Thesis (Ph. D.)--University of Hawaii at Manoa, 2004. / Includes bibliographical references (leaves 86-97).

INTRODUCTION: Prolonged sedation treatment in neonatal pediatric populations is associated with opioid and benzodiazepine tolerance, dependence, and withdrawal syndrome. Despite the clinical relevance of this problem, we have limited knowledge of the long-term repercussions. Current literature focuses on premature neonates and suggests that opioid exposure may cause neurodevelopmental sequelae. The main objective of this literature review was to investigate what infant populations are at risk of developing short-term and/or long-term consequences from prolonged infantile sedation exposure. PUBLISHED STUDIES: A literature review was conducted on previous studies that focused primarily on the effects of opioids and benzodiazepines on infants and how it may affect the future development in these children. Studies show that short-term consequences include increased heart rate, increased respiratory rate, increased blood pressure, intracranial pressure fluctuations, and risk of further complications such as intraventriculat hemorrhage (IVH), periventricular leukomalacia (PVL), or even death. Long-term repercussions incluse the possibility of decreased brain volume, decreased head circumference and body weight, intelligence deficits, and social and behavioral issues. DISCUSSION: Standard pain and sedation management involves the use of opioids and benzodiazepines. Treatment duration and medication dosage depend on severity of the patient’s illness. Since prolonged sedation administration is often associated with tolerance and dependence, future research (such as long-term follow up of these infants at later neurological milestones) is necessary to determine possible short-term and long-term neurological and behavioural sequelae for infants exposed to prolonged treatment with opioids and benzodiazepines. Standardized pain and sedation management guidelines may also increase the effectiveness of treatment and drug administration.

Made available in DSpace on 2014-06-11T19:35:12Z (GMT). No. of bitstreams: 0 Previous issue date: 2007-02-27Bitstream added on 2014-06-13T19:05:32Z : No. of bitstreams: 1 nascimento_js_dr_botfm.pdf: 722430 bytes, checksum: e2016c502b8c938e01734e5747ae7a04 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Avaliar a qualidade da sedação e os efeitos sobre a frequencia cardiaca e a pressão arterial do midazolam e do diazepam associados ou nao a clonidina, em pacientes com suspeita de doenca coronariana. Métodos: Foi desenvolvido ensaio clinico prospectivo, duplo cego, randomizado, controlado, com 160 pacientes. Estes apresentavam teste ergometrico ou cintilografia positivos para isquemia miocardica e foram submetidos a cineangiocoronariografias diagnosticas eletivas, divididos em cinco grupos de 32 pacientes cada, de acordo com o farmaco utilizado: grupo C (clonidina 0,5 Êg.kg-1); grupo M (midazolam 40 Êg.kg-1); grupo MC (associacao do midazolam 40 Êg.kg-1 e da clonidina 0,5 Êg.kg-1); grupo D (diazepam 40 Êg.kg-1); grupo DC (associacao do diazepam 40 Êg.kg-1 e da clonidina 0,5 Êg.kg-1). A sedacao foi avaliada com base na escala de Ramsay e no consumo de meperidina (0,04 mg.kg-1) que foi utilizada nos pacientes que apresentaram agitacao ou ansiedade durante o procedimento. A PA invasiva, a FC e o escore de sedacao, foram analisados a cada 5 minutos em 4 diferentes momentos: M1 - inicio do exame; M2 - 5 minutos apos o inicio do exame; M3 - metade do tempo do exame e M4 - final do exame. Resultados: Os grupos foram homogeneos com relacao a PA, FC e sedacao no momento controle (M1). Os pacientes que utilizaram o midazolam apresentaram maiores escores de sedacao e variacao da FC e PA (p<0,05). Os que utilizaram o diazepam ou a clonidina exibiram menores e mais apropriados escores de sedacao para a realizacao do exame e apresentaram menor $ variacao da PA e da FC (p>0,05). A associacao com a clonidina potencializou de forma mais precoce e acentuada os efeitos sedativos do midazolam em relacao ao diazepam (p<0,05). O consumo de meperidina nao diferiu entre os grupos estudados (p>0,10)... / Background to evaluate the effects of midazolam, diazepam and associations with clonidine on heart rate (HR), blood pressure (BP) as well as its sedative effect on patients submitted to coronary angiography. Methods A randomized, controlled and double blind, prospective clinical trial was conducted on 160 patients submitted to an elective coronary angiography. All of them have ergometric test or miocardic cintilography positive to ischemia. They were divided into five groups with 32 patients each: C group (clonidine 0,5 ìg.kg-1); M group (midazolam 40 ìg.kg-1); DC group (midazolam 40 ìg.kg-1 and clonidine 0,5 ìg/kg associated); D group (diazepam 40 ìg/kg); DC group (diazepam 40 ìg/kg and clonidine 0,5 ìg.kg-1 associated). Sedation was evaluated based on the Ramsay Scale. Administration of a 0,04 mg.kg-1 dose of meperidine was given to the patients who were agitated or anxious during the procedure. The invasive BP, HR and sedation score based on Ramsay Scale were analyzed every five minutes and four different intervals were considered for the assessment: M1- at the start of the test; M2 5 minutes after the start of the test; M3 half time of the test; M4 at the end of the test. Results The groups were homogeneous in relation the BP, HR and sedation in the control moment (M1) and there was no difference regarding the weight, age and sex. The patients that used midazolam presented deeper sedation score and HR and BP variability (p<0,05). The patients that used diazepam or clonidine have superficial sedation score and better BP and HR stability. The association with clonidine showed the midazolam sedative effects earlier and $ deeper than diazepam (p<0,05). There was no difference in meperidine use (p>0,10) Conclusions The midazolam presented higher and deeper sedative and cardiovascular effect... (Complete abstract, click eletronic address below)

