Intranasal dexmedetomidine as premedication for magnetic resonance imaging examinations in dogs with neurological disorders mitigates hypotension and hypothermia

OBJECTIVE

This study aimed to evaluate the safety and feasibility of intranasal administration of dexmedetomidine as a premedication for preventing hypotension and hypothermia in canine patients undergoing MRI examinations.

ANIMALS

Dogs undergoing MRI examinations for neurological disorders were enrolled in this study. The dogs were randomly assigned: 15 to the N-Dex group (without premedication) and 13 to the Dex group (125 μg/m2 of dexmedetomidine, intranasally, as a premedication).

METHODS

During the examination, pulse rate, systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure were recorded every 5 minutes for the first 30 minutes. Body temperature was measured before and after the examination. Any adverse events during the procedure were documented.

RESULTS

Significant changes in pulse rate during the examination were not distinguishable. Although blood pressure and body temperature decreased in both groups under anesthesia, dogs in the Dex group had a significantly smaller drop in blood pressure and body temperature and fewer hypotension events than those in the N-Dex group MRI examinations of 1 hour's duration. Two dogs in the Dex group exhibited bradycardia at 45 and 60 minutes of MRI examination, which resolved after receiving atipamezole.

CLINICAL RELEVANCE

Our results indicate that intranasal administration of 125 μg/m2 of dexmedetomidine as premedication is safe and can potentially mitigate hypothermia and hypotension in dogs with neurological disorders during MRI examinations.

Impact of institutional interventions on the rate of paclitaxel hypersensitivity reactions

PURPOSE

Paclitaxel is associated with hypersensitivity reactions (HSRs). Intravenous premedication regimens have been devised to decrease the incidence and severity of HSRs. At our institution oral histamine 1 receptor antagonists (H1RA) and histamine 2 receptor antagonists (H2RA) were adopted as standard. Standardizations were implemented for consistent premedication use in all disease states. The purpose of this retrospective study was to compare the incidence and severity of HSRs before and after standardization.

METHODS

Patients who received paclitaxel from 20 April 2018 to 8 December 2020 having an HSR were included in analysis. An infusion was flagged for review if a rescue medication was administered after the start of the paclitaxel infusion. The incidences of all HSR prior to and post-standardization were compared. A subgroup analysis of patients receiving paclitaxel for the first and second time was performed.

RESULTS

There were 3499infusions in the pre-standardization group and 1159infusions in the post-standardization group. After review, 100 HSRs pre-standardization and 38 HSRs post-standardization were confirmed reactions. The rate of overall HSRs was 2.9% in the pre-standardization group and 3.3% in the post-standardization group (p = 0.48). HSRs, during the first and second doses of paclitaxel, occurred in 10.2% of the pre-standardization and 8.5% of the post-standardization group (p = 0.55).

CONCLUSIONS

This retrospective interventional study demonstrated that same-day intravenous dexamethasone, oral H1RA, and oral H2RA are safe premedication regimens for paclitaxel. No change in the severity of reactions was seen. Overall, better adherence to premedication administration was seen post-standardization.

Impact of histamine-2 antagonist shortage on the incidence of hypersensitivity reactions to paclitaxel: a reconsideration of premedication protocols in France (PACLIREACT Study)

PURPOSE

An international shortage of ranitidine led to adjustments in premedication regimens for paclitaxel-based chemotherapy in early October 2019. In this study, we implemented and evaluated an anti-allergic protocol without histamine-2 antagonists (H2As) and aimed to assess the risk of hypersensitivity reactions (HSRs) to the different premedication regimens used.

METHODS

We conducted a single-center observational retrospective study of paclitaxel administrations (7173 administrations in 831 patients). Between January 2019 and December 2020, all allergies reported were recorded. A mixed logistic regression model was implemented to predict the risk of allergy at each injection and to account for repeated administration per patient.

RESULTS

A total of 27 HSRs occurred in 24 patients. No protective effect was observed for H2A when comparing paclitaxel injections with H2A premedication versus without H2A (OR = 1.12, p = 0.84). There was also no significant difference in risk of HSR for famotidine versus ranitidine (OR = 0.79, p = 0.78). However, the risk of HSRs was significantly lower for paclitaxel injections with corticosteroids than for those without (OR = 0.08, p = 0.03). In addition, the risk of HSR was significantly higher for the first, second, or third paclitaxel injections than for the subsequent injections (OR = 10.1, p < 0.001).

CONCLUSION

We did not find substantial evidence of an increased risk of HSR due to the absence of H2A in the premedication protocols for paclitaxel. Thus, in contrary to the existing literature on paclitaxel, our findings support the use of a premedication protocol without H2A.

Do Children With an Allergic Transfusion Reaction Require Premedication For All Blood Products?

BACKGROUND

Children with a history of allergic transfusion reactions (ATRs) receive antihistamine premedication with or without hydrocortisone to prevent subsequent reactions. We aim to examine the frequency of developing ATRs to subsequent different blood product type transfusions.

