of a multicenter prospective cohort study (EASED study). Setting/participants: We recruited consecutive adult patients with advanced cancer admitted to 23 participating palliative care units in 2017 in Japan. We compared survival from PPS20 between those who did and did not receive continuous deep sedation. Continuous deep sedation was defined as the continuous administration of sedative medication with the intention to keep a patient continuously unconscious to alleviate otherwise uncontrollable symptoms, but the dose of sedatives was adjusted to achieve adequate symptom relief for each patient. The propensity score-weighting method was used to control for potential confounders, and five sensitivity analyses were performed. Results: A total of 1926 patients were enrolled. Patients discharged alive were excluded, and we analyzed 1625 patients of whom 156 (9.6%) received continuous deep sedation. Median survival from PPS20 of 1625 patients was 81 h (95% CI: 77–88). The RASS scores decreased to ⩽−4 was 66% at 24 h. Continuous deep sedation was not associated with a significant survival risk (adjusted hazard ratio: 1.06, 95% CI: 0.85–1.33). All sensitivity analyses, including continuous deep sedation defined as the RASS score was ⩽−4 achieved the essentially the same results. Conclusions: Continuous deep sedation with careful dose adjustment was not associated with shorter survival in the last days of life in patients with advanced cancer.

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2

Twycross, Robert. "Reflections on palliative sedation." Palliative Care: Research and Treatment 12 (January 2019): 117822421882351. http://dx.doi.org/10.1177/1178224218823511.

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‘Palliation sedation’ is a widely used term to describe the intentional administration of sedatives to reduce a dying person’s consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either ‘continuous sedation until death’ or ‘continuous deep sedation’. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person’s ‘biographical life’ (the ability to interact meaningfully with other people) and shortens ‘biological life’. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become ‘normalized’ in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.

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3

Rady, Mohamed Y., and Joseph L. Verheijde. "Uniformly defining continuous deep sedation." Lancet Oncology 17, no. 3 (March 2016): e89. http://dx.doi.org/10.1016/s1470-2045(15)00585-9.

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4

Ortega Pacheco, Yesid José. "Continuous deep sedation and euthanasia." Atención Primaria 55, no. 3 (March 2023): 102568. http://dx.doi.org/10.1016/j.aprim.2023.102568.

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5

Morita, Tatsuya, Isseki Maeda, Masanori Mori, Kengo Imai, and Satoru Tsuneto. "Uniform definition of continuous-deep sedation." Lancet Oncology 17, no. 6 (June 2016): e222. http://dx.doi.org/10.1016/s1470-2045(16)30115-2.

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6

Morita, Tatsuya, Tatsuo Akechi, Yuriko Sugawara, Satoshi Chihara, and Yosuke Uchitomi. "Practices and Attitudes of Japanese Oncologists and Palliative Care Physicians Concerning Terminal Sedation: A Nationwide Survey." Journal of Clinical Oncology 20, no. 3 (February 1, 2002): 758–64. http://dx.doi.org/10.1200/jco.2002.20.3.758.

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PURPOSE: To clarify the frequency of practice of sedation therapy for terminally ill cancer patients and to identify physicians’ attitudes toward sedation. METHODS: Questionnaires were mailed to 1,436 Japanese oncologists and palliative care physicians with a request to report their practice of and attitudes toward palliative sedation therapy. RESULTS: A total of 697 physicians returned questionnaires (response rate, 49.6%). Use of mild, intermittent-deep, or continuous-deep sedation for physical and psychologic distress was reported by 89% and 64%, 70% and 46%, and 66% and 38%, respectively. In vignettes in which physicians were asked whether they would use sedation for a patient with refractory dyspnea or with existential distress, 14% and 15%, respectively, chose continuous-deep sedation as a strong possibility. Those physicians less confident with psychologic care and with higher levels of professional burnout were more likely to choose continuous-deep sedation. In vignettes in which they were asked whether they use sedation for a patient with depression or delirium, 39% and 31%, respectively, considered psychiatric treatment to be a strong possibility, and 42% and 50% regarded continuous-deep sedation as a potential treatment option. Physicians less involved in caring for the terminally ill and less specialized in palliative medicine were significantly less likely to choose psychiatric treatment. CONCLUSION: Sedation is frequently used for severe physical and psychologic distress of cancer patients. Physicians’ clinical experiences with the terminally ill and their levels of professional burnout influence the decisions. Training and education for physicians in regard to end-of-life care and valid clinical guidelines for palliative sedation therapy are necessary.

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7

Ziegler, Sarah, Margareta Schmid, Matthias Bopp, Georg Bosshard, and Milo Alan Puhan. "Using sedative substances until death: A mortality follow-back study on the role of healthcare settings." Palliative Medicine 33, no. 2 (December 5, 2018): 213–20. http://dx.doi.org/10.1177/0269216318815799.

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Background: In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated. Aim: To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control. Design: National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older. Setting/participants: Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included. Results: Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53–2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90–10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5–1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3–2.5, p = 0.001). Conclusion: In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals’ palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted.

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8

Murray, Scott A., Kirsty Boyd, and Ira Byock. "Continuous deep sedation in patients nearing death." BMJ 336, no. 7648 (March 14, 2008): 781–82. http://dx.doi.org/10.1136/bmj.39511.514051.80.

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9

Rietjens, JAC, HM Buiting, HRW Pasman, PJ van der Maas, JJM van Delden, and A. van der Heide. "Deciding about continuous deep sedation: physicians’ perspectives." Palliative Medicine 23, no. 5 (March 20, 2009): 410–17. http://dx.doi.org/10.1177/0269216309104074.

