Agitated patients are common in the prehospital environment and pose a significant danger to themselves, the public, law enforcement and prehospital medical providers. Pharmacologic and non-pharmacologic options exist for managing agitation in the prehospital setting. Severe agitation is best managed with pharmacologic methods, but the optimal drug or drug combination is unclear. Intramuscular (IM) ketamine has been shown to be very effective at obtaining fast and safe control of severely agitated patient. However, current research on this subject is limited to retrospective studies and case series. This proposal is a 2 year, single-center, double-blind randomized controlled trial which will measure the potential superiority of ketamine compared to a commonly used standard-of-care medication (IM haloperidol) for the rapid sedation of acutely agitated patients in the prehospital environment. It will be the first randomized, controlled, double blind study investigating the use of ketamine compared to haloperidol in the prehospital setting for agitation and will impact prehospital protocols for the treatment and management of agitation. It will potentially aid in the future reduction of harm to medical and law enforcement personnel by violent patients as well as decrease morbidity and mortality to the acutely agitated patients.

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Syfte: Att undersöka om frånvaro av sederingsmål påverkar sederingsnivå samt att kartlägga sederingsdjupet, bedömt enligt Richmond Agitation-Sedation Scale (RASS-skalan) hos intuberade patienter på IVA, Norrlands Universitetssjukhus (NUS). Bakgrund: Vikten av en adekvat sedering är något som medvetandegjorts de senaste åren och trenden inom intensivvård har gått från användandet av djup sedering med muskelblockad till en mer ytlig sederingsstrategi. Översedering leder till olika former av komplikationer i form av förlängd ventilatortid och vårdtid samt ökad mortalitet. Undersedering ökar riskerna för stress och smärta. En adekvat sederingsnivå innebär att patienten är lugn och komfortabel men lättväckt. För att erhålla den optimala sederingsnivån och därigenom undvika de negativa effekterna av både över- och undersedering, är sederingsskalor ett viktigt hjälpmedel. Design: En journalgranskning med kvantitativ ansats och med retrospektiv design utfördes. Metod: Under perioden 1 januari till 30 juni vårdades totalt 422 patienter på IVA, NUS. Efter granskning enligt inklusions- och exklusionskriterier återstod 46 patienter som ingick i studien. Journalerna granskades med avseende på ordinerade mål och bedömda nivåer enligt RASS. Populationsbeskrivning samt insamlade RASS mål och nivåer fördes in i Statistical Package for the Social Sciences (SPSS 23,0). Resultat: Hos studiens 46 patienter registrerades totalt 216 dygn där patienterna varit sederade och intuberade. Av dessa saknades ordinerat sederingsmål 47% av dygnen. Frånvaro av ordinerat sederingsmål påverkade inte sederingsdjupet så att statistisk signifikant skillnad förelåg mellan patienter med och utan mål. Totalt registrerades 1048 uppmätta RASS nivåer med syfte att kartlägga sederingsdjup. Medelvärdet för varje enskild patient per dygn räknades ut och alla medelvärden sammanställdes. Sederingsdjupen låg på en lägre nivå än -3 de första fyra dygnen för att därefter gå mot en ytligare nivå. Konklusion: Genom att identifierar bakomliggande faktorer till smärta och oro kan sjuksköterskan bidra med att minska många negativa konsekvenser av inadekvat sedering. Det var ett positivt fynd att sederingsdjupen förändrades över tid till en mer, enligt litteraturen adekvat, sederingsnivå. Utifrån resultatet ses ett behov av fler studier för att kunna utröna vad som påverkar RASS-nivåerna och för att utvärdera hur adekvat sederade patienter är. Det skulle vara av intresse att undersöka detta på en större population och under en längre tidsperiod. / Aim: To investigate if absence of goals for sedation affect the level of sedation and to map out the depth of sedation, assessed according to the Richmond Agitation-Sedation Scale (RASS-scale) on intubated patients at the Intensive Care Unit (ICU), Norrlands Universitetssjukhus (NUS). Background: The importance of adequate sedation is something that has been raised to awareness the last years and the trend within intensive care has gone from extensive use of sedatives with neuromuscular blocking agents to a more lightly sedative strategy. Over-sedation leads to different kinds of complications such as prolonged mechanical ventilation and hospital stay and also increases mortality rates. Under-sedation increases the risk for stress and pain. An adequate level of sedation is defined as when the patient is calm and comfortable yet easy to arouse from sleep. To obtain the appropriate level of sedation, and thereby avoiding the negative effects of both over- and under-sedation, sedation scales are an important tool. Design: Data was collected using medical records. A quantitative approach with retrospective design was performed. Method: From january 1st to june 30th 2015 a totalt of 422 patients were admitted to the ICU, NUS. After auditing the medical reccords according to the inclusion- and exklusionkriterias 46 patients were included in the study. The medical records were audited regarding sedation goals and sedation scores according to the RASS scale. All collected patients’ characteristics, RASS goals and levels were typed in to the Statistical Package for the Social Sciences (SPSS 23,0). Results: The 46 patients in the study were sedated and intubated a totalt of 216 days. Sedation goals were absent 47% of those days. An absence of sedation goals did not affect the depth of sedation, there were no significant difference between patients with and without sedation goals. In totalt 1048 sedation scores as measured by the RASS scale were collected with the purpose of maping out the sedation depth. The mean for each patient per every 24 hours were calculated and compiled. The sedation scores were lower than -3 the first four days, thereafter the scores changed towards a less heavy sedation. Conclusion: By identifying underlying factors for pain and anxiety, the ICU nurse can reduce the many negative consequences of inadequate sedation. It was a positive finding that the depth of sedation changed over time towards a, according to previous studies, more appropriate level of sedation. The results indicate that there is a need for further studies to investigate what affect the levels of sedation and to assess how appropriate patients are sedated. It would be of interest to examine this on a larger group of patients and for a longer period of time.

