Sedation and Analgesia

Background: Awareness and pain during palliative sedation is typically assessed by observational scales, but the use of such scales has been put into question. Case presentation: A woman in her mid-80s was admitted to a palliative care unit, presenting with chronic lymphatic leukemia, depression, and a cerebrovascular accident, with right-sided hemiplegia and aphasia. The patient was unable to eat and was suffering from nausea and vomiting. Before admission, the patient had expressed her desire to discontinue treatment on several occasions. Case management: The decision was made to initiate palliative sedation. The patient consented to take part in a study to assess level of comfort and pain using two monitoring devices (NeuroSense monitor and Analgesia Nociception Index monitor). Case outcome: The patient died 90 h after initiation of palliative sedation. Titration of the medication was challenging and sedation was not deep enough during the first 2 days. Thirteen assessments made with the Ramsay Sedation Scale showed that the patient was considered to be in a deep sleep, while in fact the NeuroSense monitor indicated otherwise. Conclusion: This case demonstrates the feasibility and potential advantages of using monitoring devices to objectify assessments of pain and discomfort in palliatively sedated patients.

Statement of the Problem: A prospective, randomized clinical trial (case study) over patients undergoing surgical procedures (40 Pts). All patients chosen for preemptive multimodal analgesia treatment group (40 patients). Methodology & Theoretical Orientation: To give Pregabalin (Lyrica) 75mg 2hrs or more before surgery then 75 mg QHS for 3days postoperative, to be reassessed by APS team if extension needed. No valium with lyrica. To add Celecoxib (if not contraindicated) 200-400mg tablet 1hour before surgery then 200 mg BID for 3 days only. Ranitidine 150mg BID could be added. Surgical site-specific regional analgesia whenever possible. PCA morphine can be used if indicated and as a backup plan for breakthrough pain. Then post.op, Pregabalin, Celecoxib, Solpadeine 2 tablets Q6hrs or TID.
Findings: 30 patients came calm pre-op., smooth for GA, RA blocks, other 10 patients little anxious. All patients examined second day; 30 patients had smooth sleep, no pain after regional blocks, needed PCA morphine 1-5 mg (10 patients). Other 10 patients continued only on oral tablets. Conclusion & Significance: The new preemptive multimodal analgesic combination is safe and effective postoperative, may reduce severity of adverse effects of the opioid. Review; follow up of patients postoperative by APS team for 4 days.

Insomnia is a conspicuous problem in modern 24 h society. In this brief overview, medications used to treat insomnia such as hypnotics, sedatives, medications inducing sedation as a side effect, medications directed at the sleep-associated circadian neuroendocrine system, and agents utilized in treating insomnia-inducing sleep diagnoses such as restless leg syndrome are discussed. The newer GABA-effective hypnotics are the only medications with demonstrated effectiveness in treating chronic insomnia with the majority of evidence supporting treatment efficacy for cognitive-behavioral therapy and short acting GABA-receptor agonists. In patients with comorbid insomnia the use of hypnotics can improve outcomes and potentially reduce morbidity and mortality associated with the use of more toxic medications. Except in individuals whose insomnia is secondary to circadian disturbance, mood disorder/depression and/or restless leg syndrome , there is minimal evidence supporting the efficacy of other medications used to treat insomnia despite their widespread use. Sedatives and other medications used off-label for sedative side-effects are a contributing factor to drug induced hypersomnolence, a factor in more than 30% of motor accident deaths. Hypnotic medications with low toxicity, addictive potential, minimal next day sleepiness, and an otherwise benign side-effect profile can be utilized safely and effectively to treat and improve function and quality of life for patients suffering from insomnia. These are the agents that should be exclusively classified as hypnotics and utilized to induce sleep when medications are required to treat the complaint of insomnia. Other pharmacological agents producing sedation (sedatives and agents used off-label for sedative side-effects) should be used cautiously for the treatment of insomnia due to the increased risk of next day sleepiness as well as for known toxicities and adverse side effects.