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10

Imai, Kengo, Tatsuya Morita, Masanori Mori, Naosuke Yokomichi, Toshihiro Yamauchi, Satoru Miwa, Satoshi Inoue, et al. "Family experience of palliative sedation therapy: proportional vs. continuous deep sedation." Supportive Care in Cancer 30, no. 5 (January 18, 2022): 3903–15. http://dx.doi.org/10.1007/s00520-021-06745-1.

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11

Kramer, Kyle J., Steven Ganzberg, Simon Prior, and Robert G. Rashid. "Comparison of Propofol-Remifentanil Versus Propofol-Ketamine Deep Sedation for Third Molar Surgery." Anesthesia Progress 59, no. 3 (October 1, 2012): 107–17. http://dx.doi.org/10.2344/12-00001.1.

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This study aimed to compare continuous intravenous infusion combinations of propofol-remifentanil and propofol-ketamine for deep sedation for surgical extraction of all 4 third molars. In a prospective, randomized, double-blinded controlled study, participants received 1 of 2 sedative combinations for deep sedation for the surgery. Both groups initially received midazolam 0.03 mg/kg for baseline sedation. The control group then received a combination of propofol-remifentanil in a ratio of 10 mg propofol to 5 μg of remifentanil per milliliter, and the experimental group received a combination of propofol-ketamine in a ratio of 10 mg of propofol to 2.5 mg of ketamine per milliliter; both were given at an initial propofol infusion rate of 100 μg/kg/min. Each group received an induction loading bolus of 500 μg/kg of the assigned propofol combination along with the appropriate continuous infusion combination . Measured outcomes included emergence and recovery times, various sedation parameters, hemodynamic and respiratory stability, patient and surgeon satisfaction, postoperative course, and associated drug costs. Thirty-seven participants were enrolled in the study. Both groups demonstrated similar sedation parameters and hemodynamic and respiratory stability; however, the ketamine group had prolonged emergence (13.6 ± 6.6 versus 7.1 ± 3.7 minutes, P = .0009) and recovery (42.9 ± 18.7 versus 24.7 ± 7.6 minutes, P = .0004) times. The prolonged recovery profile of continuously infused propofol-ketamine may limit its effectiveness as an alternative to propofol-remifentanil for deep sedation for third molar extraction and perhaps other short oral surgical procedures, especially in the ambulatory dental setting.

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12

Materstvedt, Lars Johan, and Georg Bosshard. "Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects." Lancet Oncology 10, no. 6 (June 2009): 622–27. http://dx.doi.org/10.1016/s1470-2045(09)70032-4.

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13

Capaccio, Pasquale, Andrea Palermo, Paolo Lucchinelli, Tiziana Marchesi, Sara Torretta, Michele Gaffuri, Paola Marchisio, and Lorenzo Pignataro. "Deep Sedation for Pediatric Parotid Sialendoscopy in Juvenile Recurrent Parotitis." Journal of Clinical Medicine 10, no. 2 (January 13, 2021): 276. http://dx.doi.org/10.3390/jcm10020276.

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Sialendoscopy is a minimally invasive diagnostic and therapeutic tool for juvenile recurrent parotitis (JRP); the procedure is under general anesthesia, but local anesthesia has been used for sialendoscopy in children >8 years. Based on the experience in children with sedation for gastrointestinal endoscopy, we investigated the reliability and safety of deep sedation for sialendoscopy in JRP. Six children (3 females, 6–13 years) with episodes of parotid swelling underwent interventional (duct dilation and steroid irrigation) sialendoscopy with intravenous bolus of 1 mg/kg propofol and 1 mcg/kg fentanyl, and continuous infusion of 2 mg/kg/h propofol. Sialendoscopy under deep sedation was successfully performed in all the patients; the procedure was well tolerated, without any adverse effects. One event of full awakening was registered and promptly solved without needing to interrupt the procedure. Effectiveness of sialendoscopy under deep sedation was subjectively attested by high positive scores obtained at post-operative standardized questionnaires administered to the patients and their parents, and objectively by the lack of clinical recurrences during the follow-up. The combination of propofol and fentanyl seems to be a reliable and safe means of sedating children with JRP undergoing sialendoscopy.

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14

Gielen, Joris, Stef Van den Branden, Trudie Van Iersel, and Bert Broeckaert. "Flemish palliative-care nurses’ attitudes to palliative sedation." Nursing Ethics 19, no. 5 (September 2012): 692–704. http://dx.doi.org/10.1177/0969733011436026.

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Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses’ attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses ( n = 415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated patient and considered it generally better not to administer artificial floods or fluids to such a patient. Two clusters were found: 58.5% belonged to the cluster of advocates of deep and continuous sedation and 41.5% belonged to the cluster of nurses restricting the application of deep and continuous sedation. These differences notwithstanding, overall the attitudes of the nurses are in accordance with the practice and policy of palliative sedation in Flemish palliative-care units.

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15

Hansen, Thor Willy Ruud, and Dominic J. C. Wilkinson. "Continuous Deep Sedation in the Newborn: Knowledge and Need." Neonatology 118, no. 6 (2021): 736–37. http://dx.doi.org/10.1159/000518659.

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16

Feen, Eli. "Continuous Deep Sedation: Consistent With Physician's Role as Healer." American Journal of Bioethics 11, no. 6 (June 2011): 49–51. http://dx.doi.org/10.1080/15265161.2011.578200.