<p>In this case study research project I have determined that multidrug sedation in children younger than eight years are possible.<br /> Conscious sedation [or sedation where verbal contact with the patient is possible] can be used successfully to decrease anxiety and fear for unpleasant experiences, like dental procedures.</p> <p><br /> Behaviour therapy in conjunction with one or more drugs can be used to depress the central nervous system in order to decrease the patient&rsquo / s awareness of unpleasant stimuli. This enables treatment to be carried out without patient interference. Extensive literature surveys were done to determine the ideal drugs as well as the ideal route for conscious sedation in dental treatment for children. In this study project drugs like midazolam, propofol, alfentanyl and ketamine were titrated intravenously to achieve conscious sedation.</p>

<p>In this case study research project I have determined that multidrug sedation in children younger than eight years are possible.<br /> Conscious sedation [or sedation where verbal contact with the patient is possible] can be used successfully to decrease anxiety and fear for unpleasant experiences, like dental procedures.</p> <p><br /> Behaviour therapy in conjunction with one or more drugs can be used to depress the central nervous system in order to decrease the patient&rsquo / s awareness of unpleasant stimuli. This enables treatment to be carried out without patient interference. Extensive literature surveys were done to determine the ideal drugs as well as the ideal route for conscious sedation in dental treatment for children. In this study project drugs like midazolam, propofol, alfentanyl and ketamine were titrated intravenously to achieve conscious sedation.</p>

Magister Scientiae Dentium - MSc(Dent) / In this case study research project I have determined that multidrug sedation in children younger than eight years are possible.Conscious sedation [or sedation where verbal contact with the patient is possible] can be used successfully to decrease anxiety and fear for unpleasant experiences, like dental procedures. Behaviour therapy in conjunction with one or more drugs can be used to depress the central nervous system in order to decrease the patient&rsquo;s awareness of unpleasant stimuli. This enables treatment to be carried out without patient interference. Extensive literature surveys were done to determine the ideal drugs as well as the ideal route for conscious sedation in dental treatment for children. In this study project drugs like midazolam, propofol, alfentanyl and ketamine were titrated intravenously to achieve conscious sedation. / South Africa

Driven by research studies and national targets, sedation practices in Intensive care Units (ICU) are undergoing change. Traditionally, ventilated patients in ICUs were kept deeply sedated and only gradually ‘weaned off’ sedation. However, current evidence supports a more ‘wakeful’ patient with the introduction of ‘sedation holds’ encouraging them to regain consciousness (Kress et al. 2000). There is little research exploring ICU nurses’ assessment and management of sedation. Employing a Heideggerian, hermeneutic phenomenological approach to enquiry, the study sought to provide insights into the world of the critical care nurse, nursing with technology, and specifically their beliefs surrounding sedation practices and how organisational factors, knowledge and personal experiences influence their clinical decisions in the care of the ventilated patient. The setting was the Royal Infirmary of Edinburgh, ICU and the purposive sample consisted of 16 ICU nurses with diverse critical care nursing experience. Bedside interviews, utilising an aide memoir, elicited narratives about the nurses’ experiences of sedation practice and a novel sedation monitor (responsiveness). The phenomenological analysis drew upon a number of existing frameworks to guide enquiry. The researcher engaged with the ‘hermeneutic circle’, acknowledging her pre-understandings and using these as a platform to move between the whole of the research and the parts, the descriptions and narratives offered, to develop new knowledge. Themes emerged that demonstrated patients’ sedation status directly impacted upon the nurses’ ICU lived experiences and left them in a state of disequilibrium regarding the requirement to deliver research based care, the desire to deliver holistic care and the duty to deliver safe care. The nurses perceived sedation holds and ‘wakefulness’ as resulting in patient agitation and distress which affected patient safety and comfort. However, the nurses equally felt a pressure of obligation to the doctors to perform such evidence based sedation holds. They described the struggling to maintain patient safety and manage their own fears and anxieties and organisational constraints, whilst experiencing guilt, blame and failure associated with their behavioural discordance with the prescribed decisions and their own clinical decision making processes and strategies. Team work between the two professions and effective leadership is evidently less than ideal. Consequently the implementation of changes in sedation practice is failing to meet either the national targets or to respond to the nurses’ concerns regarding their patient’s short term wellbeing. On both counts this potentially impairs the pursuit of best practice.

