Philosophiae Doctor - PhD / Conscious sedation or moderate sedation and analgesia is an effective and popular alternative option for procedures outside the operating theater. If conscious sedation is a viable alternative to general anaesthesia then we as sedation practitioners must use safe sedation techniques in facilities that meet all the requirements for safe practice. Three studies were done to determine the safety and efficacy of conscious sedation outside the operating theatre. In the first study post sedation satisfaction in one hundred children aged 3-9 years was evaluated. It was extremely important to determine whether the combination of midazolam, ketamine and propofol, called an advanced sedation technique (SASA, 2015), can be safely used for paediatric sedation outside the operating theatre. The incidence of side-effects after conscious sedation using multiple drugs were documented. It is clear that intravenous sedation with midazolam, ketamine and propofol is safe and effective to use. There may be side effects but they are not long lasting and usually not life-threatening. In the second study intravenous sedation was administered to 447 adults (aged 18 years and older) using fentanyl (sublimazeR), ketamine (ketalar), midazolam (dormicum) and propofol (Diprivan) (FKMP) called an advanced sedation technique. Post sedation satisfaction, post sedation recovery on arrival home, and the relationship between side effects and different dental procedures were evaluated. The results of the study show that side effects are possible, and can be expected, when we use sedative and analgesic drugs for sedation. However, we report a low incidence of side effects when we compare it with other studies in literature as mentioned. It is known that the use of combinations of drugs may cause unforeseen synergistic pharmacological effects which can be lifethreatening. Our results show that the drugs used can be safely used for advanced sedation techniques. In trying to demonstrate the safety of sedative and analgesic agents used during sedation we looked at the haemodynamic parameters, duration of sedation, pulse rate and systolic blood pressure, in the third study. The sedation records of 335 patients for dental surgery were assessed for the period 2010 – 2011. Our results show the mean Duration of sedation is substantially and statistically significantly greater with combination FKMP than with the other combinations. The mean duration of sedation is not significantly different between ketamine and propofol (KP) and fentanyl, ketamine and propofol (FKP) (Figure 10). The use of polypharmacy regarding the combination of drugs, specifically FKMP, will cause a longer duration of sedation. This has implications for safety, as well as the side effect profile during and after sedation. When we use combinations of drugs patients were more comfortable which shows that we do not yet have a single drug that has all the characteristics of an ideal drug for sedation. Different combinations of drugs are used by other practitioners with a higher incidence of side effects. It is difficult to explain the higher values of blood pressures when all four drugs were used. It may have been a ketamine effect, although one would not expect this when using propofol with ketamine. In clinical terms the higher blood pressures are no reason for concern as all our patients were classified as ASA I and II. Our research study support the view that ketamine can be used safely outside the operating theatre with exciting possibilities for Third World countries for procedures outside the operating theatre. Sedation can be considered a reasonable alternative to general anaesthesia for certain surgical procedures in the Third World. Sedation will be an attractive option not only as far as costs are involved but also the availability of sedation providers. The important lesson from all the results is that sedation providers must be trained in procedural sedation as defined by all international sedation guidelines. We proved in this research study that sedation can be done safely, however we need to make a contribution to train sedation providers. Sedation will become an attractive alternative to general anaesthesia because of the low side-effect profile and high patient satisfaction. It is interesting that few studies are available that looked at this aspect of sedation. It is clear that a high side-effect profile can contribute to an unsafe sedation technique. Severe nausea and vomiting can cause numerous haemodynamic disturbances and dehydration. Our research study support the findings of the study by Lapere et al., (2015) that there is a high rate of patient satisfaction, and a low side-effect profile during and after sedation. This is an extremely important research study and the results are crucial as far as an option for healthcare in developing countries. Sub-Saharan Africa is a densely populated and resource poor subcontinent that provides unique challenges in patient care. These challenges include a lack of facilities and staff for the performance of operative as well as non-operative procedures. In conclusion, we feel that we are part of Sub-Saharan Africa with all the problems mentioned as far as provision of healthcare is concerned. This research study can make a crucial contribution to safe and cost-effective management of healthcare in Africa for procedures outside the operating theatre.

