Dexmedetomidine for Maintaining Sedation

During prolonged mechanical ventilation, sedation with midazolam or propofol is associated with serious adverse effects. Jakob and colleagues assessed the efficacy of dexmedetomidinean 2-agonist sedativecompared with either midazolam or propofol in 2 multicenter randomized trials that involved 998 patients expected to require more than 24 hours' mechanical ventilation. Among the authors' findings was that dexmedetomidine was not inferior to midazolam or propofol in maintaining light to moderate sedation or in reducing total ventilation duration compared with midazolam. However, dexmedetomidine was associated with more adverse events. In an editorial, Wunsch discusses the costs and benefits of sedative options for critically ill patients undergoing mechanical ventilation.

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Epinephrine is widely used in resuscitation of patients with out-of-hospital cardiac arrest; however, its effectiveness is not established. Hagihara and colleagues analyzed registry data from 417188 patients with out-of-hospital cardiac arrest to assess the relationship between prehospital epinephrine use and mortality and functional status among survivors. The authors report that prehospital epinephrine use was associated with increased return of spontaneous circulation before hospital arrival but decreased the likelihood of survival at 1 month or survival with good functional status. In an editorial, Callaway discusses the evidence that epinephrine use during cardiopulmonary resuscitation may not improve patient-oriented outcomes.

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Immunosuppressive induction therapyroutine in organ transplantsreduces the risk of organ rejection but is associated with adverse effects. Infusion of bone marrowderived mesenchymal stem cells, which have immunoregulatory effects, may offer an alternative immunosuppressive approach. In a randomized trial of 159 patients undergoing living-related kidney transplants, Tan and colleagues found that compared with conventional antiinterleukin 2 receptor antibodybased therapy, a regimen that involved infusion of autologous mesenchymal stem cells was associated with a lower incidence of acute rejection and better renal function at 1 year.

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The use of anesthesiologists or nurse anesthetists to administer procedural sedation during outpatient endoscopies increases costs. In a retrospective analysis of claims data from 1.1 million Medicare beneficiaries and 5.5 million commercially insured patients, Liu and colleagues found that utilization of anesthesia services during upper endoscopies and colonoscopies increased from approximately 14% in 2003 to more than 30% in 2009. The majority of anesthesia services were provided to low-risk patients and varied across geographic regions. In an editorial, Fleisher discusses factors that may contribute to increased use of anesthesia services for patients undergoing endoscopy procedures.

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Mrs N, a 75-year-old woman, has a several-year history of hearing loss, which is more bothersome to her family than herself. Pacala and Yueh discuss the prevalence, etiology, and consequences of hearing loss in older patients; its evaluation and treatment, including the selection and fitting of hearing aids; and special challenges to effective hearing aid use among older adults with multiple comorbidities.

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