PURPOSE: To create a study designed to assess patient satisfaction and preference for oral versus intravenous sedation in conjunction with periodontal surgical procedures. METHODS: Twenty-six patients who required at least two periodontal surgery procedures and requested sedation for treatment, participated in our study at VCU Department of Periodontics. This was a randomized, cross-over design with groups which received an intravenous sedative regimen with or without oral sedation premedication for one surgery and oral sedation medication alone for the other surgery. The primary outcome measurement was the type of sedation preferred by the subject. RESULTS: 14/26 (53.8%) subjects indicated a preference for intravenous sedation, compared with 7/26 (26.9%) subjects who preferred oral sedation alone. 1/26 (3.8%) subject reported that they would prefer no sedation after experiencing both oral and oral/intravenous combination sedation methods. 4/26 (15.3%) of the subjects who completed the study reported “No Difference” with regards to their preference for either method of sedation. CONCLUSION: More subjects preferred intravenous sedation and would consent to the sedation again for any future needed surgery. This study supports the need to offer intravenous sedation with periodontal surgery

We recognise consciousness in ourselves and in those around us. Consciousness is the essence of our existence, who and what we are, but we are willing and able to let go of it daily during sleep, which we welcome and associate with rest, recovery and well being, knowing that consciousness will return reliably, when we are ready. Yet we cannot define this thing or process which makes us "us". We do not understand how it is constructed from the activity in our brains, how it is deconstructed by sleep, drugs or disease, or how it can be reconstructed by waking or recovery. Our ignorance renders us reliant on inadequate means of measuring consciousness, dependent on movement for its detection. Propofol is an intravenous anaesthetic drug with the capacity to safely, rapidly and reliably produce sedation and anaesthesia, providing an ideal model of unconsciousness for study. Functional magnetic resonance imaging (fMRI) provides a non-invasive means of measuring activity within the brain. EEG is a convenient broad measure of neuronal activity. This thesis exploits the advantages of each of these techniques, fMRI and EEG, first separately and then together, to link highly informative, spatially specific fMRI observations to convenient, reproducible electrophysiological surface measurements. A safe and reliable model of unconsciousness suitable for fMRI interrogation is first developed and explored. Changes in the spatial extent and interregional correlation of neuronal activity when subjects become unresponsive show that the functional connectivity of the striatum is specifically impaired as perception fails. Disruption of the brain’s internal temporal frame of reference impairs the synthesis of perceptions from their fragments. The second experimental chapter specifically examines the behaviour of sleep oscillations during ultraslow increases and decreases in the depth of sedation with propofol. Functional activity shows that the brain is intensely active despite loss of consciousness and reveals measurable transitions in neuronal activity. Combined simultaneous EEG/FMRI then shows that these transitions reflect stepwise changes in the processing of experience and a shift from externally modulated thalamocortical signaling to an internal dialogue.

Propofol has been gaining increased attention as a sole agent in providing procedural sedation due to its predictable pharmacokinetics and favorable amnestic properties. Oral and maxillofacial surgical procedures are unique in duration and concomitant use of local anesthesia making it difficult to evaluate data obtained from other specialties. The purpose of our study is to evaluate the safety, efficacy and satisfaction among surgeons and patients using propofol only, for procedural sedation during the extraction of third molars. Propofol 10mg/ml was administered using an induction dose of 0.5 to 1mg/kg over 60 seconds followed by bolus doses of 10 – 20mg every minute to achieve a Ramsay sedation score of at least 3. Respiratory compromise was identified in 15% of patients. Hemodynamic compromise was identified in 15%. Patient and surgeon satisfaction was high however propofol does not represent the ideal drug as a sole agent for procedural sedation in oral surgery due to the frequent need for hand restraint (40%).