Patient-controlled sedation

Morley HR, Karagiannis A, Schultz DJ, Walker JC, Newland HS. Sedation for vitreoretmal surgery a comparison of anaesthetist-administered midazolam and patient-controlled sedation with propofol. Anaesth Intensive Care 2000 28(1) 37 2. 

Droperidol 0.5 micrograms reduced the need for postoperative morphine delivered via a patient-controlled analgesia device (31). At these doses it was non-sedating and caused no dyskinetic movements. 

Forty anxious day-case patients undergoing extraction of third molar teeth under local anesthesia with sedation, were studied in a randomized, double-blind, controlled trial (38). A target-controlled infusion of propofol was compared with patient-controlled propofol for sedation, combined with a small dose of intravenous midazolam (0.03 mg/kg) to improve amnesia. Five patients became over-sedated in the target-controlled group compared with none in the patient-controlled group. 

Burns R, McCrae AF, Tiplady B. A comparison of target-controlled with patient-controlled administration of propofol combined with midazolam for sedation during dental surgery. Anaesthesia 2003 58 170-6. 

Relief of pain after surgery can be achieved with a variety of techniques. An epidural infusion of a mixture of local anaesthetic and opioid provides excellent pain relief after major surgery such as laparotomy. Parenteral morphine, given intermittently by a nurse or by a patient-controlled system, will also relieve moderate or severe pain but has the attendant risk of nausea, vomiting, sedation and respiratory depression. The addition of regular paracetamol and a NSAID, given orally or rectally, will provide additional pain relief and reduce the requirement for morphine. NSAIDs are contraindicated if there is a history of gastrointestinal ulceration of if renal blood flow is compromised. 

Sedation and nausea are relatively frequent. When buprenorphine is used for patient-controlled analgesia, minor dysphoria or euphoria has been reported (SEDA-16, 88). 

The more novel routes of administration of opioids, including oral, nasal, rectal, transdermal, spinal, and by patient-controlled methods, have been outlined (SEDA-17, 78). Oral transmucosal fentanyl administration, avoiding first-pass metabolism, produces analgesia and sedation in both adults and children undergoing short, painful outpatient procedures. The quality of analgesia is good, and the adverse effects are those typical of the opioids. 

Drug administration route Patient-controlled epidural analgesia with bupivacaine 0.06% and hydromorphone 10 micrograms/ml in postoperative 3736 orthopedic patients was associated with nausea (30%), pruritus (15%), hypotension (10%), and sedation (0.08%) [105. Respiratory depression was not reported, and Acre were no epidural hematomas or abscesses. 

In a comparison of intravenous morphine and oxycodone in patient-controlled postoperative analgesia after laparoscopic hysterectomy in 91 patients, oxycodone consumption at 24 hours was less than morphine consumption [137 ]. Those who received oxycodone reported less pain and were significantly less sedated. There were no other differences in adverse reactions. 

Remifentanil (40 micrograms/bolus, lockout of 2 minutes, limit 1200 micrograms/hour, n=52), pethidine (49.5 mg- -5 mg bolus, lockout 10 minutes, limit 200 mg, =53), and fentanyl (50 micrograms - - 20 microgram boluses, lockout 5 minutes, limit 200 micrograms/hour, =54) have been compared for obstetric patient-controlled analgesia [172 "]. Remifentanil was associated with more periods of desaturation and more sedation and pruritus. 

Nilsson A, Nilsson L, Ustaal E, Sjoberg F. Alfentanil and patient-controlled propofol sedation - facilitate g)maecological outpatient surgery with increased risk of respiratory events. Acta Anaesthesiol Scand 2012 56 1123-9. 

The most common adverse reaction associated with phenobarbital is sedation, which can range from mild sleepiness or drowsiness to somnolence. These dru > may also cause nausea, vomiting, constipation, bradycardia, hypoventilation, skin rash, headache fever, and diarrhea Agitation, rather than sedation, may occur in some patients. Some of these adverse effects may be reduced or eliminated as therapy continues. Occasionally, a slight dosage reduction, without reducing the ability of the drug to control the seizures, will reduce or eliminate some of these adverse reactions. 

Propofol (Diprivan) is used for induction and maintenance of anesthesia. It also may be used for sedation during diagnostic procedures and procedures that use a local anestiietic. This drug also is used for continuous sedation of intubated or respiratory-controlled patients in intensive care units. 

Imipramine treatment resulted in a higher rate of remission of anxiety symptoms than trazodone, diazepam, or placebo (e.g., 73% versus 69% versus 66% versus 47%) in an 8-week controlled trial of DSM-III-diagnosed GAD patients. Antidepressants were more effective than diazepam or placebo in reducing psychic symptoms of anxiety. The use of TCAs generally is limited by bothersome adverse effects (e.g., sedation, orthostatic hypotension, anticholinergic effects, and weight gain). 

Antihistamines such as diphenhydramine are known for their sedating properties and are frequently used over-the-counter medications (usual doses 25-50 mg) for difficulty sleeping. Diphenhydramine is approved by the FDA for the treatment of insomnia and can be effective at reducing sleep latency and increasing sleep time.43 However, diphenhydramine produces undesirable anticholinergic effects and carryover sedation that limit its use. As with TCAs and BZDRAs, diphenhydramine should be used with caution in the elderly. Valerian root is an herbal sleep remedy that has inconsistent effects on sleep but may reduce sleep latency and efficiency at commonly used doses of 400 to 900 mg valerian extract. Ramelteon, a new melatonin receptor agonist, is indicated for insomnia characterized by difficulty with sleep onset. The recommended dose is 8 mg at bedtime. Ramelteon is not a controlled substance and thus may be a viable option for patients with a history of substance abuse. 

---