O presente estudo objetivou avaliar a sedação e analgesia promovida pela morfina em teiús (Salvator merianae). Foram utilizados oito animais jovens, de ambos os sexos, pesando entre 300 e 1800gr, os quais foram submetidos a três tratamentos, a saber: G5 - 5mg/kg de morfina via intramuscular (IM); G10 - 10mg/kg de morfina IM e G0 - o qual recebeu 0,5mL de NaCl 0,9% IM. O presente estudo foi dividido em duas etapas. A primeira etapa avaliou a sedação promovida pela morfina através da avaliação da atividade locomotora e através dos parâmetros comportamentais. A segunda etapa consistiu na avaliação da analgesia promovida pela morfina frente a um desafio de estímulo térmico. Em ambas as etapas, os animais foram avaliados antes do tratamento (basal) e em 0,5, 1, 2, 3, 4, 6, 12 e 24 horas após o tratamento e os avaliadores desconheciam os tratamentos. As diferenças foram consideradas significantes quando P < 0,05. A temperatura corpórea foi avaliada durante a realização das duas etapas, e em ambas, a temperatura se manteve constante em todos os grupos em relação ao basal, com exceção do momento 12 horas. Na comparação entre grupos, G5 e G10 diferiram de G0 nos momentos 4 e 6 horas durante a primeira etapa e não apresentaram diferenças em relação a G0 durante a segunda etapa. Na avaliação da atividade locomotora, G0 manteve-se constante em todos os momentos em relação ao basal, exceto no momento 12 horas, G5 se mostrou diferente do basal nos momentos 0,5, 4 e 12h e G10 entre os momentos 0,5 hora e 12 horas. Na comparação entre grupos, G5 foi menor que G0 e igual a G10 nos momentos 0,5, 3 e 4horas, porem foi maior que G10 e igual a G0 nos momentos 1,2 e 6h. A avaliação dos parâmetros comportamentais evidenciou diferença entre G5 e o basal nos momentos 2 e 4 horas e em G10 nos momentos 3 e 6 horas, na comparação entre grupos, G5 foi diferente de G0 nos momentos 2 e 4h, e G10 e G0 diferiram entre 1 e 6 horas. G5 e G10 foram iguais entre si em todos os momentos, com exceção do momento 6 horas. A avaliação da analgesia mostrou G0 igual ao basal em todos os momentos de avaliação, exceto em 12 horas após o tratamento, já G5 e G10 demonstraram maior tolerância ao estímulo térmico nos momentos 0,5, 1 e 12h e nos momentos 2, 3, 4, 6 e 12 horas, respectivamente. A comparação entre grupos demonstrou um maior tempo para a retirada do membro, G5 foi maior que G0 nos momentos 0,5, 1 e 4 horas e G10 a partir de 1 hora até 12 horas após o tratamento. A morfina promove redução da atividade locomotora, aumento na pontuação dos parâmetros comportamentais e aumento do tempo de retirada do membro de forma dose-dependente, sugerindo uma ação sedativa e analgésica em teiús. / This study aimed evaluate the sedation and analgesia provided by morphine in tegus (Salvator merianae). Eight young animals were used, of both sexes, weighing between 300 and 1800gr, which underwent three treatments: G5 - 5 mg / kg of morphine intramuscularly (IM); G10 - 10 mg / kg IM and G0 morphine - which received 0.5 ml of 0.9% NaCl (IM). The study was divided into two stages. The first step sedation assessed by morphine promoted by evaluating locomotor activity and through behavioral parameters. The second step was to assess the analgesia provided by morphine facing a challenge of thermal stimulus. In both phases, animals were assessed before treatment (baseline) and 0.5, 1, 2, 3, 4, 6, 12 and 24 hours after treatment and blinded to the treatments. The body temperature was evaluated during the course of the two stages, and both the temperature remained constant in all groups compared to baseline, except the moment 12 hours. In the comparison between groups, G5 and G10 differed G0 in moments 4 and 6 hours during the first stage and showed no differences from G0 during the second stage. In the assessment of locomotor activity, G0 remained constant at all times over the baseline, except at 12 hours, G5 showed different from baseline at times 0.5, 4 and 12 hours and G10 times between 0.5 hours and 12 hours. In the comparison between groups, G5 was lower than G0 and the same of G10 at times 