Sedation and Analgesia

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.

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.

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.

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.

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.

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.

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

The rising use of nonanesthesiologist-administered
sedation for gastrointestinal endoscopy has clinical
significances. Most endoscopic patients require some
forms of sedation and/or anesthesia. The goals of
this sedation are to guard the patient’s safety, minimize physical discomfort, to control behavior and to
diminish psychological responses. Generally, moderate
sedation for these procedures has been offered by the
nonanesthesiologist by using benzodiazepines and/or
opioids. Anesthesiologists and nonanesthesiologist
personnel will need to work together for these challenges
and for safety of the patients. The sedation
training courses including clinical skills and knowledge
are necessary for the registered nurses to facilitate the
patient safety and the successful procedure. However,
appropriate patient selection and preparation, adequate
monitoring and regular training will ensure that the use
of nurse-administered sedation is a feasible and safe
technique for gastrointestinal endoscopic procedures.

Context: Pain processing implicates multiple concurrent mechanisms of nociceptive transmission and modulation. Electroacupuncture (EA) analgesia involves mainly the activation of the endogenous anti-nociceptive systems that modulate pain transmission in addition to the regulation of glial activity and inhibition of pro-inflammatory cytokines in the spinal cord. Aims: To examine the potential anti-hyperalgesic effects the EA and the combination EA-ketamine in patients with post-herpetic neuralgia (PHN). Methods: Sixty-eight patients with PHN irritable nociceptor type were randomly allocated to 3 groups: group I (n=26), that received treatment with EA (10 Hz, 2-3 mA, 0.5 ms, 20 min/15 sessions) alone, group II (n=21) with a combination EA-ketamine (0.25-0.5 mg/kg, i.m.) or group III (n=21) with sham EA-ketamine for 15 days. The average daily pain score (ADPS) using the Likert scale, area and rate of dynamic allodynia, the rate of thermal allodynia, and frequency of intermittent lancinating pain were evaluated during five visits – before treatment and at 15, 30, 60, 90 days. Results: ADPS and sensory abnormalities decreased significantly concerning baseline data at 90 days in the three groups, but patients treated with the combination EA-ketamine significantly improved compared with the other groups. Conclusions: These results suggest that the combination EA-ketamine shows an early and long-term anti-hyperalgesic effect in PHN patients. However, a controlled clinical trial is necessary to confirm this hypothesis.

Objectives: to study the physiological changes, as well as the psychosedative and analgesic effects of nitrous oxide, in experimental conditions.
Study Design: 101 dental students volunteers participated in a single nitrous oxide sedation session without dental treatment. Signs and symptoms were registered during and after the procedure. Pulse rate and hemoglobin oxygen saturation were monitored at: 100 per cent O2, 30 per cent N2O, 50 per cent N2O and 5 minutes after 100 per cent O2. A Likert scale was used to evaluate pain perception. The analgesic effects of nitrous oxide were evaluated at: 30 per cent N2O, 50 per cent N2O, and five minutes postoperatively.
Results: Pulse rate and hemoglobin oxygen saturation decreased significantly through all the procedure and after recovery. However, oxygen saturation recovered after the final oxygenation. Only 8.2% of subjects reported the pain stimulus as being quite annoying when they inhaled 30 per cent N2O, while this percentage was of 15.8 % when inhaling 50 per cent N2O, and of 32.7 % during the recovery period. The most common effects of nitrous oxide sedation were bright eyes (99%), voice change (98%) and smiling (91%). Most of the subjects reported tingling (98%) and relax (91.1%)
Conclusions: nitrous oxide causes a significant decrease in heart rate and oxygen saturation, but always within safe- ty limits. Maintaining an appropriate level of consciousness was confirmed as a feature in 50 per cent dose in this study. The analgesic effect of nitrous oxide was confirmed but a dose dependency could not be established.

n Abstract: Severe chronic neuropathic pain is a challenge to treat, and due to adverse effects of classical oral medication, optimal and effective dose levels are difficult to reach. Therefore, administration of topical analgesics might be an option, due to reduced adverse effects, and increased patient compliance.

Introduction: Among the focal issues of barriers to pain management include the physicians' lack of knowledge about cancer pain and negative attitudes towards opioids. Many physicians and educators attribute this, at least in part, to limited exposure to pain and palliative care education during medical school.

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.

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.

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.

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.

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

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.

