Guideline for administration of sedatives and analgesics by physicians who are not anesthesiologists. National Organization for Quality Assurance in Hospitals]

A consensus text for sedation or analgesia in diagnostic or therapeutic procedures has been developed for application by non-anaesthetist physicians. The final consensus text has the support of 17 scientific societies in the Netherlands. There is not enough medical manpower for direct, personal, specialist-based supervision of level 3 sedation procedures (the patient is relaxed, with eyes closed, but promptly reacts to verbal commands) for significant number of patients in the Netherlands. Sedation and analgesia may be administered by other health care personnel than anaesthesiologists when a number of conditions are met. These concern risk management, information to the patient, patient's consent, requirements for medical and supporting personnel, equipment, sedation procedures, monitoring, data management, recovery and aftercare. The consensus party favours titrated administration of small doses of short acting sedative or analgetic drugs. Combining sedative and analgesic drugs increases risk. Sedation and analgesia in children and patients with mental handicaps is acceptable in terms of quality, but requires special expertise, because of the greater psychic and physical vulnerability of these categories of patients.     

Safe and sound: pediatric procedural sedation and analgesia

Providing procedural sedation for pediatric patients presents unique challenges. Children's hospitals have protocols in place to provide safe, high-quality sedation care delivered by specialists in pediatric sedation and anesthesiology. However, the demand for procedural sedation for diagnostic and therapeutic procedures is increasing. This article describes some of the key components involved in establishing a protocol for safe and effective pediatric sedation services including screening techniques for patients at higher risk for complications and appropriate monitoring and rescue plans. We also review medications commonly used for pediatric sedation and pain management and discuss resources available to physicians who provide pediatric sedation.     

儿童白血病无痛性化疗鞘注的临床研究

目的探讨儿童急性白血病(急性淋巴细胞白血病、急性髓细胞白血病)化疗鞘注过程中应用芬太尼联合异丙酚进行镇静、镇痛,减少鞘注困难甚至操作失败,为今后急性白血病患儿化疗鞘注提供一种无痛的操作方法。方法选择需进行化疗鞘注患儿用芬太尼联合异丙酚镇痛、镇静为实验组,以只用利多卡因局麻后行化疗鞘注为对照组,观察术中配合情况、给药时的反应、异丙酚用量、术中反应。结果实验组给药后能达到较好的镇静、镇痛状态,剂量控制好后无明显呼吸抑制的发生,少数有鼾声呼吸的发生,但术后均能迅速恢复;对照组术前、术中配合率低、躁动、哭叫明显,操作难度大。结论实验组患儿在鞘注中疼痛明显减少、依从性、一次腰穿成功率高,与对照组相比P<0.01,用芬太尼联合异丙酚对小儿镇静、镇痛进行化疗鞘注安全、有效。     

儿童白血病无痛性化疗鞘注的临床研究

目的探讨儿童急性白血病（急性淋巴细胞白血病、急性髓细胞白血病）化疗鞘注过程中应用芬太尼联合异丙酚进行镇静、镇痛,减少鞘注困难甚至操作失败,为今后急性白血病患儿化疗鞘注提供一种无痛的操作方法。方法选择需进行化疗鞘注患儿用芬太尼联合异丙酚镇痛、镇静为实验组,以只用利多卡因局麻后行化疗鞘注为对照组,观察术中配合情况、给药时的反应、异丙酚用量、术中反应。结果实验组给药后能达到较好的镇静、镇痛状态,剂量控制好后无明显呼吸抑制的发生,少数有鼾声呼吸的发生,但术后均能迅速恢复;对照组术前、术中配合率低、躁动、哭叫明显,操作难度大。结论实验组患儿在鞘注中疼痛明显减少、依从性、一次腰穿成功率高,与对照组相比P〈0．01,用芬太尼联合异丙酚对小儿镇静、镇痛进行化疗鞘注安全、有效。     