The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at end-of-life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia, and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.

Animals kept as pets or for farming, including all mammals, birds and fish, have pain systems and their welfare can be poor because of pain or fear. The extent of pain can be measured using physiological and behavioural measures such as thermography or grimace scales in sheep, horses and mice. It is important to evaluate the magnitude of poor welfare, a function of severity and duration.
In general, our laws prohibit treatment of animals that causes pain or other poor welfare. However, there are exceptions in laws for reasons of tradition, financial cost, gastronomic preference, convenience in management or breeding, or avoidance of other problems. Some activities that harm animals are considered to be “sport”. For example the bull pierced by numerous lances in the corrida, the deer chased by dogs and by humans on horseback, or the dog or cock forced to fight. These “sports” have entirely negative effects for the animal. Another example is the animal killed during shechita or halal slaughter without prior stunning. The justifications for this are: tradition, edict from an interpretation of a holy book, and the mistaken belief that blood in a carcass is in some way unclean.
Evidence from welfare assessment studies shows that: cutting the throat without prior stunning causes up to two minutes of extreme pain. Castration, disbudding, or beak-trimming, without anaesthetic or analgesic causes pain for many hours, and often leads to more prolonged pain because of neuroma formation. Tail removal prevents normal defence against flies in cattle and social signalling in pigs and dogs. Tail-biting by pigs and injurious behaviour by hens can be prevented by giving the animals manipulable materials and more space. This costs more but the painful procedures can be avoided. Foie-gras production necessitates confined rearing conditions, aversive force-feeding and failure of the detoxifying function of the liver so that death would result soon after the normal killing time. Caponising is a major operation that is painful and the wounds take some days to cease to cause pain. In all these cases, the main beneficiary is human and the cost is borne by the animal.

Gastrointestinal endoscopy has become an essential modality for evaluation and treatment of gastrointestinal tract abnormalities. This procedure is complex and may be unsafe if special concerns are not considered. The goal of procedural sedation in endoscopic procedure is the safe and effective control of pain and anxiety, to provide an appropriate degree of memory loss or decreased awareness
and to improve endoscopic performance especially in therapeutic procedures. Regardless of regimen used, the safe administration of sedative and analgesic drugs requires an awareness of the particular needs of the patients. The most commonly used sedation regimen for sedation in gastrointestinal endoscopic procedure is still the
combination of benzodiazepines and opioids. In addition, the use of propofol has increased enormously in the past decade. New sedative agents are currently used and studied. Although sedation in this endoscopic procedure is considered safe, the sedation has a potential for complications. Sedation-related complications can more easily occur even in healthy populations. Risk evaluation
before the procedure and monitoring during and after the procedure as well as increased awareness of the sedation-related complications must be performed. Furthermore, properly trained staff and emergency equipment should be available. This article reviews pharmacokinetics and pharmacodynamics of sedative and analgesic drugs and discusses the clinical use in gastrointestinal endoscopic
procedure.

Clinical evaluation of pupils is considered as an essential part of neurological examination. The pu-pillary response to light is controlled by the autonomic nervous system. Numerous factors affect pupils dynamics, like e.g. luminance, visual field area, pain, drug administration, age, the functional integrity of anatomical structures involved, e.t.c. Moreover, pupillometry card method and examina-tion of pupil reaction with the use of a penlight is subjective to a lot of bias. Portable infrared pupil-lometry allows a more objective and detail evaluation of pupil’s dynamics. That’s why it has al-ready found applications in various clinical areas, like e.g. neurology, psychology, ophthalmology, endocrinology, anesthesia, pain management, intensive care, emergency medicine. This review fo-cuses on physiology of pupil’s dynamics and on applications of infrared pupillometry in periopera-tive setting

The healthcare system has only recently begun to approach patient safety in a more systematic way. There is a clear need to improve the qual- ity of child sedation that presently permits an alarmingly high annual rate of medical errors that harm children and drive up costs. Effective sedation, controlling pain and anxiety, improves patient and parent satisfaction. Pediatric sedation is rapidly growing in its use around the world owing to its simplicity, cost savings, tolerance, and rapid emergence. The usual approach within medicine has been to stress the responsibility of the individual, and to encourage the belief that the way to eliminate adverse events is to get individual clinicians to perfect their practices. This simplistic approach to the safety of pediatric sedation not only fails to address the important and complex systematic flaws that contribute to the genesis of adverse events in sedation, but also perpetuates a myth of infallibility that is a disservice to both clinicians and their patients.