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17

Miccinesi, Guido, Judith A. C. Rietjens, Luc Deliens, Eugenio Paci, Georg Bosshard, Tore Nilstun, Michael Norup, and Gerrit van der Wal. "Continuous Deep Sedation: Physicians' Experiences in Six European Countries." Journal of Pain and Symptom Management 31, no. 2 (February 2006): 122–29. http://dx.doi.org/10.1016/j.jpainsymman.2005.07.004.

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18

Seale, Clive. "Continuous Deep Sedation in Medical Practice: A Descriptive Study." Journal of Pain and Symptom Management 39, no. 1 (January 2010): 44–53. http://dx.doi.org/10.1016/j.jpainsymman.2009.06.007.

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19

Juth, Niklas, Anna Lindblad, Niels Lynöe, Manne Sjöstrand, and Gert Helgesson. "Moral differences in deep continuous palliative sedation and euthanasia." BMJ Supportive & Palliative Care 3, no. 2 (March 6, 2013): 203–6. http://dx.doi.org/10.1136/bmjspcare-2012-000431.

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20

Bodnar, John. "A Review of Agents for Palliative Sedation/Continuous Deep Sedation: Pharmacology and Practical Applications." Journal of Pain & Palliative Care Pharmacotherapy 31, no. 1 (January 2, 2017): 16–37. http://dx.doi.org/10.1080/15360288.2017.1279502.

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21

Bruns, Nora, Carolina A. Joist, Constantin M. Joist, Anna Daniels, Ursula Felderhoff-Müser, Christian Dohna-Schwake, and Eva Tschiedel. "Correlation of Comfort Score and Narcotrend Index during Procedural Sedation with Midazolam and Propofol in Children." Journal of Clinical Medicine 13, no. 5 (March 4, 2024): 1483. http://dx.doi.org/10.3390/jcm13051483.

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Background/Objectives: Precise assessment of hypnotic depth in children during procedural sedation with preserved spontaneous breathing is challenging. The Narcotrendindex (NI) offers uninterrupted information by continuous electrocortical monitoring without the need to apply a stimulus with the risk of assessment-induced arousal. This study aimed to explore the correlation between NI and the Comfort Scale (CS) during procedural sedation with midazolam and propofol and to identify an NI target range for deep sedation. Methods: A prospective observational study was conducted on 176 children (6 months to 17.9 years) undergoing procedural sedation with midazolam premedication and continuous propofol infusion. Statistical analyses included Pearson correlation of NI and CS values, logistic regression, and receiver operating curves. Results: Median NI values varied with CS and age. The correlation coefficient between CS and NI was 0.50 and slightly higher in procedure-specific subgroup analyses. The optimal NI cut-off for deep sedation was between 50 and 60 depending on the analyzed subgroup and displayed high positive predictive values for sufficient sedation throughout. Conclusion: Our study found a moderate correlation between NI and CS, demonstrating reliable identification of adequately sedated patients.

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22

Oh, Chahyun, Jiyong Lee, Jieun Lee, Yumin Jo, Sanghun Kwon, Minhae Bang, Chaeseong Lim, Yoon-Hee Kim, Sun Yeul Lee, and Boohwi Hong. "Apnea during moderate to deep sedation using continuous infusion of remimazolam compared to propofol and dexmedetomidine: A retrospective observational study." PLOS ONE 19, no. 4 (April 17, 2024): e0301635. http://dx.doi.org/10.1371/journal.pone.0301635.

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Remimazolam’s rapid onset and offset make it an innovative sedative for use during regional anesthesia. However, its respiratory safety profile is not well understood. We compared the continuous infusion of remimazolam with commonly used sedatives, propofol and dexmedetomidine, after regional anesthesia. In this retrospective study, the incidence of apnea (>10 seconds) was assessed in patients who underwent orthopedic surgery under regional anesthesia and received moderate to deep sedation using continuous infusion of remimazolam (group R: 0.1 mg/kg in 2 minutes followed by 0.5 mg/kg/hr). The incidence was compared with that of propofol (group P: 2–3 μg/mL target-controlled infusion) and dexmedetomidine (group D: 1 μg/kg in 10 minutes followed by 0.4–1 μg/kg/hr). Propensity score weighted multivariable logistic regression model was utilized to determine the effects of the sedative agents on the incidence of apnea. A total of 634 (191, 278, and 165 in group R, P, and D) cases were included in the final analysis. The incidence of apnea was 63.9%, 67.3%, and 48.5% in group R, P, and D, respectively. The adjusted odds ratios for apnea were 2.33 (95% CI, 1.50 to 3.61) and 2.50 (95% CI, 1.63 to 3.85) in group R and P, compared to group D. The incidence of apnea in patients receiving moderate to deep sedation using continuous infusion of remimazolam with dosage suggested in the current study was over 60%. Therefore, careful titration and respiratory monitoring is warranted.

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23

Morita, Tatsuya, Kengo Imai, Masanori Mori, Naosuke Yokomichi, and Satoru Tsuneto. "Defining “Continuous Deep Sedation” Using Treatment Protocol: A Proposal Article." Palliative Medicine Reports 3, no. 1 (February 1, 2022): 8–15. http://dx.doi.org/10.1089/pmr.2021.0058.

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24

Rady, Mohamed Y., and Joseph L. Verheijde. "Continuous Deep Sedation Until Death: Palliation or Physician-Assisted Death?" American Journal of Hospice and Palliative Medicine® 27, no. 3 (December 14, 2009): 205–14. http://dx.doi.org/10.1177/1049909109348868.