0.5, 3 and 4 hours, however was higher than G10 and the same as G0 in times 1.2 and 6 hours. The behavioral parameters showed difference between G5 and baseline at times 2 and 4 hours and G10 and baseline at times 3 and 6 hours, in comparison between groups G5 and G10 were different in at 2 and 4 hours, and G10 and G0 were different at 1 to 6 hours. G5 and G10 were the same at all times, except at 6 hours after treatment. The evaluation of analgesia showed G0 equal to baseline at all times except at 12 hours after treatment, as G5 and G10 showed increased tolerance to thermal stimulus at times 0.5, 1 and 12h and at times 2, 3, 4, 6 and 12 hours, respectively. Comparison between groups showed a longer time for the withdrawal hind limb, G5 is greater than G0 at times 0.5, 1 and 4 hours and G10 from 1 hour to 12 hours after treatment. Morphine causes a reduction of locomotor activity, increased score of behavioral parameters and increased time of withdrawal hind limb in a dose-dependent manner, suggesting a sedative and analgesic action in tegus.

After steep declines due to overharvest and habitat loss, North American river otter (Lontra canadensis) populations have been increasing in most of the U.S. Radiotelemetry is an essential tool for understanding river otter habitat use, survival rates, and sources of mortality, which is important for successfully managing these growing populations. Surgically implanting radiotransmitters is standard for river otters, but strict requirements for the handling and transport of DEA-scheduled drugs for sedation, and the lack of accessible surgery suites, can limit researchers. My objectives were to: (1) develop a non-scheduled drug combination to sedate river otters and surgically implant intra-abdominal transmitters in a field setting, (2) determine survival rates and causes of mortality for river otters, and (3) quantify fourth order habitat selection at river otter daytime resting sites. During 2018-2020, I surgically implanted 24 river otters with transmitters in southern Illinois and monitored them via radiotelemetry to determine survival and causes of mortality. The effectiveness of the drug combination of Dexmedetomidine and Nalbuphine for chemically immobilizing river otters was tested to determine the appropriate dosage. I used homing to track river otters to 132 daytime resting sites where I described the structure used, closest water type, and distance to water; for 51 of these resting sites I also measured understory cover, overstory cover, distance to water, and presence of river otter and beaver sign. These 51 sites were paired with 1-4 random riparian locations, where I measured the same habitat variables. I then modeled habitat selection of daytime resting sites using conditional logistic regression. A combination of 0.06 mg dexmedetomidine/kg and 1.2 mg nalbuphine/kg injected intramuscularly followed by a 10-15 min induction period was sufficient to chemically immobilize river otters enough for further sedation with 1-4% isoflurane gas. Surgery in the field was successful, with only 2 sedation-related mortalities recorded. Estimated river otter survival was 0.84 ± 0.09 with no difference between males (0.83 ± 0.11) and females (0.86 ± 0.13) ( = 0, P = 0.900) and or between protected areas (0.80 ± 0.10) and harvested areas (0.83 ± 0.15) ( = 0.3, P = 0.600). Four river otters died (2 harvest, 2 unknown causes) during my study. Daytime rest sites were located in non-enclosed vegetation (n = 54) as well as enclosed sites, such as bank dens (n = 39), beaver lodges (n = 33), and wood piles (n = 6). River otters selected for greater understory cover at all sites, though enclosed sites had less understory cover than non-enclosed sites (all P ≤ 0.001). The top habitat selection model included the parameters understory cover and the beaver sign but did not include canopy cover. My study offers a novel way to sedate river otters without DEA-scheduled drugs, updates information about river otter survival, and provides new information on fourth order habitat selection at daytime resting sites.