The focus on the actions of individuals, without addressing the underlying microsystem, as the sole cause of adverse events inevitably results in continued system failures and the resultant injuries and deaths of children.
Strategies to make sedation care more reliable and even safer might include: adoption of reliability engineering principles, setting up robust near miss reporting systems, applying critical event analysis tools, wide adoption of simulation and sedation team training, adopting checklists, standardizing medication protocols, implementing robust hand off protocols and patient identification checklists, and adherence to the ASA Sedation practice parameters.

Objetivou-se comparar os efeitos
cardiorrespiratório, analgésico e sedativo de diferentes doses
de tramadol em cadelas submetidas à
ovariosalpingohisterectomia (OSH). Foram avaliadas 24
cadelas SRD, adultas, distribuídas aleatoriamente em três
grupos de oito animais, tratados com tramadol pela via
intravenosa (IV) nas doses de 1, 2 e 4mg kg-1 (T1, T2 e T4,
respectivamente). Na medicação pré-anestésica, foi
administrada acepromazina (0,05mg kg-1 IV). Vinte minutos
após, a anestesia foi induzida com propofol (4mg kg-1 IV), com
posterior manutenção anestésica com isofluorano. O tramadol
foi administrado 5 minutos antes da incisão cirúrgica em todos
os tratamentos. Foram mensurados: frequência cardíaca,
frequência respiratória, temperatura retal, pressão arterial
sistólica, grau de analgesia, grau de sedação, concentração
sérica de cortisol e efeitos adversos. Mínimas alterações
cardiorrespiratórias foram observadas, sem diferença entre os
tratamentos. O cortisol, o grau de sedação e o grau de analgesia
não variaram entre os tratamentos, com exceção da terceira
hora pós-cirúrgica, em que menores escores de dor foram
observados no T4. Vômito foi observado em 50% dos animais
do T4. Conclui-se que as diferentes doses de tramadol induziram
efeitos analgésicos semelhantes, com discreto efeito sedativo e
mínimas alterações cardiorrespiratórias. Paralelamente, a dose
de 4mg kg-1 de tramadol induziu alta incidência de vômito em
cadelas submetidas à OSH.

Objectives: To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.
Design: A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-
formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE1 methodology. Due to the current paucity of
sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.
Results: The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.
Conclusion: Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

Los prejuicios de género campan a sus anchas por el territorio endometriosis. Medicinas alternativas, complementarias y convencionales culpabilizan a las afectadas. La paradoja es que en una de las enfermedades con sensibilización central más “físicas” (tumoraciones, implantes, nódulos y quistes como sus manifestaciones físicas) aún es una de las más cuestionadas e infradiagnosticadas, e insuficientemente “analgesizada”.

Many drugs induce sedation. Drug induced hypersomnolence has significant negative personal and social effects, including an involvement in at least one-third of motor vehicular accident (MVA) deaths 1.  Drugs of abuse most often induce hypersomnolence as a direct effect (ethanol, cannabis, opiates), or by potentiating sleep disturbances known to induce daytime sleepiness such as sleep apnea (ethanol, opiates) and chronic sleep deprivation (amphetamines). Drug induced sleepiness is among the most commonly reported effect and/or side effect of pharmacological agents 2.  Sedating prescription medications are generally classified as: 1) hypnotics - short-acting agents clinically utilized to induce sleep with minimal effects on waking performance; 2) sedatives - agents that diminish arousal, and commonly produce sedation that affects both wake and sleep; and 3) agents utilized clinically for other purposes that produce sedation as a side effect.  These categories are not concrete, and some drugs meet criteria for multiple categories.