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25

Ziegler, Sarah, Margareta Schmid, Matthias Bopp, Georg Bosshard, and Milo Alan Puhan. "Continuous Deep Sedation Until Death—a Swiss Death Certificate Study." Journal of General Internal Medicine 33, no. 7 (March 20, 2018): 1052–59. http://dx.doi.org/10.1007/s11606-018-4401-2.

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26

Chambaere, K., J. Bilsen, J. Cohen, J. A. Rietjens, B. D. Onwuteaka-Philipsen, F. Mortier, and L. Deliens. "Continuous Deep Sedation Until Death in Belgium: A Nationwide Survey." Archives of Internal Medicine 170, no. 5 (March 8, 2010): 490–93. http://dx.doi.org/10.1001/archinternmed.2009.542.

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27

Iratxe, Gonzalez-Mendibil, García-Pascual Eduardo, Villanueva Ane, and García-Gutiérrez Susana. "Bispectral Index Monitoring: Ability to Detect Deep Sedation during Endoscopy." Annals of Clinical Gastroenterology and Hepatology 7, no. 1 (October 24, 2023): 028–64. http://dx.doi.org/10.29328/journal.acgh.1001042.

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Background: Clinical practice guidelines recommend monitoring the depth of anesthesia during endoscopic examination of the gastrointestinal tract using sedation scales, despite their subjective nature, while the use of the bispectral index, an objective measure, during sedation, remains controversial. The main objective of this study was to assess the ability of bispectral index monitoring to characterize the depth of anesthesia during endoscopy. Methods: We conducted a cross-sectional study to assess the performance of the bispectral index using data from a multicentre clinical trial with 180 patients undergoing scheduled colonoscopies. Sedation was monitored using the bispectral index and Ramsay Sedation Scale. Data on sedation were recorded at five-time points (t1 to t5) during the colonoscopy. Results: Bispectral values were significantly associated with Ramsay scores (rho, -0.73; p < 0.0001). In regression analysis, each unit increase in bispectral value was associated with a reduction in the risk of a high Ramsay score (> 3) at all points (OR 0.922; 95% CI: 0.865–0.979; p < 0.0001 at t1). Receiver operating characteristic curve analysis found areas under the curve of 0.8272 for a bispectral index cut-off for deep sedation of 69.76 (sensitivity, 95.35%; negative predictive value, 97.53%) when reaching the colic flexure (t2) and 0.8399 for a cut-off of 69.29 (sensitivity, 96.15%; negative predictive value, 98.81%) at the end of the colonoscopy (t5). Conclusion: Bispectral index monitoring enables objective real-time reliable assessment of sedation. It enables easy continuous monitoring with a very good performance for detecting deep sedation and correlates with a clinical scale routinely used in endoscopic procedures.

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28

Ahmed, Sheikh, James Slaven, Mara Nitu, and Shawn Hicks. "Intermittent Bolus versus Continuous Infusion of Propofol for Deep Sedation during ABR/Nuclear Medicine Studies." Journal of Pediatric Intensive Care 06, no. 03 (December 30, 2016): 176–81. http://dx.doi.org/10.1055/s-0036-1597628.

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Objective A comparison of intermittent bolus (IB) versus continuous infusion of propofol for deep sedation. Material and Methods A retrospective review of patients sedated for Auditory Brainstem Response (ABR)/nuclear medicine studies between September 2008 and February 2015. A ketamine bolus (0.5 mg/kg < 20 kg, 0.25 mg/kg > 20 kg) followed by propofol bolus of 1 mg/kg over 2 minutes. In the IB group, maintenance of deep sedation was with incremental bolus of 10 to 20 mg of propofol. In continuous infusion group (CG), maintenance was with a continuous infusion of 83 mcg/kg/min of propofol. Results Of the 326 cases completed, 181 were in CG group and 145 were in IB group. There were no statistical differences in patient's age, weight, and American Society of Anesthesiologist (ASA) classification. The cardiovascular and respiratory parameters in the two groups were not different statistically. Mean total propofol dose was higher in CG group versus IB group (CG 7.6 mg ± 3.6 mg, IB 6.5 mg ± 3.6 mg; p = 0.008). Procedure time in CG group was longer by 8 minutes compared with IB group (CG 49.8 min ± 25.4 min versus 42.3 min ± 19.2 min; p = .003). CG group has both shorter recovery time (CG 8.1 min ± 4.7 min versus IB 10.0 min ± 8.5 min; p = 0.01) and discharge time. Conclusion Satisfactory sedation and completion of the procedure was accomplished with both sedation protocols.

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29

Giebel, Heidi. "Ethical end-of-life palliative care: response to Riisfeldt." Journal of Medical Ethics 46, no. 1 (August 8, 2019): 51–52. http://dx.doi.org/10.1136/medethics-2019-105451.

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In a recent article, 1 Riisfeldt attempts to show that the principle of double effect (PDE) is unsound as an ethical principle and problematic in its application to palliative opioid and sedative use in end-of-life care. Specifically, he claims that (1) routine, non-lethal opioid and sedative administration may be “intrinsically bad” by PDE’s standards, (2) continuous deep palliative sedation (or “terminal sedation”) should be treated as a bad effect akin to death for purposes of PDE, (3) PDE cannot coherently be applied in cases where death “indirectly” furthers an agent’s intended end of pain relief via medically appropriate palliative care, and (4) application of PDE requires sacrificing common beliefs about the sanctity of human life. I respond by showing that Riisfeldt’s understanding of PDE is seriously mistaken: he misattributes Kantian and Millian reasoning to the principle and conflates acts’ intrinsic properties with their effects. Further, a corrected understanding of PDE can address Riisfeldt’s case-specific objections.

