丙泊酚和七氟烷对小儿骨科手术苏醒期躁动的影响

目的 观察丙泊酚和七氟烷在神经阻滞复合喉罩全身麻醉的小儿骨科手术中，对小儿术后苏醒期躁动的影响。方法 选择本院小儿骨科手术患儿80例，随机分成丙泊酚组和七氟烷组。患儿采用改良耶鲁术前焦虑量表（the modified Yale Preoperative Anxiety Scale, m-YPAS）评估后入手术室，常规静脉诱导后置入喉罩机械通气，采用不同的麻醉药物进行维持，随后局麻下行超声引导神经阻滞。所有患儿在恢复自主呼吸后氧饱和度均维持在95%以上，拔除喉罩送至苏醒室。观察比较两组患儿苏醒时的拔管时间、小儿麻醉苏醒期躁动量化评分表（pediatric anesthesia emergence delirium scale, PAED）评分及儿童疼痛行为量表（The face, legs, activity, cry, consolability behavioral tool, FLACC）评分和Richmond躁动-镇静量表（Richmond agitation and sedation scale, RASS）评分。结果 丙泊酚组和七氟烷组患儿的m-YPAS评分分别为（26.94±11.07）分、（26.10±8.22）分，差异无统计学意义（P=0.699）。丙泊酚组拔管时间明显长于七氟烷组［（9.95±5.27） min vs. （5.30±2.94） min］，急性躁动PAED评分明显低于七氟烷组［（7.15±2.30）分 vs. （9.50±2.44）分］，苏醒期躁动发生率明显低于七氟烷组（5% vs. 15%），上述指标比较，差异均有统计学意义（P均＜0.001）。躁动患儿的FLACC评分为3~8分，RASS评分为-3~-2分，处于轻度至中度镇静状态。结论 小儿骨科手术神经阻滞复合喉罩全身麻醉术后苏醒躁动仍有发生；丙泊酚维持麻醉术后躁动发生率较七氟烷低，患儿舒适安全，值得临床推广。     

Experiences of nursing home staff using the targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms (TIME) – a qualitative study

Background/Aims: Neuropsychiatric symptoms (NPS) in dementia pose great challenges for residents and staff in nursing homes. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a randomized controlled trial demonstrated reductions in NPS. We explored the participating staff's experiences with the model and how it meets the challenges when dealing with the complexity of NPS.

Methods: Three to six months after the end of the intervention, we interviewed 32 of the caregivers, leaders, and physicians participating in the trial, in five focus groups. We used thematic content analysis.

Results: The analysis yielded two main themes: (1) a systematic reflection method enhanced learning at work; (2) the structure of the approach helped staff to cope with NPS in residents with dementia.

Conclusion: TIME shifts the way of learning for the staff from a traditional to a more innovative and reflection-based learning through a process of learning how to learn at work. The staff's experienced increased coping in their approach to complex problems. Our results emphasise the importance of a structured and biopsychosocial approach to NPS in clinical practice. Future research should explore models for integrating situated learning in daily routines in nursing homes.     

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics

Background

Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available.

Symptomatic palliative care for children with neurodisability

Paediatric palliative care and neurodisability are two relatively new, evolving paediatric sub-specialities that have increasing relevance in the current paediatric landscape. For many people palliative care has been synonymous with end of life care, but in paediatrics it encompasses much more and is for all children with life-threatening or life-limiting conditions, from the point of diagnosis. This breadth of focus is demonstrated well through the interface between paediatric palliative care and paediatric neurodisability. In this article we explore this unique interface through the three domains of complex symptom management, advanced care planning and end of life care. We describe the practicalities involved in all three areas and highlight the importance of early referral and the process of “dual” or “parallel” planning. We cover in more depth the specific management of the symptoms: dystonia/abnormalities of muscle tone, seizures, pain, agitation, secretions, respiratory failure, and gut failure.     

When and How to Treat Agitation in Alzheimer's Disease Dementia With Citalopram and Escitalopram

Agitation is a common neuropsychiatric symptom (NPS) in the early and middle stages of Alzheimer's disease (AD) dementia, which is difficult to treat and causes much distress. The U.S. Food and Drug Administration (U.S. FDA) issued black box warnings against the use of antipsychotics in dementia in 2005 and 2008 due to the increased risk of morbidity and mortality, resulting in the reduction in antipsychotic use for treating dementia-related NPS and spurring the quest for safer and more effective pharmacological options. The data favoring the use of citalopram for treating agitation in AD dementia is particularly compelling, and this may be a class effect for all selective serotonin reuptake inhibitors. However, concerns about the cardiac side-effects of citalopram have limited its widespread use for this indication. In this article, available efficacy and safety data for the use of citalopram and escitalopram in treating agitation in AD dementia is reviewed, using a composite case to illustrate key points. Practical recommendations are made to facilitate the use of these medications in routine clinical practice, risk mitigation strategies are discussed and salient issues for future clinical research are emphasized.     