Materials and Methods This retrospective study was approved by the Institutional Review Board of the Faculty Medicine Siriraj Hospital, Mahidol University. Between January 2006 and June 2008, data were collected prospectively on all children younger than aged 18 ...

Ketamine, an old intravenous anesthetic, is a non-narcotic and non-barbiturate drug. It mainly works by noncompetitive
antagonist at the N-methyl-D-aspartate (NMDA) receptors. Ketamine has several properties of the ideal
anesthetic agent. Therefore, its properties are interesting in various clinical settings, although it can produce the
psychological adverse effects. This present short review aims to describe the pharmacology of ketamine.

AIM: To evaluate and compare the complication rate of propofol-based deep sedation (PBDS) for colonoscopy in marked obesity (BMI > 30) and non-obesity (BMI < 25) patients in a teaching hospital in Thailand.
METHODS: We undertook a retrospective review of the sedation
service records of adult patients who underwent colonoscopic
procedures from December 2009 to April 2011. All patients were classified into two groups according to the body mass index (BMI). In group A, the patients had BMI < 25. In group B, the patients had BMI > 30. The primary outcome variable was the overall complication rate. The secondary outcome variables were sedation and procedure-related complications during and immediately after the procedure.
RESULTS: After matching age, gender, ASA physical status,
sedation time and indications of procedure, there were 100
colonoscopic procedures in group A and 33 colonoscopic
procedures in group B. All sedation was given by residents or
anesthetic nurses directly supervised by staff anesthesiologist in the endoscopy room. There were no significant differences in patients’ characteristics, sedation time, indication of procedure, overall complication rate, anesthetic personnel and mortality rate between the two groups. However, upper airway obstruction in group B was relatively higher than in group A. All complications were easily treated, with no adverse sequelae.
CONCLUSION: PBDS for colonoscopic procedure in marked
obesity patients by trained anesthetic personnel with appropriate monitoring was relatively safe and effective. The complication rate of this technique in marked obesity (BMI > 30) patients was not different or worse than in non-obesity (BMI < 25) patients. Serious complications were rare in our population.

Editor’s Perspective:

What We Already Know about This Topic:

It is unknown whether adding low-dose dexmedetomidine to propofol for colonoscopies enhances hemodynamic stability without prolonging recovery

What This Article Tells Us That Is New:

One hundred and one patients were randomly assigned to propofol alone or propofol combined with low-dose dexmedetomidine for outpatient colonoscopies, both groups targeting a Bispectral Index of 60

Adding dexmedetomidine provoked hypotension and prolonged recovery

Background: Enhanced recovery protocols employ various approaches to minimize detrimental side effects of anesthetizing agents. The authors tested the hypothesis that adding low-dose dexmedetomidine to propofol for anesthesia in ambulatory colonoscopies, compared with propofol alone, would lower the propofol requirement, improve the intra-procedure hemodynamic state, and not increase time-to-discharge.

Methods: In this noninferiority, double-blind, randomized controlled trial, patients having colonoscopies received total IV anesthesia either with propofol and placebo (n = 50), or propofol and a bolus dose of dexmedetomidine, 0.3 μg/kg (n = 51). Additional propofol was administered to maintain a Bispectral Index score of 60. Following the procedure, readiness for discharge was assessed regularly using the Modified Post Anesthetic Discharge Scoring System until discharge criteria were met. The primary outcome was the percentage of patients meeting discharge criteria within 30 min from procedure end-time.