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30

Morita, Tatsuya, Kengo Imai, Naosuke Yokomichi, Masanori Mori, Yoshiyuki Kizawa, and Satoru Tsuneto. "Continuous Deep Sedation: A Proposal for Performing More Rigorous Empirical Research." Journal of Pain and Symptom Management 53, no. 1 (January 2017): 146–52. http://dx.doi.org/10.1016/j.jpainsymman.2016.08.012.

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31

Inghelbrecht, Els, Johan Bilsen, Freddy Mortier, and Luc Deliens. "Continuous Deep Sedation Until Death in Belgium: A Survey Among Nurses." Journal of Pain and Symptom Management 41, no. 5 (May 2011): 870–79. http://dx.doi.org/10.1016/j.jpainsymman.2010.07.022.

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32

Lindblad, Anna, Niklas Juth, Carl Johan Fürst, and Niels Lynöe. "Continuous deep sedation, physician-assisted suicide, and euthanasia in Huntington’s disorder." International Journal of Palliative Nursing 16, no. 11 (November 2010): 527–33. http://dx.doi.org/10.12968/ijpn.2010.16.11.80019.

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33

Papavasiliou, Evangelia (Evie), and Sheila Payne. "Unaddressed biases in reported prevalence of continuous deep sedation until death." Journal of Clinical Epidemiology 68, no. 10 (October 2015): 1241–42. http://dx.doi.org/10.1016/j.jclinepi.2014.11.007.

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34

Le Dorze, Matthieu, Stanislas Kandelman, Benoit Veber, Elodie Brunel, Houtin Baghdadi, Antoine Baumann, Frédérique Claudot, et al. "Deep continuous sedation maintained until death, in French Intensive Care Units." Anaesthesia Critical Care & Pain Medicine 39, no. 1 (February 2020): 115–16. http://dx.doi.org/10.1016/j.accpm.2019.07.008.

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35

Feng, Rui, Florian Richter, Alec Gleason, Madeline Fields, Felix Richter, Neha Dangayach, and Benjamin Rapoport. "322 Pose Tracking of Patient Video Data in the Neuroscience Intensive Care Unit: A Preliminary Analysis." Neurosurgery 71, Supplement_1 (April 2025): 76. https://doi.org/10.1227/neu.0000000000003360_322.

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INTRODUCTION: Patients are routinely sedated in the Neuroscience Intensive Care Unit (NSICU) for procedures, imaging, and clinical pathologies including cerebral edema and elevated intracranial pressure. Titrating sedation is challenging: patients need to be sedated enough to tolerate uncomfortable therapies but not overly sedated to be mistaken for declining neurological status. Thus, accurate and continuous characterization of level of arousal are acornerstone of neurocritical care. Concurrently, there is a vast amount of patient video monitoring data being collected, but it is not routinely analyzed. METHODS: We obtained video-EEG from a patient in the NSICU. We calculated pose with a deep learning computer vision approach, MMPose. As a summary metric of movement, we calculated the standard deviation (SD) in pose within each 10 second interval. We then correlated movement with the Richmond Agitation-Sedation Scale (RASS), a validated sedation scale. Lastly, we trained an XGBoost classifier to predict level of sedation. RESULTS: We compared movement between light and deep sedation (RASS=0 vs RASS=-4). Movement was approximately twice as high with RASS 0 (SD=1.7 pixels) compared to RASS -4 (SD=0.84 pixels, Wilcoxon rank sum test P=1.4x10^-45). Furthermore, movement was higher in the distal extremities compared to the head at RASS 0 (P=1.5x10-^15) but not RASS -4 (P=0.77), further supporting the algorithm’s performance in detecting light versus deep sedation. Sedation prediction with XGBoost had high performance on training and test sets (ROC-AUCs 0.999 and 0.995, respectively). CONCLUSIONS: We used pose tracking to differentiate light versus deep sedation in a patient in the NSICU. This technology may improve sedation titration and, more generally, offer a scalable, minimally invasive tool for monitoring all patients with acute neurological illness.

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Jung, Jaewoong, Juhui Park, Yang Hoon Chung, and Won Seok Chae. "Procedural Sedation of Preterm Neonate with Frequent Apnea during Magnetic Resonance Imaging: A Case Report." Soonchunhyang Medical Science 27, no. 2 (December 31, 2021): 88–90. http://dx.doi.org/10.15746/sms.21.021.

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Magnetic resonance imaging (MRI) is a useful and safe imaging modality for examining preterm infants. However, MRI examination requires careful precautions, and infants and children are likely to require deep sedation or anesthesia to keep them still during the examination. Sedation has various risks and the greatest concern of sedation is cardiorespiratory events. In addition, delicate titration is also necessary for preterm infants because propofol pharmacokinetics is different from those in older children. We successfully completed sedation of a preterm neonate (gestational age, 32+1 weeks; birth weight, 1,970 g) with a history of frequent apnea through careful assessment and continuous monitoring. We want to suggest alternative options for airway management of the high risk of respiratory complications.