阈下剂量氯胺酮用于臂丛神经阻滞镇痛镇静效果观察

目的观察阈下剂量（0．4mg／kg）加入局麻药用于臂丛神经阻滞的镇痛、镇静效果。方法60例ASA评级Ⅰ～Ⅱ级侄臂丛神经阻滞下的上肢手术患者,随机双肓法分为三组,每组20例,局麻药为0．375％布比卡因和1％利多卡因混合液20ml作肌间沟臂丛神经阻滞。A组：复合氯胺酮0．4mg／kg;B组：氯胺酮0．4mg／kg,肌注;C组：不用氯胺酮。记录麻醉起效时间、镇痛持续时间、术后12h、24h、48h视觉模拟评分（VAS）,注药后10min、30min的镇静／警觉评分（OAA／S）及麻醉期倒谵妄、多语、头晕、视物不清、呼吸抑制等不良反应。结果A组较其他两组麻醉起敬时间短,镇痛持续时间长;A组和B组术后12h、24h、48hVAS均低于C组,A组则更优于B组（P〈0．05）;A组和B组在注药后均有一定镇静作用,注药10rain后OAA／S评分A组较B组低（P〈0．05）,30rain后两组无明显区别（P〉0．05）;视物不清、头晕等发应率A组和B组无显著性差异（P〉0．05）,但较C组高（P〈0．05）。结论臂丛神经阻滞加用阈下剂量氯胺酮能缩短麻醉起效时间,有短时间的镇静作用,明显增强镇痛作用和延长术后镇痛时间。     

Procedural sedation and implications for quality and risk management

A successful procedural sedation program requires a robust institutional policy backed by a solid educational program and an administrative structure. Given the nature of the services provided, combined with the growth in complexity of both patients and procedures, sedation presents a potential liability for both the provider and the institution. A sedation program is built with a multidisciplinary team of experts representing all stakeholders: healthcare providers, risk and quality improvement managers, and facility administration. An institutional procedural sedation policy should be based on nationally and state recognized practice requirements and guidelines. Clinical care must be supported with a robust risk and quality structure built within the program to ensure best practice at the point of care.     

Treatment of pain in hospital paediatrics

The paper presents a review of pain at the paediatric age, which can be considered a question of maximum interest given the novel application of analgesia or other procedures for avoiding and controlling the different types of pain in the course of normal practice during childhood. After a brief introduction on the history of pain and the scarce attention that it has received until recently, the concepts and different actions for dealing with pain are set out, which depend on its aetiology and localisation: pain in oncology, post-operational pain, pain in chronic or acute diseases, pain in intensive care, etc. Tables are presented with the normal doses used at these ages in the different situations required by the child and which the professional might find himself facing. The non-pharmacological attitude is set out as this can be of great use in the initial stages of controlling pain at these ages, and the different forms of sedation and analgesia at the paediatric age are explained, with regard to the medicines employed, the form of administering them and the importance of a multidisciplinary team: paediatricians, child anaesthetists, nursing personnel as well as the necessary technical support for taking the corresponding action.     

The treatment of kidney and ureteral stones using a second-generation kidney stone lithotriptor

In January 1988 a Siemens Lithostar lithotriptor was installed in the Radboud University Hospital in Nijmegen. Over 1600 treatments have been performed since. The results of 582 treatments of the first 500 patients are discussed. After three months 51.3% of the patients were free of stones. After six months this percentage was 64.5 and in addition 25.4% of the patients were free of symptoms although residual particles were still present. In only 10.1% of the patients did the ESWL treatment not succeed. In over 50% of the cases treatment was performed on an outpatient basis. Among 90% of the patients in whom treatment was performed without auxiliary procedures only 50% needed i.v. sedation or analgesia. The other 50% did not need any form of sedation or analgesia. Major complications did not occur although 376 patients (75.2%) suffered from a short period of haematuria and many patients had a skin lesion. With the possibility of outpatient treatment, the use of less anaesthesia and a success rate of 89.9% (residual stones, less than 5 mm in diameter, which can be evacuated spontaneously) after six months, the Lithostar is an improvement in the treatment of urolithiasis.     

Medical house officers' attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide

In 2000, the authors surveyed 236 medical house officers in three internal medicine residency programs in Connecticut to assess attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide. The goal was to identify associations between these attitudes and training, demographic, and religious factors. The results of the study indicated that most medical house officers supported vigorous analgesia, the majority supported terminal sedation, but only a minority supported physician-assisted suicide. Some house officers' attitudes toward terminal sedation and assisted suicide may have been influenced by their religious commitments and the pressures of training.     

Codeine and its alternates for pain and cough relief: 5. Discussion and summary

This chapter concludes the survey of experimental and clinical data on the analgesic and antitussive properties of codeine and its potential therapeutic alternates. From an evaluation of their effectiveness on the one hand and the side-effects, including tolerance, dependence and abuse liability on the other, it would appear that the therapeutic goals of codeine could be achieved by other substances, except perhaps where analgesia, cough relief, and sedation are required simultaneously. The use of these other substances would, however, result in no particular gain and probably no particular loss.     