Orientador: Norma Sueli Pinheiro Módolo / Banca: Angélica de Fátima Assunção Braga / Banca: Glória Maria Braga Potério / Banca: Geraldo Rolim Rodrigues / Banca: José Manuel Castelhano Ribeiro Ponte / Resumo: Avaliar a qualidade da sedação e os efeitos sobre a frequencia cardiaca e a pressão arterial do midazolam e do diazepam associados ou nao a clonidina, em pacientes com suspeita de doenca coronariana. Métodos: Foi desenvolvido ensaio clinico prospectivo, duplo cego, randomizado, controlado, com 160 pacientes. Estes apresentavam teste ergometrico ou cintilografia positivos para isquemia miocardica e foram submetidos a cineangiocoronariografias diagnosticas eletivas, divididos em cinco grupos de 32 pacientes cada, de acordo com o farmaco utilizado: grupo C (clonidina 0,5 Êg.kg-1); grupo M (midazolam 40 Êg.kg-1); grupo MC (associacao do midazolam 40 Êg.kg-1 e da clonidina 0,5 Êg.kg-1); grupo D (diazepam 40 Êg.kg-1); grupo DC (associacao do diazepam 40 Êg.kg-1 e da clonidina 0,5 Êg.kg-1). A sedacao foi avaliada com base na escala de Ramsay e no consumo de meperidina (0,04 mg.kg-1) que foi utilizada nos pacientes que apresentaram agitacao ou ansiedade durante o procedimento. A PA invasiva, a FC e o escore de sedacao, foram analisados a cada 5 minutos em 4 diferentes momentos: M1 - inicio do exame; M2 - 5 minutos apos o inicio do exame; M3 - metade do tempo do exame e M4 - final do exame. Resultados: Os grupos foram homogeneos com relacao a PA, FC e sedacao no momento controle (M1). Os pacientes que utilizaram o midazolam apresentaram maiores escores de sedacao e variacao da FC e PA (p<0,05). Os que utilizaram o diazepam ou a clonidina exibiram menores e mais apropriados escores de sedacao para a realizacao do exame e apresentaram menor $ variacao da PA e da FC (p>0,05). A associacao com a clonidina potencializou de forma mais precoce e acentuada os efeitos sedativos do midazolam em relacao ao diazepam (p<0,05). O consumo de meperidina nao diferiu entre os grupos estudados (p>0,10)... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Background to evaluate the effects of midazolam, diazepam and associations with clonidine on heart rate (HR), blood pressure (BP) as well as its sedative effect on patients submitted to coronary angiography. Methods A randomized, controlled and double blind, prospective clinical trial was conducted on 160 patients submitted to an elective coronary angiography. All of them have ergometric test or miocardic cintilography positive to ischemia. They were divided into five groups with 32 patients each: C group (clonidine 0,5 ìg.kg-1); M group (midazolam 40 ìg.kg-1); DC group (midazolam 40 ìg.kg-1 and clonidine 0,5 ìg/kg associated); D group (diazepam 40 ìg/kg); DC group (diazepam 40 ìg/kg and clonidine 0,5 ìg.kg-1 associated). Sedation was evaluated based on the Ramsay Scale. Administration of a 0,04 mg.kg-1 dose of meperidine was given to the patients who were agitated or anxious during the procedure. The invasive BP, HR and sedation score based on Ramsay Scale were analyzed every five minutes and four different intervals were considered for the assessment: M1- at the start of the test; M2 5 minutes after the start of the test; M3 half time of the test; M4 at the end of the test. Results The groups were homogeneous in relation the BP, HR and sedation in the control moment (M1) and there was no difference regarding the weight, age and sex. The patients that used midazolam presented deeper sedation score and HR and BP variability (p<0,05). The patients that used diazepam or clonidine have superficial sedation score and better BP and HR stability. The association with clonidine showed the midazolam sedative effects earlier and $ deeper than diazepam (p<0,05). There was no difference in meperidine use (p>0,10) Conclusions The midazolam presented higher and deeper sedative and cardiovascular effect... (Complete abstract, click eletronic address below) / Doutor