家长陪同对口腔门诊患儿七氟烷全身麻醉苏醒期躁动的影响研究

 目的　研究家长陪同对口腔门诊患儿七氟烷全身麻醉苏醒期躁动的影响。方法　选取2017年6—12月于重庆医科大学附属口腔医院行七氟烷全身麻醉口腔治疗患儿120例，随机分为陪同组和未陪同组，每组60例。陪同组患儿在治疗前麻醉诱导期及治疗后苏醒期均有家长陪同，未陪同组患儿在麻醉诱导期及苏醒期均无家长陪同。采用小儿麻醉苏醒期躁动量化评分表（pediatric anesthesia emergence delirium scale，PAED）对患儿麻醉苏醒期躁动情况进行评分，并计算躁动发生率。结果　陪同组PAED评分为（9.18 ± 3.41）分，未陪同组PAED评分为（10.57 ± 3.62）分，两组PAED评分比较，差异有统计学意义（t = 2.04，P = 0.03）。陪同组躁动发生率（26.67%）明显低于非陪同组（50.00%），差异有统计学意义（χ2 = 6.91，P = 0.01）。结论　治疗前麻醉诱导期及治疗后苏醒期有家长陪同，可减少患儿躁动的发生，提高家长对口腔治疗的满意度，促进良好的医患关系。     

三种不同时机下术前导尿配合手术室护理对全麻手术患者苏醒期躁动的影响

摘要 目的 观察三种不同时机下术前导尿配合手术室护理对全身麻醉（全麻）手术患者苏醒期躁动的影响。方法 选择2017年1月～2018年12月于我院行择期全麻手术的患者100例，根据术前导尿时机分为3组：A组（手术当日清晨在病房导尿，33例）、B组（麻醉前在手术室导尿，30例）、C组（麻醉平稳后在手术室导尿，37例）。记录并比较3组麻醉时间、术中输液量、术中出血量、苏醒时间及导尿前后收缩压（SBP）、舒张压（DBP）及心率（HR）变化，比较3组一次性导尿成功率、术后导尿管适应度及苏醒期躁动发生情况，采用自拟问卷调查患者护理满意度。结果 3组麻醉时间、术中输液量、术中出血量及苏醒时间比较，差异无统计学意义（P>0.05）；A组导尿后SBP、DBP、HR较导尿前均显著升高（P<0.05），B组和C组SBP、DBP、HR与导尿前比较，差异无统计学意义（P>0.05）；A组一次性导尿成功率显著低于B组和C组，术后导尿管适应度显著差于B组和C组（P<0.05）；A组苏醒期躁动发生率显著高于C组，苏醒期躁动分级显著高于C组P<0.05）；A组护理满意度评分显著低于B组和C组，差异有统计学意义（P<0.05）。结论 在麻醉前后于手术室进行导尿的效果明显优于手术当日清晨在病房导尿，配合手术室护理干预可有效提高患者术后对导尿管的适应度，降低苏醒期躁动发生率，提高患者护理满意度。     

Cost-Effectiveness of Midazolam Versus Haloperidol Versus Olanzapine for the Management of Acute Agitation in the Accident and Emergency Department

ObjectivesA multicenter randomized clinical trial in Hong Kong Accident and Emergency (A&E) departments concluded that intramuscular (IM) olanzapine is noninferior to haloperidol and midazolam, in terms of efficacy and safety, for the management of acutely agitated patients in A&E setting. Determining their comparative cost-effectiveness will further provide an economic perspective to inform the choice of sedative in this setting.MethodsThis analysis used data from a randomized clinical trial conducted in Hong Kong A&E departments between December 2014 and September 2019. A within-trial cost-effectiveness analysis comparing the 3 sedatives was conducted, from the A&E perspective and a within-trial time horizon, using a decision-analytic model. Sensitivity analyses were also undertaken.ResultsIn the base-case analysis, median total management costs associated with IM midazolam, haloperidol, and olanzapine were Hong Kong dollar (HKD) 1958.9 (US dollar [USD] 251.1), HKD 2504.5 (USD 321.1), and HKD 2467.6 (USD 316.4), respectively. Agitation management labor cost was the main cost driver, whereas drug costs contributed the least. Midazolam dominated over haloperidol and olanzapine. Probabilistic sensitivity analyses supported that midazolam remains dominant > 95% of the time and revealed no clear difference in the cost-effectiveness of IM olanzapine versus haloperidol (incremental cost-effectiveness ratio 667.16; 95% confidence interval ?770.89, 685.90).ConclusionsIM midazolam is the dominant cost-effective treatment for the management of acute agitation in the A&E setting. IM olanzapine could be considered as an alternative to IM haloperidol given that there is no clear difference in cost-effectiveness, and their adverse effect profile should be considered when choosing between them.