Colonoscopy has become an essential modality for evaluation and treatment of lower gastrointestinal tract. This endoscopic procedure is complex and may be unsafe if special concerns are not considered. It is well accepted that children undergoing colonoscopy should receive sedation for the procedure. Nevertheless, considerable practice variation prevails. The goal of procedural sedation is the
safe and effective control of pain, anxiety and motion as well as to provide an appropriate degree of memory loss or decreased awareness. Regardless of regimen used, the safe administration of sedation to children requires an awareness of the particular needs of this population. Although colonoscopy is considered safe, the procedure has a potential for complications. Procedure and sedation-related complications can more easily occur in pediatric patients. Increased awareness of the complications associated with sedation during colonoscopy in children and involving the anesthesiologists in caring for these children may be optimal for safety. Proper patient preparation, endoscopic personnel and endoscopic unit are imperative
to successful sedation and procedure. Additionally, postprocedural monitoring is important to insure that children have fully recovered from sedation.

The management of acute pain and anxiety in children undergoing diagnostic and therapeutic procedures has
developed substantially in the past two decades. An increase in the numbers of investigations and non-surgical
interventions in children has created an enormous demand for sedation services. Procedural sedation and analgesia
for children is now widely practiced by a various group of the specialists. The goal of procedural sedation is the
safe and effective control of pain, anxiety and motion as well as to provide an appropriate degree of memory loss
or decreased awareness. Short acting, rapid onset drugs with little adverse effects and improved safety profiles are
replacing outdated regimens. This article is to discuss the decision making process used to determine appropriate
drug selection, dosing and sedation endpoint. It also reviews the current status of sedation and analgesia for pediatric
procedures in a developing country.

Background: The aim of this study was to evaluate the clinical efficacy of intravenous sedation for pediatric gastrointestinal endoscopy (GIE) at a tertiary care teaching hospital in a developing country.
Methods: We undertook a retrospective review of the sedation service records of pediatric patients who underwent GIE. All endoscopies were performed by a pediatric gastroenterologist. All of the sedation was administered by staff anesthesiologist or anesthetic personnel in the gastroenterology procedure room.
Results: Sedation was provided for 222 procedures in 214 patients ranged in age from younger than 1 to 17 years and in weight from 2.7 to 80.0 kg. Intravenous sedation was provided in 176 patients (82.2%). Of these patients, 185 procedures were performed and reviewed, with 152 (82.2%) procedures were esophagogastroduodenoscopy (EGD)
alone, 14 (7.6%) procedures were colonoscopy alone, 18 (9.7%) procedures were EGD and colonoscopy, and one procedure was endoscopic ultrasonography (EUS). Most common indications of the procedure were screening for esophageal varices (25.2%), abdominal pain (15.9%), history of upper gastrointestinal hemorrhage (13.6%), and unexplained anemia (10.3%). The majority of preanesthetic
problems were hematologic disease, anemia (38.2%); liver disease, cirrhosis (13.5%); and electrolyte imbalance (13.5%). Propofol (94.0%), fentanyl (87.0%), and midazolam (67.8%) were frequently used. The mean dose of propofol was 7.8 ± 4.1 mg/kg/h, fentanyl 2.3 ± 1.1 mcg/kg/h, and midazolam 0.1 ± 0.1 mg/kg/h). Most of them were used in combination. The combination of propofol, fentanyl, and midazolam was commonly employed (46.4%). The mean sedation time of all procedures was 28.2 min and was different according to procedure type. Complications occurred infrequently (13.5%) and were medication or airway related. All complications were easily treated, with no adverse sequelae. Intravenous sedation was successful except for one patient who required general anesthesia. However, all procedures were completed successfully.
Conclusions: In the setting of the developing country, intravenous sedation for pediatric GIE by trained anesthetic personnel with appropriate monitoring was safe and effective. Serious adverse events were rare in our population.

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.

All vertebrates, including fish and other farmed animals, are shown to have pain systems with the same function but with different areas of the brain involved in different groups of animals.There has been rapid development in animal welfare science, including pain assessment, so that we now have better information to use when judging when anaesthesia and analgesia should be used. Evidence from studies using physiological and behavioural measures indicates the extent of pain during farm operations such as castration, disbudding, branding and mulesing. Pain resulting from different disbudding and castration methods is discussed. Disease can cause substantial pain in humans, farm animals and companion animals. Examples of new pain indicators include the grimace scales, that have been developed for rodents, sheep, goats and horses, and the use of thermographic imaging. The public demand ethical decisions in relation to pain avoidance.

Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been
established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians.
Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (>86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger (<86 years old)
Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE
procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic
personnel in the endoscopy room. The cohort was divided into three groups, <65 years old (group 1), 65-85 years
old (group 2), and >86 years old (group 3).
Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in
2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups.
Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p <0.001).
Mean procedure time in group 3 was longer than in group 1 or 2 (p=0.010). Adverse events in group 3 occurred more frequently when compared to group 1 or 2 (p <0.001). Transient hypotension was the main complication across all aged groups.
Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

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.

physiological variables such as the patient's temperature, blood pressure and pulse at diagnosis of CDAD were recorded as were any haematological and biochemical investigations taken within 24 h of diagnosis. Results Hospital admissions between 14 and 30 days (p¼0.031), increasing co-morbidities (p¼0.05), systolic blood pressure <100 mm Hg (p¼0.048) and heart rate greater than 100 beats per minute (p¼0.043) were significantly associated with increased 30day mortality. There was a clear trend of increased mortality for increasing length of stay (LOS) on the current admission before development of diarrhoea (If LOS greater than 7 days before onset, p¼0.07), temperature <358C (p¼0.07), recent discharge from hospital within 30 days (p¼0.106) and to a lesser degree, low albumin (albumin <30 g/l p¼0.221) at the time of diagnosis, age >85 years (p¼0.947) and current PPI use (p¼0.224). From the data, a scoring system was derived whereby 1 point was given to the nonstatistically significant trends and 2 points to the statistically significant trends. If there were 1 to 3 co-morbidities, this was scored as 1 and greater than 3 co-morbidities scored as 2. There was a maximum score of 14. On applying this retrospectively to the existing database, 39 patients were identified where all the parameters in the scoring system were available. Of these, a score of 4 or less was associated with low risk of 30-day mortality (0% mortality in 13 patients). A score of 5 to 7 was associated with moderate risk of 30-day mortality (33.3% mortality in 15 patients) and a score of 8 or more to be associated with a high risk of 30-day mortality (72.7% mortality in 11 patients). Conclusion A simple scoring system holds promise for defining those patients at greatest risk of 30-day mortality from CDAD in our population. However a note of caution should be exercised. Applying a scoring system retrospectively to a dataset from which information has been used to derive the score does not validate it and a prospective study is planned to validate the York scoring system.

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”.

Background : Endoscopic ultrasonography (EUS) is a procedure for diagnosis and treatment in patients with
abnormality of gastrointestinal tract and adjacent organs. It commonly performed under intravenous sedation. The
efficacy by which a patient is sedated remains controversial. Objective : To evaluate the clinical efficacy of intravenous
sedation for the EUS procedure in Siriraj Hospital.
Methods : The patients on whom EUS had been performed by using intravenous sedation (IVS) during the period of September, 2005 to February, 2009 at Siriraj GI Endoscopy Center were retrospective analyzed. The patients’ characteristics, pre-sedation problems, sedative agents, time and complications were assessed.
Results : During the study period, a total of 521 EUS procedures were reviewed. Of these, 513 patients (249
male and 264 female ; mean age 55.2 ± 15.3 years and ranged from 17 year to 97 years) were performed under IVS
technique. Most patients were classified in ASA class I or II (43.6%, 47.4%). Mean sedation time was 52.3 ± 23.7
minutes and ranged from 15 to 225 minutes. Indications for EUS were pancreatic abnormality (38.4%), gastric abnormality (19.5%), hepatobiliary abnormality (14.4%), abdominal pain (10.1%), esophageal tumor (5.5%), abdominal lymphadenopathy (4.9%), abdominal mass (2.1%) and others (5.1%). Preanesthetic problems were hypertension (16.2%), hematalogic diseases (13.1%) and diabetes mellitus (9.2%). Of 513 patients, 332 procedures (64.7%) were performed only for diagnosis. Pancreas, stomach and hepatobiliary tract were the main target organs. The main sedative agents used were propofol, fentanyl and midazolam. Mean dose of propofol in patients aged < 60 years was significantly higher than in the other aged groups. However, the mean dose of fentanyl and midazolam was not significantly different. The combination of propofol, fentanyl and midazolam was commonly used. Overall complication rate was 40.7%. Cardiovascular adverse event including hypotension was the most frequent sedative complication. By comparison according to age, ASA physical status and combination of sedative agents, all adverse events were not significantly different.
Conclusion : IVS performed by anesthetic personnel for EUS procedure is relatively safe and effective. Serious adverse events are rare.