Results: Twenty-six of 51 (51%) patients receiving propofol-dexmedetomidine were ready for discharge by 30 min from procedure end time, compared with 44 of 50 (88%) receiving propofol (P < 0.001). Propofol consumption was lower in subjects receiving propofol–dexmedetomidine (140 µg · kg-1 · min-1) compared to those receiving propofol (180 µg · kg-1 · min-1) with P = 0.011. The lowest mean arterial pressure decreased further from baseline in those receiving propofol–dexmedetomidine (−30%; mean decrease −30 ±10.5 mmHg) compared to propofol (−21%; mean decrease, −22 ± 14.2 mmHg) with P = 0.003. There was no difference in incidence of bradycardia, with sustained bradycardia occurring in 3 of 51 (6%) patients receiving propofol–dexmedetomidine compared to 1 of 50 (2%) patients receiving propofol (P = 0.62). No apnea episodes requiring positive-pressure ventilation occurred in either group.

Conclusions: For anesthesia in ambulatory colonoscopy, combining low-dose dexmedetomidine with propofol delayed discharge readiness and provoked hypotension compared to propofol alone.

Objectives To describe practice patterns and adverse events associated with nitrous oxide (N 2 O) administration as the primary sedative outside the operating room in varied settings by a diverse range of providers, and to identify patient and sedation characteristics associated with adverse events. Study design Data prospectively collected by the Pediatric Sedation Research Consortium, which is comprised of 40 children's and general/community hospitals, was retrospectively analyzed for children who received N 2 O as the primary sedative. Descriptive measures of patient and sedation characteristics and adverse events were reported. A multivariable regression model was used to assess potential associations between patient and sedation characteristics and adverse events. Results A total of 1634 N 2 O administrations were identified. The majority was performed in sedation units, and most by advanced practice nurses or physician assistants. The most common adjunct medication was midazolam. There was a low prevalence of adverse events (6.5%), with vomiting as the most common (2.4%) and only 3 (0.2%) serious adverse events reported. The odds of vomiting increased when concomitant opioids were administered (OR 2.89, 95% CI 1.14, 7.32) and when nil per os (NPO) clear fluids <2 hours (OR 4.16, 95% CI 1.61, 10.76). NPO full meal <6 hours did not change the odds of vomiting (OR 1.42, 95% CI 0.57, 3.57). There were no aspiration events. Conclusions There was a very low prevalence of serious adverse events during N 2 O administration in children outside of the operating room and by nonanesthesiologists. The odds of vomiting increased when concomitant opi-oids were administered and NPO clear fluids <2 hours. (J Pediatr 2016;169:260-5). N itrous oxide (N 2 O) is a colorless, odorless, gas with anxiolytic, analgesic, and amnestic properties, and a longstanding history of use by anesthesiologists and dentists. 1-4 Given its favorable sedative characteristics and impressive record of safety, the use of N 2 O for facilitating painful and/or distressing procedures in children has been adopted for use by other providers in settings outside of the operating room, in addition to dental practices. Nurse practitioners, hospitalists, emergency medicine physicians, and intensivists administer N 2 O in their respective settings and in the context of a sedation service for a wide variety of procedures in the pediatric population. 1,5-15 The practice patterns and adverse events associated with N 2 O administration performed by this varied population of practitioners in these settings have not been well described. Most descriptions of N 2 O administration to date have been limited to reports from individual centers with a specific scope of practice. It is unclear if their experiences and reported adverse event profiles are generalizable to a broader and more diverse population of providers. 1,7-14 Our aim was to describe the practice patterns of N 2 O sedation and analgesia in children outside of the operating room among a consortium of pediatric sedation services. We also aimed to describe the adverse events associated with N 2 O administration in these contexts and to identify any patient and sedation characteristics associated with adverse events. Methods We retrospectively analyzed consecutive pediatric N 2 O administrations from the Pediatric Sedation Research Consortium (PSRC) database between November 2011 and July 2014. Data was prospectively collected, and each administration corresponded to a unique patient. The data collection methodology of the PSRC has been detailed in a report of its first 30 000 sedations, and in subsequent publications involving up to 140 000 sedation encounters. 11,16-19