MRI‐guided stereotactic neurosurgical procedures in a diagnostic MRI suite: Background and safe practice recommendations

The development of navigation technology facilitating MRI‐guided stereotactic neurosurgery has enabled neurosurgeons to perform a variety of procedures ranging from deep brain stimulation to laser ablation entirely within an intraoperative or diagnostic MRI suite while having real‐time visualization of brain anatomy. Prior to this technology, some of these procedures required multisite workflow patterns that presented significant risk to the patient during transport. For those facilities with access to this technology, safe practice guidelines exist only for procedures performed within an intraoperative MRI. There are currently no safe practice guidelines or parameters available for facilities looking to integrate this technology into practice in conventional MRI suites. Performing neurosurgical procedures in a diagnostic MRI suite does require precautionary measures. The relative novelty of technology and workflows for direct MRI‐guided procedures requires consideration of safe practice recommendations, including those pertaining to infection control and magnet safety issues. This article proposes a framework of safe practice recommendations designed for assessing readiness and optimization of MRI‐guided neurosurgical interventions in the diagnostic MRI suite in an effort to mitigate patient risk. The framework is based on existing clinical evidence, recommendations, and guidelines related to infection control and prevention, health care–associated infections, and magnet safety, as well as the clinical and practical experience of neurosurgeons utilizing this technology.     

Florida hospital cuts failed pediatric sedation rate 98%

* In a survey of Broward General Medical Center, The Joint Commission found fault with the administration of sedation for pediatric outpatient diagnostic procedures. * There is a great deal of variation among health care facilities on sedatives use and techniques and safety standards used. * Broward's initiative eliminated rescheduled exams and failed procedures by 98%.     

Anesthesia ambulatory one-day surgery]

The spreading of the cost-benefit attitude is a considerable help in the progress of the one day surgery. The patient selection, the preoperative patient preparations and the preoperative examination has done in the anaestesiologic ambulance. Aims of ambulatory anaesthesia are to achieve sedation, hypnosis, analgesia, amnesia and muscle relaxation during the operation, to preserve preoperative mental and physiologic state, analgesia and to make early postoperative nourishing possible. Besides personnel and equipment of anaesthesia and reanimation, monitoring of circulation, respiration and neuromuscular transmission is needed. Anaesthetic methods: local, regional and general anaesthesia or sedation. Ways of general anaesthesia are intravenous, inhalation or combined. Intravenous anaesthetic drugs (barbiturates, ketamine, etomidate, midazolam, propofol and eltanolon) can be used in monotherapy or in combination with each other or opioids (morphine, alfentanil, fentanyl, sufentanil, remifentanil). Among inhalatic agents N2O isoflurane, desflurane, sevoflurane are advisable. Recommended non depolarising muscle relaxants are the short-acting atracurium, mivacurium, vecuronium and rocuronium. Methods for loco-regional anaesthesia are infiltration, peripheral nerve blockade, epidural and intradural anaesthesia which can be used with additional vigil sedation. Blockades with local analgetics, intraoperative opioids, non-steroid anti-inflammatory drugs, sedatives, pre-emptiv analgesia and patient controlled analgesia can be used for postoperative pain relief. Besides the patient and intervention type selection the adequate perioperative anaesthesiologic work and the prudent specifications of leaving conditions is the most important terms of the safety of one-day surgery and anaesthesia.     

Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections--2002.

Since publication of CDC's 1993 guidelines (CDC, Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR 1993;42[No. RR-12]:1-39), nucleic acid amplification tests (NAATs) have been introduced as critical new tools to diagnose and treat C. trachomatis and Neisseria gonorrhoeae infections. NAATs for C. trachomatis are substantially more sensitive than previous tests. When using a NAAT, any sacrifice in performance when urine is substituted for a traditional swab specimen is limited, thus reducing dependence on invasive procedures and expanding the venues where specimens can be obtained. NAATs can also detect both C. trachomatis and N. gonorrhoeae organisms in the same specimen. However, NAATs are usually more expensive than previous tests, making test performance from an economic perspective a key consideration. This report updates the 1993 guidelines for selecting laboratory tests for C. trachomatis with an emphasis on screening men and women in the United States. (In this report, screening refers to testing persons in the absence of symptoms or signs indicating C. trachomatis or N. gonorrhoeae infection.) In addition, these guidelines consider tests from an economic perspective and expand the previous guidelines to address detection of N. gonorrhoeae as well as C. trachomatis infections. Because of the increased cost of NAATs, certain laboratories are modifying manufacturers' procedures to improve test sensitivity without incurring the full cost associated with screening with a NAAT. Such approaches addressed in these guidelines are pooling of specimens before testing with a NAAT and additional testing of specimens whose non-NAAT test result is within a gray zone. This report also addresses the need for additional testing after a positive screening test to improve the specificity of a final diagnosis. To prepare these guidelines, CDC staff identified pertinent concerns, compiled the related literature published during 1990 or later, prepared tables of evidence, and drafted recommendations. Consultants, selected for their expertise or disciplinary and organizational affiliations, reviewed the draft recommendations. These final guidelines are the recommendations of CDC staff who considered contributions from scientific consultants. These guidelines are intended for laboratorians, clinicians, and managers who must choose among the multiple available tests, establish standard operating procedures for collecting and processing specimens, interpret test results for laboratory reporting, and counsel and treat patients.     