Introduktion/Bakgrund: Patienter i livets slutskede som upplever outhärdliga symtom kan få palliativ sedering. Sjuksköterskor har en viktig roll när palliativ sedering tillämpas. De har ansvar för att stötta och företräda både patient och närstående. Det finns en brist på forskning om närståendes upplevelser av palliativ sedering. Syfte: Syftet med litteraturstudien var att belysa hur det upplevs att vara närstående till en patient som får palliativ sedering. Metod: Litteraturstudien genomfördes enligt Polit och Becks (2016) nio steg. Databassökningen gjordes i tre databaser; PubMed, Cinahl samt PsycINFO där åtta artiklar identifierades till resultatet. Resultat: Närståendes upplevelser sammanställdes i fem teman: önskan om en god död, behov av information och kunskap, tankegångar, möjlighet till avsked och känsla av ansvar. Slutsats: Närstående hade en positiv upplevelse av palliativ sedering. De tveksamheter som närstående generellt hade var om patientens välmående, eventuell förkortning av livet samt ifall sederingen gav en god död. Resultatet visade ett stort behov av information och kunskap från vårdgivare för att närstående skulle ha en bättre upplevelse.

Background: Mechanical ventilation and sedation are common in intensive care and can be stressful for the patient as many experience physical and mental complications such as delirium. Nurses in intensive care play an important role in assessing the need for pain relief and sedation. The care environment and communication opportunities are also factors that affect patients' experiences. Aim: The aim of the study was to make patients' experiences of having been mechanically ventilated and/or sedated in an intensive care unit visible. Method: A literature study was chosen to get a picture of the current state of knowledge. Based on a thematic analysis method 15 articles were analyzed. Results: The analysis resulted in the following themes: fear and anxiety with subthemes physical and psychological experiences, security and trust with subthemes environment and communication as well as cognition and memories with subthemes confusion and dreams. Conclusion: It is a difficult experience to be mechanically ventilated and/or sedated in an intensive care unit. Communication difficulties were a prominent experience that affected many patients. Continued research: Continued research is necessary in the subject matter of the study. There is also a need for research on the care environment and communication aids for intensive care patients.  Keywords: Sedation, mechanical ventilation, intensive care and experiences. / Bakgrund: Mekanisk ventilation och sedering är vanligt förekommande inom intensivvården och kan vara påfrestande för patienten då många upplever fysiska och psykiska komplikationer som till exempel delirium. Specialistsjuksköterskor inom intensivvård har en viktig roll vid bedömning av behov av smärtlindring och sedering. Även vårdmiljö och kommunikationsmöjligheter är faktorer som påverkar patienters upplevelser. Syfte: Syftet med studien var att synliggöra patienters upplevelser av att ha varit mekaniskt ventilerade och/eller sederade på en intensivvårdsavdelning. Metod: En litteraturstudie valdes för att få en bild av det aktuella kunskapsläget. Utifrån tematisk analysmetod analyserades 15 artiklar. Resultat: Analysen resulterade i följande teman: rädsla och ångest med subteman fysiska- och psykologiska upplevelser, trygghet och tillit med subteman omgivning och kommunikation samt kognition och minnen med subtema förvirring och drömmar. Slutsats: Det är en svår upplevelse att vara mekaniskt ventilerad och/eller sederad på en intensivvårdsavdelning. Kommunikationssvårigheter var en framträdande upplevelse som påverkade många patienter. Fortsatt forskning: Fortsatt forskning är nödvändig inom ämnet som studien berör. Det finns även behov av forskning kring vårdmiljön samt kommunikationshjälpmedel för intensivvårdspatienter.  Nyckelord: Sedering, mekanisk ventilering, intensivvård och upplevelser.