Authors: Lisnyy I.,  Zakalska O., Dmytriiev D., Dmytriiev K., Dobrovanov O.
Background: Safety and effectiveness of dexketoprofen compared with ketorolac and placebo for pre-emtpive analgesia in oncological urology surgery. Design: Single-center randomized double-blind, parallel, placebo controlled study. Participants: 111 patients, who were scheduled for the transurethral resection of the urinary bladder or prostatic gland under the spinal anesthesia. 91 patient fulfilled study requirements. Intervention: Pre-emptive analgesia 20-22 hours prior to the transurethral resection of the urinary bladder or prostatic gland using Dexketoprofen 25 mg 2 times per day (BID) and ketorolac 10 mg BID or placebo. Outcome: Postoperative pain severity and need in additional anesthesia in postoperative period.
Results: 111 patients (dexketoprofen n=37, ketorolac n=37, placebo n=37) were randomized in the trial. Randomization was performed using programmed block method with 3 patients in a block. 2 patients of group (Gr.) D and 4 patients in groups K and P were excluded from the study due to the technical issues with the spinal puncture. There also were problems with samples of blood and liquor of 10 Gr. P patients, who were also excluded from the study and analysis, leaving 91 patients (n=35; n=33; n=23) for analysis. Patients who received dexketoprofen a day before the operation had lower pain level during the first two days after the operation when compared to the patients, who received ketorolac and placebo (P=0.001). Plasma prostaglandin E2 (PGE2) level (P<0.05) and liquor (P=0.0001) was lower in patients who received dexketoprofen before the operation, when compared to the patients who received ketorolak and placebo. There was no reliable difference in the glucose level and blood loss during the operation between 3 groups. No adverse events reported during the study.
Conclusions: Dexketoprofen injection in the dose 25 mg BID a day before the operation cause a significant reduction in pain level in the first two days of postoperative period after surgeries in oncological urology. This regimen does not cause an increase of blood loss during operation.
Key words: anesthesiology, nonsteroidal drugs, pain, pre-emptive analgesia, prostaglandin E2

Background: It has been a decade since the year 2007 was dedicated towards painless motherhood. However the use and acceptance of labor analgesia is still very rare in developing countries. Objective: The present study was aimed to assess the knowledge, acceptance and reasons for rejection of labor analgesia among the expectant mothers. Methods: The present observational study was conducted after approval from the institute. All Original Research Article Prakash et al.; BJMMR, 21(10): 1-7, 2017; Article no.BJMMR.33980 2 antenatal women who attended antenatal clinic were approached during January to March 2017. Data was collected from the consented women using a pretested questionnaire. Data were expressed in absolute numbers and percentage scale. Measures of central tendencies were calculated for quantitative data using INSTAT software and p < 0.05 was considered significant for comparison. Results: Response from 280 women with mean ± SD age and gestational age of 25.49 ± 4.89 years and 28.25 ± 8.75 weeks respectively were analyzed. 126 were primi or multiparous; 56 graded labor pain as unbearable yet only 30 (23.81%) wanted labor analgesia. Only 20 (7.14%) prospective mothers were having knowledge of labor analgesia. The nulliparous wanted significantly less labor analgesia compared to primi and multiparous (p 0.003). Desire to bear natural birth was the commonest reason to refuse painless labor. One quarter of the participants believed that labor analgesia was bad for child and against the will of God. Conclusion: Knowledge and acceptance of labor analgesia is poor although women who had previous experience were significantly more inclined towards it. Misinformation and myths is also a major contributor for non acceptance of labor analgesia.

Objective: To report on safety and efficacy of intravenous usage of Dexmedetomidine for endodontic intervention in young and anxious pediatric patients.

Methods: This prospective pilot investigation enrolled 10 healthy ASA status I, 2-6 year old children who were anxious (Venham’s score ≥ 4) and were scheduled to undergo primary molar pulpectomy under sedation. Sedation induction was done with 1 mg/kg of propofol bolus followed by 0.2-0.8 µg/kg of dexmedetomidine infusion for maintenance. Sedation was titrated to achieve Houpt’s overall behavior score of ≥ 4. In case of insufficient sedation, rescue propofol boluses (1 mg/kg) were administered. Vitals were monitored every 5 minutes and recovery was evaluated using Alderete Modified Post Anesthesia Discharge Scoring System. Adverse events, i.e., ≥ ± 20% baseline fluctuations in vital signs, tachycardia, bradycardia, apnea, desaturation, stridor and/or laryngospasm were recorded.