Chapter 1 reviews the literature. It gives a historical overview of hypnosis. It reviews the literature on dental anxiety, including its prevalence and aetiology. It reviews behavioural and cognitive behavioural treatments of dental fear. Inhalation sedation its mechanism of action, effectiveness and draw-backs are discussed. The literature on hypnosis is selectively reviewed, its use in anxiety and dentistry and lastly, the combination of sedation techniques, particularly IHS, is discussed. It is concluded that evidence for the use of hypnosis for the alleviation of dental anxiety needs to be critically addressed. Chapter 2 presents the published protocol of a Cochrane systematic review followed by qualitative results of this review. 11 studies of generally poor quality were included in the review which concludes that there are significant problems with the evidence due to methodological issues, the different outcome measures used and the generally high or unclear risks of bias. There is some evidence that hypnosis may help patients who have a normal range of dental anxiety but who are undergoing a stressful dental procedure. Studies of phobic patients were characterised by high levels of drop-out behaviour and hypnosis could not be shown to be superior to other forms of behavioural treatment. Chapter 3 describes two studies which aimed to develop a Mood Induction Procedure to induce temporary dental anxiety in volunteers. This was used in two later studies. A non-clinical sample was used as a ‘proof of concept’ study was desirable. Study 1tested excerpts of a film, producing only a medium rise in anxiety (ES r = .49). The second study used a shorter, more concentrated film. This produced a large increase in anxiety (ES r=.86). Heart rate was investigated as a possible physiological measure of anxiety, but was not found useful. Chapter 4 describes two randomised controlled studies aiming to investigate whether hypnosis combined with IHS would reduce the anxiety produced by the film more than a control procedure in which IHS was combined with the reading of a story. These studies suggested there may be some effects attributable to hypnosis, but conclusive benefit was not demonstrated. Chapter 5 presents discussion and the overall conclusions of the thesis. Conclusions include the need for further well designed large scale trials involving hypnosis.

When pediatric patients are admitted to the inpatient or outpatient hospital setting they potentially have to endure procedures that cause pain, fear, and anxiety which can have a lifelong impact on the child's response to future healthcare needs. The purpose of this project was to create a comprehensive program proposal for a nitrous oxide sedation program to minimize those perceptions towards medical procedures. The project utilized a systematic review of literature and secondary data to address the most important indicators for developing a comprehensive program proposal to present to the pediatric leadership team. Multiple studies have shown nitrous oxide having an excellent safety profile in the pediatric population while providing an almost pain and anxiety free procedure. The program proposal will be used to improve pain and anxiety management for pediatric patients requiring procedures such as intravenous access, venipuncture, voiding cystourethrograms, lumbar puncture, bone marrow biopsy, port-a-cath access, PICC line insertion, dressing changes, chest tubes, and wound care. Key stakeholders and content experts were brought together to create the nitrous oxide program proposal which included a new practice guideline, a comprehensive policy and procedure for nitrous oxide administration, and an education plan. The program proposal included other key components necessary for a safe and efficient program such as a pre-assessment to determine if the child is a candidate, monitoring and documentation of nitrous oxide administration, and education for the child/parent(s). The nitrous oxide program for pediatrics was designed as a minimal sedation method to minimize procedural pain, fear, and anxiety in children where medical procedures are a necessary part of treatment.

No description available.