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Schultheis, Jennifer M., Travis S. Heath, and David A. Turner. "Association Between Deep Sedation from Continuous Intravenous Sedatives and Extubation Failures in Mechanically Ventilated Patients in the Pediatric Intensive Care Unit." Journal of Pediatric Pharmacology and Therapeutics 22, no. 2 (April 1, 2017): 106–11. http://dx.doi.org/10.5863/1551-6776-22.2.106.

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OBJECTIVE The primary objective of this study was to determine whether an association exists between deep sedation from continuous infusion sedatives and extubation failures in mechanically ventilated children. Secondary outcomes evaluated risk factors associated with deep sedation. METHODS This was a retrospective cohort study conducted between January 1, 2009, and October 31, 2012, in the pediatric intensive care unit (PICU) at Duke Children's Hospital. Patients were included in the study if they had been admitted to the PICU, had been mechanically ventilated for ≥48 hours, and had received at least one continuous infusion benzodiazepine and/or opioid infusion for ≥24 hours. Patients were separated into 2 groups: those deeply sedated and those not deeply sedated. Deep sedation was defined as having at least one documented State Behavioral Scale (SBS) of −3 or −2 within 72 hours prior to planned extubation. RESULTS A total of 108 patients were included in the analysis. Both groups were well matched with regard to baseline characteristics. For the primary outcome, there was no difference in extubation failures in those who were deeply sedated compared to those not deeply sedated (14 patients [22.6%] versus 7 patients [15.2%], respectively; p = 0.33). After adjusting for potential risk factors, patients with a higher weight percentile for age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00–1.03), lower Glasgow Coma Score (GCS) score prior to intubation (OR 0.85; 95% CI 0.74–0.97), and larger maximum benzodiazepine dose (OR 1.93; 95% CI 1.01–3.71) were associated with greater odds of deep sedation. A higher GCS prior to intubation was significantly associated with increased odds of extubation failure (OR 1.19; 95% CI 1.02–1.39). CONCLUSIONS While there was no statistically significant difference in extubation failures between the 2 groups included in this study, considering the severe consequences of extubation failure, the numerical difference reported may be clinically important.

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Emmerich, Nathan, and Bert Gordijn. "Ethics of crisis sedation: questions of performance and consent." Journal of Medical Ethics 45, no. 5 (April 20, 2019): 339–45. http://dx.doi.org/10.1136/medethics-2018-105285.

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This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term ‘crisis sedation.’ We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.

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Rietjens, Judith, Johannes van Delden, Bregje Onwuteaka-Philipsen, Hilde Buiting, Paul van der Maas, and Agnes van der Heide. "Continuous deep sedation for patients nearing death in the Netherlands: descriptive study." BMJ 336, no. 7648 (March 14, 2008): 810–13. http://dx.doi.org/10.1136/bmj.39504.531505.25.

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Scherrens, Anne-Lore, Marc Roelands, Lieve Van den Block, Benedicte Deforche, Luc Deliens, and Joachim Cohen. "What influences intentions to request physician-assisted euthanasia or continuous deep sedation?" Death Studies 42, no. 8 (January 19, 2018): 491–97. http://dx.doi.org/10.1080/07481187.2017.1386734.

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Rady, Mohamed Y., and Joseph L. Verheijde. "Empirical Clinical Research in Continuous Deep Sedation at the End of Life." Journal of Pain and Symptom Management 53, no. 6 (June 2017): e10-e12. http://dx.doi.org/10.1016/j.jpainsymman.2017.01.006.

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Beauverd, Michel, Marta Mazzoli, Josiane Pralong, Martyna Tomczyk, Steffen Eychmüller, and Jan Gaertner. "Palliative sedation – revised recommendations." Swiss Medical Weekly 154, no. 2 (February 15, 2024): 3590. http://dx.doi.org/10.57187/s.3590.

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Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term “continuous deep sedation” by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient’s symptoms and suffering.

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Koike, Kazuhiko, Takeshi Terui, Yuji Takahashi, Yasuo Hirayama, Naomi Mizukami, Michiaki Yamakage, Junji Kato, and Kunihiko Ishitani. "Effectiveness of multidisciplinary team conference on decision-making surrounding the application of continuous deep sedation for terminally ill cancer patients." Palliative and Supportive Care 13, no. 2 (November 4, 2013): 157–64. http://dx.doi.org/10.1017/s1478951513000837.

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AbstractObjective:Continuous deep sedation (CDS) is a way to reduce conscious experience of symptoms of severe suffering in terminally ill cancer patients. However, there is wide variation in the frequency of its reported. So we conducted a retrospective analysis to assess the prevalence and features of CDS in our palliative care unit (PCU).Methods:We performed a systemic retrospective analysis of the medical and nursing records of all 1581 cancer patients who died at the PCU at Higashi Sapporo Hospital between April 2005 and August 2011. Continuous deep sedation can only be administered safely and appropriately when a multidisciplinary team is involved in the decision-making process. Prior to administration of CDS, a multidisciplinary team conference (MDTC) was held with respect to all the patients considered for CDS by an attending physician. The main outcome measures were the frequency and characteristics of CDS (patient background, all target symptoms, medications used for sedation, duration, family's satisfaction, and distress). We mailed anonymous questionnaires to bereaved families in August 2011.Results:Of 1581 deceased patients, 22 (1.39%) had received CDS. Physical exhaustion 8 (36.4%), dyspnea 7 (31.8%), and pain 5 (22.7%) were the most frequently mentioned indications. Continuous deep sedation had a duration of less than 1 week in 17 (77.3%). Six patients (0.38%) did not meet the appropriate criteria for CDS according to the MDTC and so did not receive it. Although bereaved families were generally comfortable with the practice of CDS, some expressed a high level of emotional distress.Significance of results:Our results indicate that the prevalence of CDS will be decreased when it is carried out solely for appropriate indications. Continuity of teamwork, good coordination, exchange of information, and communication between the various care providers are essential. A lack of any of these may lead to inadequate assessment, information discrepancies, and unrest.