Results: The procedure was successfully completed in all of the subjects with the current sedation regime as per the study protocol. Rescue propofol boluses were needed in 8 subjects. No untoward fluctuations in vital signs or adverse events were reported in either intra-operative phase or post-operatively.

Conclusion: Intravenous Dexmedetomidine is safe and efficient sedative for endodontic intervention in young and anxious pediatric patients.

These data do not support the routine use of IABP in patients with acute myocardial infarction with or without cardiogenic shock or patients undergoing high-risk elective PCI. In high-risk patients undergoing CABG, prophylactic use of IABP may be considered, although further large scale multi-center trials are needed to confirm previous marginal data. Other indications such as postcardiotomy cardiogenic shock or mechanical complications in acute myocardial infarction, in which IABP could be useful, need to be identified and require further investigations.

Xylazine Hcl was generally used in veterinary medicine for its sedative and moderate analgesic effect. This experimental study was undertaken to determine the effect of repeated intravenous (IV) administration of xylazine on sedation and analgesia as well as cardiac arythemia using ECG in donkeys. Three repeated injections of xylazine (0.5 mg/kg) with 10 minute interval were injected IV in six healthy adult donkeys. Sedation score, analgesic score, heart rate (HR), respiratory rate, rectal temperature and ECG were recorded before and after 2, 5 and 10 minutes from injection for each injection and then at 5 minutes intervals until complete recovery from sedation and the normal ECG was recorded. Deep sedation was obtained 5 minutes after the second injection in all donkeys, and the length of sedation lasted 71 ± 6 minutes. The deep analgesia was obtained 5 minutes after the third injection in all donkeys, and the length of analgesia lasted 62 ± 5 minutes. There was a highly significant decrease in HR after the third injection (P < 0.05). Normal HR was obtained in all donkeys after 75 ± 10 minutes of the third injection. In addition to cardiac arrhythmia as atrial fibrillation and AV block which was recorded after the second and third injection. Repeated injection of xylazine Hcl give acceptable results either for sedation or cardiovascular parameters in donkeys.