Purpose: Compare moderate oral sedation of pediatric patients using Hydroxyzine and Meperidine with either Diazepam or Midazolam in management of pediatric dental patients. Methods: Randomized, double-blind, crossover pilot study of patients 3 to 7 years of age requiring two sedation visits. Frankl and Houpt behavior scores recorded at injection time, initiation of treatment and 100% oxygen at end of treatment. Postoperative phone call surveys conducted within eight hours and within 24 hours of discharge. Wilcoxon Signed-Rank tests, Fisher’s Exact Chi-squared test and 0.10 significance level. Results: 25 subjects completed 35 sedations. Eight participants completed both treatments and demonstrated significantly higher total Houpt Scores with Diazepam at all treatment stages. Frankl scores favored Diazepam at injection time. More abnormal behavior was found with Midazolam, less memory of the visit with Diazepam, but longer sleep time with Diazepam. Conclusions: Sedation with the Hydroxyzine, Meperidine and Diazepam regimen may allow for a better overall sedation experience. Postoperative monitoring is essential. The results are promising and demonstrate the value of a larger study on sedation with Diazepam.

O presente estudo objetiva mostrar ao Cirurgião Dentista, os quesitos necessários para se formar um Odontólogo apto a praticar a sedação inalatória, bem como os itens de segurança e de respaldo legal que deverão compor o seu ambiente de trabalho ao se utiliza desta técnica. O estudo foi fundamentado a partir de revisão de literatura sobre o tema, tendo como metodologia o estilo de Vancouver. A analgesia inalatória pela mistura gasosa de óxido nitroso e oxigênio constitui um excelente instrumento no controle da dor e da ansiedade dos pacientes durante o tratamento odontológico. É importante observar que a técnica de analgesia inalatória pela mistura gasosa de óxido nitroso e oxigênio deve ser realizada por meio de normatização técnica para garantir a eficiência da técnica e evitar transtornos. O roteiro proposto no trabalho visa apresentar as características de segurança e detalhamento das especificações técnicas dos estabelecimentos de assistência odontológica para o emprego da técnica de analgesia inalatória pela mistura gasosa de óxido nitroso e oxigênio. / This study has as objective to suggest a number of propositions in order to prepare and develop a dental office to perform conscious sedation by inhalatory analgesia using nitrous oxide/oxygen mixture. It was based on the revision of literature about the subject, having as methodology the Vancouver style. The conscientious sedation constitutes an excellent instrument in the control of the patient?s anxiety during dental treatment. It also will show to the Dentist the necessary requirements to the training of his personal and himself. It is important to observe that the technique itself must follow normative rules to guarantee its efficiency. The scope considered in the work aims present characteristics of security and detailed specifications to establish dental assistance for the use of conscious sedation by nitrous oxide/oxygen mixture.

This dissertation will support full ethical endorsement of terminal sedation for those most urgently in crisis and need of beneficence, those who are dying and in the final hours or days and suffering. To clarify the practice I first detail ethical differences between euthanasia, physician assisted suicide and terminal sedation. Moreover, I identify new areas where harms and benefits need to be evaluated as affecting not only patients, but also families and caregivers. I evaluate the current practice to allow the development of ethical guidelines and greater consensus on deciding the hard cases. This work may also serve to assist those looking to enlarge the practice in the future with ETS for those with debilitating diseases or disability, but they are not my primary goal. Below is the standard I propose for moral allowability for the use of terminal sedation. I will refer to it often in the pages that follow simply as my standard . Terminal sedation is the appropriate and intentional use of medications (benzodiazepines and/or narcotics) to produce ongoing, deep unconsciousness upon 1) a terminal patient’s (or surrogates) request due to 2) suffering intractable pain or other distressing clinical symptoms intolerable to the patient when 3) death is expected within hours or days (less than two weeks) due to the terminal illness, injury, or disease. I offer two versions of initial guidelines for development of hospital policy. The first version outlines minimal guidelines that ought to be utilized to allow TS for patients who fit my standard. The minimal guideline is based upon the recommendations of the American Medical Association with some modifications. The guideline is admittedly restrictive in hopes of gaining wider societal support for a currently controversial practice. Secondly, I offer more moderate guidelines for policy that could become a standard in the future. It maintains the restrictive focus of the minimal guidelines and offers additional education and support to others which has yet to be broadly provided. The moderate guidelines would mark an important step forward for allowing more choices in dying and offering additional supports to those involved with dying patients.