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Barr, Juliana, Katayoun Zomorodi, Edward J. Bertaccini, Steven L. Shafer, and Eran Geller. "A Double-blind, Randomized Comparison of IV Lorazepam versus Midazolam for Sedation of ICU Patients via a Pharmacologic Model." Anesthesiology 95, no. 2 (August 1, 2001): 286–98. http://dx.doi.org/10.1097/00000542-200108000-00007.

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Background Benzodiazepines, such as lorazepam and midazolam, are frequently administered to surgical intensive care unit (ICU) patients for postoperative sedation. To date, the pharmacology of lorazepam in critically ill patients has not been described. The aim of the current study was to characterize and compare the pharmacokinetics and pharmacodynamics of lorazepam and midazolam administered as continuous intravenous infusions for postoperative sedation of surgical ICU patients. Methods With Institutional Review Board approval, 24 consenting adult surgical patients were given either lorazepam or midazolam in a double-blind fashion (together with either intravenous fentanyl or epidural morphine for analgesia) through target-controlled intravenous infusions titrated to maintain a moderate level of sedation for 12-72 h postoperatively. Moderate sedation was defined as a Ramsay Sedation Scale score of 3 or 4. Sedation scores were measured, together with benzodiazepine plasma concentrations. Population pharmacokinetic and pharmacodynamic parameters were estimated using nonlinear mixed-effects modeling. Results A two-compartment model best described the pharmacokinetics of both lorazepam and midazolam. The pharmacodynamic model predicted depth of sedation for both midazolam and lorazepam with 76% accuracy. The estimated sedative potency of lorazepam was twice that of midazolam. The predicted C50,ss (plasma benzodiazepine concentrations where P(Sedation > or = ss) = 50%) values for midazolam (sedation score [SS] > or = n, where n = a Ramsay Sedation Score of 2, 3, ... 6) were 68, 101, 208, 304, and 375 ng/ml. The corresponding predicted C50,ss values for lorazepam were 34, 51, 104, 152, and 188 ng/ml, respectively. Age, fentanyl administration, and the resolving effects of surgery and anesthesia were significant covariates of benzodiazepine sedation. The relative amnestic potency of lorazepam to midazolam was 4 (observed). The predicted emergence times from sedation after a 72-h benzodiazepine infusion for light (SS = 3) and deep (SS = 5) sedation in a typical patient were 3.6 and 14.9 h for midazolam infusions and 11.9 and 31.1 h for lorazepam infusions, respectively. Conclusions The pharmacology of intravenous infusions of lorazepam differs significantly from that of midazolam in critically ill patients. This results in significant delays in emergence from sedation with lorazepam as compared with midazolam when administered for ICU sedation.

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Bode, Kerstin, Peter Whittaker, Johannes Lucas, Andreas Müssigbrodt, Gerhard Hindricks, Sergio Richter, and Michael Doering. "Deep sedation for transvenous lead extraction: a large single-centre experience." EP Europace 21, no. 8 (May 18, 2019): 1246–53. http://dx.doi.org/10.1093/europace/euz131.

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Abstract Aims Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS. Methods and results Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 μg/kg, 24.3 ± 6.8 μg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses. Conclusion Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.

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Liu, Richard, Thaddeus Mason Pope, and April Xiaoyi Xu. "Deep and Continuous Palliative Sedation Without Artificial Nutrition and Hydration: An International Review." Indiana International & Comparative Law Review 35, no. 1 (February 5, 2025): 67–152. https://doi.org/10.18060/28786.

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Deep and continuous palliative sedation combined with withholding or withdrawal of artificial nutrition and hydration (“PSs̄ANH”) is a medical process regularly used in end-of-life care to alleviate suffering. But in contrast to other end-of-life options like VSED and MAID which have been the subject of significant commentary and policy attention, PSs̄ANH remains largely unexamined. This Article fills this gap by clarifying the legal status and medical practice of PSs̄ANH in twelve jurisdictions around the world.

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Hu, M., Z. Mohmand, W. Wu, and N. Bollegala. "A93 AN ANALYSIS OF POST-ENDOSCOPY EXPERIENCES WITHIN AN EARLY ADULT IBD PATIENT POPULATION AT A NATIONAL IBD CENTRE." Journal of the Canadian Association of Gastroenterology 7, Supplement_1 (February 14, 2024): 66–67. http://dx.doi.org/10.1093/jcag/gwad061.093.