Introduction: Adequate post-intubation sedation and analgesia (PISA) practices are important in the pre-hospital setting where vibration and noise of the transport vehicle may contribute to anxiety and pain in the patient. Inadequate post-intubation practices may lead to long-term detrimental effects in patients. Despite this, these practices are poorly described in the prehospital setting. This study aims to describe the current pre-hospital PISA practices in a private South African emergency medical service. Methodology: Patient report forms (PRF) of intubated patients between 1 Jan 2017 and 31 Dec 2017 from a single private ambulance service were reviewed. Data was analysed descriptively. Correlations were calculated with Spearman's Rank correlations and group differences were calculated with Independent T tests and Mann-Whitney U tests. Significant correlations were entered into a binomial regression model to determine predictive value of receiving PISA. Results: The number of PRFs included for analysis was 437. Of these, 69% of patients received some type of PISA. The estimated time from intubation to 1st PISA ranged from 9 to 12 minutes. There were statistically significantly more PISA interventions in patients who had received Rocuronium (p< 0.01). There was weak but significant correlation between the number of interventions and the mean arterial pressure, (rs = 0.17, p< 0.01) and Glasgow Coma Scale (rs = -0.15, p< 0.01) prior to intubation, along with the transport time to hospital (rs = 0.23, p< 0.01). Conclusion: The PISA practices in the South African pre-hospital setting is comparable to international pre-hospital settings. The time to 1st PISA appears to be shorter in the SA setting. There is an increased number of interventions in the patients who received Rocuronium, which may indicate practitioners being mindful of wakeful paralysis. Practitioners also take the level of consciousness and blood pressure prior to intubation into account when administering PISA. Longer transport times attribute to patients receiving more PISA interventions.

Indiana University-Purdue University Indianapolis (IUPUI) / Treating pediatric dental patients four years old and younger can be difficult at times due to patient behavior. Conscious sedation has been employed as a means to control pediatric dental patients for several years. Butorphanol tartrate has been used safely for pain control in pediatric patients for several years, but has never been used for sedating pediatric dental patients. The purpose of this study is to compare the behavioral and physiologic effects of conscious sedation on pediatric dental patients using intramuscular meperidine and an equipotent dosage of intramuscular butorphanol. Forty conscious sedations of ASA I pediatric dental patients between the ages of 13 and 60 months were accomplished using either 2.0 mg/kg of intramuscular meperidine or 0.03 mg/kg of intramuscular butorphanol. Each sedation was videotaped and three viewers viewed the videotapes rating them with a computer program (ACS) involving a four-code behavior rating scale. The tlrree viewers rated patient behavior for each sedation also with a form with global rating, categorical, and dichotomous scales. Physiologic signs of oxygen saturation, blood pressure, heart rate, and respiration rate were monitored at baseline and every 5 minutes during treatment. The operator also rated the sedation patient behavior with a form that had pre-treatment Frankl, post-treatment Frankl, global rating categorical, dichotomous, and sedation success rating scales. The two groups demographic data, physiologic data, ACS data, the three viewer's behavior rating form, and the operator's behavior rating form were analyzed for any statistically significant differences between the groups. The statistical analysis of the demographic data revealed a statistically significant trend in the butorphanol group toward extractions. The meperidine group had a statistically significant higher mean oxygen saturation during treatment (99.63 percent) than the butorphanol group (99.20 percent). The butorphanol group spent significantly more time in the annoyed ACS behavior rating code and showed a trend toward less time spent in the quiet ACS behavior rating code. There were no statistically significant differences in the three viewers ratings of global rating, categorical, and dichotomous scales. The operators' ratings showed the meperidine group had a statistically significant better global rating than the butorphanol group. Overall butorphanol appears to be equal clinically to meperidine in physiologic effects and patient behavior effects. No adverse effects occurred with either medication. Butorphanol may be offered as an alternative sedative agent to other narcotic sedative agents with more side effects.