RESUMEN Objetivo: automedicación es el uso de productos medicinales sin prescripción médica. En estudiantes de medicina es una práctica común y puede asociarse con efectos adversos. El objetivo del presente trabajo fue determinar la prevalencia de automedicación con antibióticos y analgésicos en estudiantes de pregrado de medicina y caracterizar las actitudes, los conocimientos y las prácticas frente a este comportamiento. Metodología: estudio transversal que contó con 625 estudiantes de pregrado de medi-cina de una universidad privada de Medellín-Colombia. Se diseñó una encuesta con 45 preguntas. La variable dependiente fue la automedicación de antibióticos y analgésicos. Se obtuvieron proporciones y promedios con sus medidas de dispersión. Se exploraron posibles asociaciones entre la práctica de la automedicación, el sexo y el semestre de formación. Se tomó como valor significativo p <0.05. Resultados: se incluyeron 625 estudiantes que aceptaron responder la encuesta, lo cual equivale al 58% de la totalidad de estudiantes matriculados. El 67% está conformado por mujeres. La razón mujer: hombre fue 2:1. La mediana para la edad fue 20 años (rango intercuartil: 3). La prevalencia de automedicación con analgésicos fue de 84% para las mujeres y 81% para los hombres y la de antibióticos de 28% para mujeres y 21% para hombres. El 90.1% de los estudiantes considera la automedicación como una práctica insegura; el 93% afirma que automedicarse con antibióticos produce resistencia antimi-crobiana; sin embargo, el 78.6% afirma que continuará automedicándose. Discusión: la automedicación de analgésicos y antibióticos es un comportamiento común y complejo en estudiantes de pregrado de medicina. A pesar de tener el conocimiento de los riesgos que asumen por esta práctica, la mayoría no está dispuesta a cambiarla. Palabras clave: automedicación; conocimientos, actitudes y práctica en salud; educación de pregrado en medicina.
ABSTRACT Objective: Self-medication is a common practice among university students worldwide. It is also common among medical students and has been associated, in the case of non-steroid, antiinflamatory drugs, with renal, cardiovascular, and gastrointestinal adverse effects and multidrug-resistance in the case of antibiotics. The objective of this study was to determine the prevalence of self-medication with antibiotics and analgesics in undergraduate medical students and to characterize the attitudes, knowledge, and practices related to this behavior. Methodology: Cross-sectional study. 625 undergraduate medical students from a private university in Medellín, Colombia participated. A 45-question survey was designed. The dependent variable was self-medication of antibiotics and analgesics. Proportions and means with their dispersion measurements were obtained. We explored possible associations between the practice of self-medication, gender, and the training semester. Significant value was taken as p <0.05. Results: The survey was taken by 625 undergraduate medical students, that is, 58% of all students. Of these, 67% were women. The female to male ratio was 2:1. The median age was 20 years (interquartile range: 3). The prevalence of self-medication with analgesics was 84% for women and 81% for men, while with antibiotics it was 28% for women and 21% for men. 90.1% of students expressed that practicing self-medication was unsafe; likewise, 93% of students recognized that self-medication with antibiotics produces antimicrobial resistance. Regardless, 78.6% said they would continue to self-treat.
Discussion: Self-medication with analgesics and antibiotics is a  common and complex behavior in undergraduate medical students. While they are aware of the risks involved in this practice, most are not willing to change it.
RESUMO
Objetivo: automedicação é o uso de produtos medicinais sem prescrição médica. Em estudantes de medicina é uma prática comum e pode associar-se com efeitos adversos. O objetivo do presente trabalho foi determinar a prevalência de automedicação com antibióticos e analgésicos em estudantes de graduação de medicina e caracterizar as atitudes, os conhecimentos e as práticas frente a este comportamento. Metodologia: estudo transversal que contou com 625 estudantes de graduação de medicina de uma universidade privada de Medellín-Colômbia. Se desenhou uma enquete com 45 perguntas. A variável dependente foi a automedicação de antibióticos e analgésicos. Se obtiveram proporções e médias com suas medidas de dispersão. Se exploraram possíveis associações entre a prática da automedicação, o sexo e o semestre de formação. Se tomou como valor significativo p <0.05. Resultados: se incluíram 625 estudantes que aceitaram responder a enquete, o qual equivale a 58% da totalidade de estudantes matriculados. 67% está conformado por mulheres. A razão mulher: homem foi 2:1. A média da idade foi 20 anos (faixa interquartil: 3). A prevalência de automedicação com analgésicos foi de 84% para as mulheres e 81% para os homens e a de antibióticos de 28% para mulheres e 21% para homens. 90.1% dos estudantes considera a automedicação como uma prática insegura; 93% afirma que automedicar-se com antibióticos produz resistência antimicrobiana; porém, 78.6% afirma que continuará se automedicando. Discussão: a automedicação de analgésicos e antibióticos é um comportamento comum e complexo em estudantes de graduação de medicina. Apesar de ter o conhecimento dos riscos que assumem por esta prática, a maioria não está disposta a mudar.

Core tip: Gastrointestinal endoscopic (GIE) procedures are relatively safe. However, these procedures have been shown to cause various effects on cardiorespiratory systems. Sedation-related complications while providing any level of sedation can occur. Fortunately, these complications during GIE procedures are commonly transient and of a mild degree. In addition, significant unwanted complications can generally be prevented by careful pre-procedure assessment and preparation, appropriate monitoring and support. Periodical assessment of the level of sedation and continuous monitoring of cardiovascular and respiratory systems provides timely information. Standardized discharge criteria should be used to determine the patient's readiness for discharge.