Remifentanil versus Fentanyl/Midazolam in Painless Reduction of Anterior Shoulder Dislocation; a Randomized Clinical Trial

Introduction: Performance of painful diagnostic and therapeutic procedures is common in emergency department(ED), and procedural sedation and analgesia (PSA) is a fundamental skill for every emergency physician.This studywas aim to compare the efficacy of remifentanil with fentanyl/midazolam in painless reduction of anteriorshoulder dislocation. Methods: In this randomized, double blind, clinical trial the procedural characteristics,patients satisfaction as well as adverse events were compared between fentanyl/midazolamand remifentanilfor PSA of 18–64 years old patients, which were presented to ED following anterior shoulder dislocation.Results: 96 cases were randomly allocated to two groups (86.5% male). There were no significant difference betweengroups regarding baseline characteristics. Remifentanil group had lower duration of procedure (2.5§1.6versus 4.6§1.8 minutes, p Ç 0.001), higher pain reduction (53.7§13.3 versus 33.5§19.6, p Ç 0.001), lower failurerate (1 (2.1%) versus 15 (31.3%), p Ç 0.001), higher satisfaction (p Æ 0.005). Adverse events were seen in 12 (25%)patients in midazolam/fentanyl and 8 (16.7%) cases in remifentanil group (p Æ 0.122). Conclusion: It seemsthat use of remifentanil resulted in lower procedural time, lower failure rate, and lower pain during procedureas well as higher patient satisfaction in comparison with midazolam/fentanyl combination in anterior shoulderdislocation

A Randomized Clinical Trial of Intravenous and Intramuscular Ketamine for Pediatric Procedural Sedation and Analgesia

Introduction: Ketamine is an agent used broadly for pediatric procedural sedation and analgesia in emergency departments. It has been found to be safe and with a low risk of complications. As choosing between intravenous (IV) and intramuscular (IM) injections is a matter of concern, we did comparison between two methods in terms of their efficacy and the rate of complications. Methods: This single-blind clinical trial study recruited 240 children (age: three months to 15 years, weight > 5 kg), who underwent short and painful procedures at the emergency departments. They were randomly allocated in to two groups of 120 patients to receive either IV or IM ketamine with doses of 1.5 and 4 mg/kg, respectively. Indications for use, dose, side effects, and efficacy of the medications as well as duration of the procedure and time to recovery were compared between two groups. Results: The mean age of the IV and IM groups were 6.5 ± 3.6 and 3.05 ± 2.6 years, respectively (p < 0.001). The onset of action of ketamine was 1.7 ± 1.1 minutes in the IV group and 8.6 ± 3.1 in the IM ones (p < 0.001). Patients of the IV and IM groups remained in optimal sedation for 20.6±12.0 and 37.2±11.8 minutes, respectively (P < 0.001). Time until emergency department discharge was 65.3 ± 36.9 minutes in the IV group and 72.2 ± 14.5 in the IM group (P = 0.40). Ketamine had excellent and moderate efficacy in 66.7% and 32.5% of the IV group and 70.0% and 25.0%  in the IM group, respectively (p = 0.02). Totally, 60.0% of IV group patients and 40.0% of IM group experienced drug side effects (p = 0.21). Need to rescue dose was significantly higher in IV group (26.7% vs. 10.0%; p < 0.001). Finally, recovery was tranquil and comfortable in 88 patients (73.3%) of the IV group and 108 patients (90.0%) of the IM group (p = 0.06). Conclusion: We found that although the sedative and analgesic effects of IM and IV ketamine are not significantly different, duration of effect and onset of action are more desirable in the IV group for suturing, fracture reduction, and foreign body removal. Meanwhile, the IM method can lead to lesser need of rescue doses

Evaluating different sedative drugs applied in procedural sedation

There are various criteria that affect the efficacy of the procedural sedation strategies required for performing different processes in emergency departments. Selecting the most effective and the safest sedative with or without analgesic effect for every individual patients and intervention is one of the main parts of the each emergency department practices. Based on previous studies, various sedative agents have been proposed, which have different benefits and adverse effects including propofol, ketamine, etomidate etc. Different side effects of administrating each drug, alone or in combination with each other, have been proposed such as vomiting, respiratory depression, hypoxia, hypotension and cardiac arrest. In this study we aimed to briefly review the properties of applied sedatives in different studies and also mention few related clinical trials with proper blinding, which were conducted to evaluate the efficacy of the sedative in procedural sedation

Comparison between intravenous and intramuscular administration of ketamine in children sedation referred to emergency department

Ketamine, among wide variety of sedative drugs, has shown beneficial effects when using during the procedural sedation, specifically in pediatrics. Various parameters should be considered in order to perform a safe and effective procedural sedation including optimum dosage of the sedative, administration methods of sedation, and need for applying any adjuvant drug. In this study, we aimed to review the studies, which have compared the efficacy of the different ways of the injection of ketamine such as intravenous or intramuscular ketamine application. Based on data obtained from the related articles, efficacy and safety of these two methods of ketamine usage in the pediatric procedural sedation were widely similar, but the intravenously administration of the ketamine can be proposed as the preferable mode

Surgery and Anesthesia Management for Intraoral Synechia: A Case Report

Introduction: Intraoral synechia is a rare congenital condition, generally associated with other maxillo-facial malformations. We present a neonate with congenital intraoral bilateral synechia without any other facial anomalies.   Case Report: In this paper, we present a 19-day-old male neonate with congenital intraoral bilateral synechia without any other facial anomalies. We review the literature to discuss the surgical andanesthesia management of this rare congenital disease.   Conclusion: The disease manifested with a wide spectrum of symptoms. Most cases need surgery and airway management. In patients with a low risk of bleeding or a compromised airway, it is possible to manage them withfacemask-inhalation anesthesia and maintain spontaneous breathing

Evaluation of the Effect of Amino Acid Administration on Hypothermia during General Anesthesia in Hypospadias Surgery on Children Aged 2 to 6 Years

Abstract Introduction: Hypothermia is an important complication during surgery, especially in children, and is highly associated with serious adverse outcomes. One of the preventive methods is the intraoperative administration of amino acids, which can be effective through increasing thermogenesis and stimulating energy consumption. No studies have been conducted in this regard on children; therefore, we evaluated the preventive effect of intraoperative administration of amino acid on hypothermia in children. Materials and Methods: Forty children, aged 2 to 6 years, who were candidates for hypospadias surgery in Dr. Sheikh Hospital, Mashhad-Iran, were divided into two groups. In the case group, 10% amino acid (2 cc/kg/h) was administered two hours before the operation, and in the control group, normal saline was given as required. All patients underwent a similar method of anesthesia. body temperature was recorded before the anesthesia, immediately after it, and every ten minutes. Results: The mean age and weight had no difference between the groups. Duration of patients' awakening time was (13.60 ± 4.91 min), which in the case and control groups was reported as (11.90 ± 5.27) and (15.30 ± 3.96 min), respectively (P<0.05). The patients' body temperature was higher in the case group. It was not significantly different between the groups before, and until 20 min after the start of the surgery. In the next measurements, the temperature was significantly different among the groups; the difference became more prominent as the time passed. Conclusion: Perioperative administration of 10% amino acid causes an increase in children's body temperature, leading to faster awakening time of the patients