右美托咪啶在重症监护病房中的应用

目的：比较右美托咪啶和咪达唑仑在重症监护病房的患者中的镇静、镇痛效果,评价右美托咪啶的作用。方法：选取本院50例ICU需要镇静镇痛的患者,按收治的先后顺序将他们分成A、B两组,A组应用右美托咪啶,B组应用咪达唑仑,对两组药物的作用效果及副作用进行分析。结果：A、B两组的镇静镇痛效果的满意度都很高。A组唤醒时间短于B组,但两组机械通气时间和VAS评分比较差异无统计学意义。A组呼吸减弱、低血压、心动过缓、顺行性遗忘等现象的出现频率均优于B组,比较差异有统计学意义（P〈0．05）。结论：右美托咪定对重症监护病房的患者的镇静镇痛效果好,低血压,呼吸过缓,心动过缓,顺行性遗忘等副作用的发生概率小,可广泛应用于重症监护病房。     

Multi-society guideline for reprocessing flexible gastrointestinal endoscopes. Society for Healthcare Epidemiology of America.

Flexible gastrointestinal endoscopy is a valuable diagnostic and therapeutic tool for the care of patients with gastrointestinal and pancreaticobiliary disorders. Compliance with accepted guidelines for the reprocessing of gastrointestinal endoscopes between patients is critical to the safety and success of their use. When these guidelines are followed, pathogen transmission can be effectively prevented. Increased efforts and resources should be directed to improve compliance with these guidelines. Further research in the area of gastrointestinal endoscope reprocessing should be encouraged. The organizations that endorsed this guideline are committed to assisting the FDA and manufacturers in addressing critical infection control issues in gastrointestinal device reprocessing.     

Sex bias in the management of coronary artery disease in Quebec.

This study tests the hypothesis that, given the absence of financial barriers to major coronary procedures in Quebec, women are as likely as men to undergo such procedures. The use of coronary procedures in 33,940 patients with ischemic heart disease, admitted during 1 year to 78 Quebec hospitals, was analyzed. The male-to-female age- and severity-adjusted odds ratios for the use of these procedures were 1.47 for diagnostic procedures, 1.38 for therapeutic procedures, and 1.26 for diagnostic and therapeutic procedures. These results suggest that differences in the use of coronary procedures by sex are influenced by factors other than financial accessibility.     

CBO guideline 'Breast cancer: screening and diagnosis'

New developments in the diagnostic procedures for women with an increased risk for, or symptoms related to breast cancer led to development of new guidelines by a working group under the auspices of the Dutch Institute for Health Care Improvement, the Organisation of Comprehensive Cancer Centres and the National Breast Group of the Netherlands. Based on the best available evidence this working group formulated recommendations on the following topics: indications for screening within the population screening programme, screening outside the population screening programme, the diagnostic procedures of symptomatic and asymptomatic lesions in the breast and the organisation of the diagnostic work-up of patients with breast symptoms. The most important recommendations in the guidelines are: individual screening is recommended to certain groups of women who do not participate in the population screening programme, based on their risk profiles; available evidence does not support the extension of the population screening programme to women 40-49 years of age; diagnosis and treatment have to take place in a structured context, the so-called breast team; to guarantee optimal diagnostic procedures a multidisciplinary clinic is mandatory; the diagnostic work-up of breast abnormalities is based on the triple assessment: physical examination, imaging by mammography and/or ultrasound and needle biopsy. For quality-controlled implementation of this guideline, uniform prospective registration of patients, diagnosis and treatment related data is an important condition.