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Abstract Background Up to 25% of IBD patients are diagnosed before the age of 18, necessitating a process of transition from pediatric to early adult care. Poor endoscopy experiences have been described to jeopardize the overall patient experience with the healthcare system. There is a paucity of literature evaluating the endoscopy experiences of IBD patients during this pivotal point in their disease management. Aims The aim of this study is to describe the reported post-endoscopy experiences of early adult IBD patients (18 to 25 years old) compared to those in an adult model of care (26 years old, or above). Methods A retrospective analysis of patients with IBD treated at Mount Sinai Hospital from January 1st, 2017 to December 31st, 2021 who underwent an outpatient colonoscopy was performed. Qualitative and quantitative data were longitudinally collected from endoscopy records. The first phase of the study consisted of a comparison of outcomes between early adults (18 to 25 years) and adults (26 years, or above). The second phase consisted of a comparison of outcomes between sedation types (deep versus conscious). T-test was used to compare differences for continuous variables and Fisher exact test was used for categorical variables. Results In this initial pilot study of 171 patients, 12.9% of early adults underwent deep sedation compared to 11.4% of adults. Patients who underwent deep sedation were more likely to have Crohn’s disease compared to Ulcerative Colitis (95.2%, 57.7%, pampersand:003C0.01). There were no differences in mean procedure lengths in minutes (18.3, 18.6, p=0.80). Early adults who underwent conscious sedation required additional sedative medications during the procedure in 48.9% of cases compared to 32.3% in the adult cohort (p=0.04), however the mean total of conscious sedation medication used had no differences between the two groups (p=0.59). Nursing post-procedure subjective scoring measuring pain and nausea showed no significant difference (p=0.29). Physician narrative note descriptions of subjective procedural tolerance also showed no significant differences (p=0.78). Conclusions Patients with Crohn’s disease are more likely to require deep sedation for their adult colonoscopies compared to patients with Ulcerative Colitis. Gastroenterologists are not adequately prepared to gauge the amount of conscious sedation an early adult patient will require, necessitating top-up amounts peri-procedure more frequently. Current tools in the forms of subjective scoring and narrative documentation utilized by healthcare providers to measure procedural experience and tolerance are poor markers of actual patient experience. Future efforts should be focused on better understanding the endoscopic experience of the early adult IBD patient population and utilizing an innovative and collaborative approach. Funding Agencies Division of Gastroenterology, University of Toronto Faculty of Medicine Resident Research Grant

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Bodine, Kelly M., and Elizabeth J. Beckman. "Characterization of Awareness and Depth of Blockade During Neuromuscular Blockade Infusions in Critically Ill Children." Journal of Pediatric Pharmacology and Therapeutics 29, no. 4 (August 1, 2024): 368–74. http://dx.doi.org/10.5863/1551-6776-29.4.368.

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OBJECTIVE The Society of Critical Care Medicine released the first guideline for the prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients but offered conditional recommendations for sedation practices and monitoring during neuromuscular blockade. This study aimed to characterize sedation practices, patient awareness, and depth of blockade with neuromuscular blocking agent (NMBA) infusion administration in a single pediatric and cardiac intensive care unit. METHODS This retrospective chart review of critically ill pediatric patients queried orders for continuous infusion NMBA. Analgosedation agent(s), dose, and dose changes were assessed, along with depth of blockade monitoring via Train of Four (TOF) and awareness via Richmond Agitation and Sedation Scale (RASS). RESULTS Thirty-one patients were included, of which 27 (87%) had a documented sedation agent infusing at time of NMBA initiation and 17 patients (54%) were receiving analgesia. The most common agents used were rocuronium (n = 28), dexmedetomidine (n = 23), and morphine (n = 14). RASS scores were captured in all patients; however, 9 patients (29%) had recorded positive scores and 1 patient (3%) never achieved negative scores. TOF was only captured for 11 patients (35%), with majority of the scores being 0 or 4. CONCLUSIONS Majority of the study population did not receive recommended depth of blockade monitoring via TOF. Similarly, RASS scores were not consistent with deep sedation in half of the patients. The common use of dexmedetomidine as a single sedation agent calls into question the appropriateness of current sedation practices during NMBA continuous infusions.

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Kim, You Sun, Bongjin Lee, Wonjin Jang, Yonghyuk Jeon, and June Dong Park. "A deep learning model for estimating sedation levels using heart rate variability and vital signs: a retrospective cross-sectional study at a center in South Korea." Acute and Critical Care 39, no. 4 (November 30, 2024): 621–29. http://dx.doi.org/10.4266/acc.2024.01200.

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seBackground:Optimal sedation assessment in critically ill children remains challenging due to the subjective nature of behavioral scales and intermittent evaluation schedules. This study aimed to develop a deep learning model based on heart rate variability (HRV) parameters and vital signs to predict effective and safe sedation levels in pediatric patients.Methods: This retrospective cross-sectional study was conducted in a pediatric intensive care unit at a tertiary children’s hospital. We developed deep learning models incorporating HRV parameters extracted from electrocardiogram waveforms and vital signs to predict Richmond Agitation-Sedation Scale (RASS) scores. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC). The data were split into training, validation, and test sets (6:2:2), and the models were developed using a 1D ResNet architecture.Results: Analysis of 4,193 feature sets from 324 patients achieved excellent discrimination ability, with AUROC values of 0.867, 0.868, 0.858, 0.851, and 0.811 for whole number RASS thresholds of −5 to −1, respectively. AUPRC values ranged from 0.928 to 0.623, showing superior performance in deeper sedation levels. The HRV metric SDANN2 showed the highest feature importance, followed by systolic blood pressure and heart rate.Conclusions: A combination of HRV parameters and vital signs can effectively predict sedation levels in pediatric patients, offering the potential for automated and continuous sedation monitoring in pediatric intensive care settings. Future multi-center validation studies are needed to establish broader applicability.

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Miyamori, Tadashi, Yukari Hattori, and Hiroshi Ishiguro. "Integrated Distress Activity Score (IDAS): A Possible Tool for Determining Continuous Deep Sedation." Palliative Care Research 15, no. 3 (2020): 245–49. http://dx.doi.org/10.2512/jspm.15.245.

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