Bakgrund: Sjuksköterskan är omvårdnadsansvarig och har en central roll inom palliativ vård där målet är att främja välbefinnande och värdighet för patienten. I de fall palliativa patienter upplever outhärdliga symtom trots symtomlindring kan en sista utväg för minskat lidande vara palliativ sedering. Syfte: Syftet var att sammanfatta och beskriva sjuksköterskors erfarenheter av palliativ sedering. Metod: Studiens design är deskriptiv och resultatet är uppbyggt på tio vetenskapliga artiklar som söktes fram via databaserna PubMed och CINAHL. Huvudresultat: Resultatet i litteraturstudien visade att sjuksköterskor som arbetat med palliativ sedering hade flera olika roller. Inom yrkesrollen skulle sjuksköterskan utföra omvårdnad, administrera läkemedel, samarbeta med läkare och bemöta anhöriga. Resultatet visade även att palliativ sedering kunde väcka etiska frågeställningar hos sjuksköterskor vilket kunde leda till emotionell påfrestning. Framträdande i studierna var att trots svårigheter fanns en vilja och tröst i att sjuksköterskans handlingar syftar till att lindra lidande i livets slutskede. Slutsats: Sjuksköterskor kan uppleva etiska svårigheter och en emotionell börda i sin yrkesroll som sjuksköterska vid palliativ sedering. De kan även möta utmaningar då de har flera roller att axla vid palliativ sedering och förutom att lindra patientens lidande ska de också vara ett stöd för anhöriga och informera dem. Sjuksköterskor har en betydelsefull roll i livets slutskede eftersom deras främsta fokus är att främja välbefinnande för patient och anhöriga. / Background: The nurse is responsible for the nursing care and has a central role in palliative care where the aim is to promote well-being and dignity for the patient. In cases where palliative patients experience unbearable symptoms despite symptom relief medications, a last resort for reduced suffering may be palliative sedation. Aim: The aim was to summarize and describe nurses’ experiences of palliative sedation. Method: The study’s design is descriptive and the results are based on ten scientific articles that were gathered through the databases PubMed and CINAHL. Main results: The results of the literature study showed that nurses who had worked with palliative sedation had several different roles. Within the professional role, the nurse would provide nursing care, administer medications, collaborate with doctors and care for patients’ relatives. The results also showed that palliative sedation could raise ethical dilemmas for the nurses, which could lead to emotional distress. However, prominent in the studies was that despite difficulties there was a will and comfort in the fact that the nurses’ actions aim to alleviate suffering in the end of the patients’ lives. Conclusion: Nurses can experience ethical difficulties and an emotional burden related to their professional role in palliative sedation. Nurses can face challenges as they have several roles to play during palliative sedation, and in addition to alleviating the patients’ suffering, the nurses also have to support and give information to the patients’ relatives. Nurses play an important role in patients end of life-care since their main focus is to promote well-being for the patient and relatives.

Figueroa-Ramosa et al. (2013) concluded that the combination of sedation withdrawal and mechanical ventilation withdrawal trial was feasible and well tolerated. The conclusion is not well supported because of the absence of a comparison to the uncombined protocol and due to evidence that the patients did not tolerate them particularly well.

Background Procedural sedation and analgesia (PSA) is considered a core competency in emergency medicine as patients present to the Emergency Centre (EC) on an unscheduled basis, often complex complaints that necessitate emergent management (1). Previous evidence has consistently shown that procedural sedation and analgesia(PSA) in the EC in the paediatric population, even the very young, is safe if appropriate monitoring is performed and appropriate medications are used (2–5). The aim of the study was to describe the indications for PSA in the paediatric EC population, the fasting status of paediatric patients undergoing PSA, and the complications observed during PSA in a single Western Cape emergency centre. Methods A retrospective, descriptive study was conducted at Mitchells Plain Hospital, a district-level hospital situated in Mitchells Plain, Cape Town. All paediatric patients younger than 13 years of age who presented to the EC and received PSA during the study period (December 2020 – April 2021) were included in the study. Data was extracted from a standardised PSA form and simple descriptive statistics were used. Results A total of 116 patients (70,7% male) were included: 13 infants (<1 year of age) 48 young children (1-5 years of age) and 55 older children (5-13 years of age). There were only 2 (1,7%) complications documented, both of which were vomiting and did not require admission. The most of patients received ketamine (93,1%). The standardised PSA form was completed in 49,1% of cases. Indications for PSA included burns debridement (11,2%), suturing (17,2%), fracture reduction (23,3%), lumbar punctures (31,9%) and others (27,6%). The indications for PSA varied between the different age groups. Conclusion The study findings are in accordance with previous international literature. Emergency Centre PSA in the paediatric populations did not show an increase in interventions or complications, despite the fasting status (6). Safe, timely PSA with minimal pain and unnecessary suffering can become the norm in Emergency Medicine practice in South Africa.