METHODS

A retrospective chart review of children who received blood product transfusions (packed red blood cells, platelets, frozen plasma, intravenous immunoglobin, albumin, and cryoprecipitate) and developed ATRs. Cases were identified through Transfusion Transmitted Injuries Surveillance System- Ontario database with a complementary chart review. Demographics and subsequent transfusions records were described.

RESULTS

During this period, 35,925 blood products were transfused to 4153 patients. Thirty-eight ATRs were reported in 30 patients. All ATRs were minor except 1 anaphylaxis to albumin transfusion. Seven patients (23%) developed multiple ATRs, and all of them were of the same blood product type. A total of 60 subsequent different blood product types were transfused to the 7 patients who had multiple ATRs; none of those transfusions caused ATR.

CONCLUSION

In children with a history of ATR, developing a reaction to a different blood product type is rare. Hence, premedicating those transfusions is not warranted.

Evaluating the Effect of Duloxetine Premedication on Postoperative Analgesic Requirement in Patients Undergoing Laparoscopic Cholecystectomies: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study

OBJECTIVE

The aim was to evaluate the effect of oral administration of preoperative duloxetine on postoperative pain and total analgesic requirement in the postoperative period as the primary objective. The secondary objective was to evaluate the perioperative hemodynamic parameters, sedation scores, demographic data, and incidence of side effects (if any) in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

This was a prospective, randomized, double-blind, placebo-controlled study conducted in a tertiary level medical college on 60 patients of either sex posted for laparoscopic cholecystectomies with American Society of Anesthesiologists (ASA) I and II. The patients were divided into 2 groups (n=30), the patients were given duloxetine 60 mg capsules and placebo capsules (Becosules) 2 hours before surgery.

RESULTS

The total requirement for both first and second rescue analgesics was higher in placebo as compared with duloxetine and was found to be significant ( P <0.05). The difference in mean visual analog scale score was significantly ( P <0.001) higher in placebo as compared with duloxetine at all-time intervals postoperatively 0 minute (7.6±0.7 vs. 4.6±0.8); 15 minutes (5.9±0.8 vs. 4.2±1.0); 30 minutes (4.4±0.5 vs. 3.6±0.9); 4 hours (6.6±0.06 vs. 5.3±1.3); 8 hours (5.2±1.2 vs. 3.9±1.0); and 12 hours (5.1±1.3 vs. 2.3±0.7). The mean arterial blood pressure and heart rate were significantly higher in placebo compared with duloxetine in most of the time intervals in the perioperative period. There was no significant difference in the sedation score between the groups except the 30 minutes and 8 hours postoperative.

DISCUSSION

Preoperative oral duloxetine during laparoscopic cholecystectomy could reduce postoperative pain, postoperative analgesic requirements, and better optimization of hemodynamics without causing major side effects.

The effect of intravenous maropitant on blood pressure in healthy awake and anesthetized dogs

OBJECTIVE

To evaluate the effects of intravenous maropitant on arterial blood pressure in healthy dogs while awake and under general anesthesia.

DESIGN

Experimental crossover study.

ANIMALS

Eight healthy adult Beagle dogs.

PROCEDURE

All dogs received maropitant (1 mg kg-1) intravenously under the following conditions: 1) awake with non-invasive blood pressure monitoring (AwNIBP), 2) awake with invasive blood pressure monitoring (AwIBP), 3) premedication with acepromazine (0.005 mg kg-1) and butorphanol (0.2 mg kg-1) intramuscularly followed by propofol induction and isoflurane anesthesia (GaAB), and 4) premedication with dexmedetomidine (0.005 mg kg-1) and butorphanol (0.2 mg kg-1) intramuscularly followed by propofol induction and isoflurane anesthesia (GaDB). Heart rate (HR), systolic (SAP), diastolic (DAP), and mean blood pressures (MAP) were recorded before injection of maropitant (baseline), during the first 60 seconds of injection, during the second 60 seconds of injection, at the completion of injection and every 2 minutes post injection for 18 minutes. The data were compared over time using a Generalized Linear Model with mixed effects and then with simple effect comparison with Bonferroni adjustments (p <0.05).

RESULTS

There were significant decreases from baseline in SAP in the GaAB group (p < 0.01) and in MAP and DAP in the AwIBP and GaAB (p < 0.001) groups during injection. A significant decrease in SAP (p < 0.05), DAP (p < 0.05), and MAP (p < 0.05) occurred at 16 minutes post injection in GaDB group. There was also a significant increase in HR in the AwIBP group (p < 0.01) during injection. Clinically significant hypotension occurred in the GaAB group with a mean MAP at 54 ± 6 mmHg during injection.

CONCLUSION

Intravenous maropitant administration significantly decreases arterial blood pressure during inhalant anesthesia. Patients premedicated with acepromazine prior to isoflurane anesthesia may develop clinically significant hypotension.

Patient Factors But Not the Use of Novel Anticoagulants or Warfarin Are Associated With Internal Jugular Vein Access-Site Hematoma After Right Heart Catheterization

INTRODUCTION

Right heart catheterization (RHC) is routinely performed to assess hemodynamics. Generally, anticoagulants are held prior to the procedure. At our center, anticoagulants are continued and ultrasound guidance is always used for internal jugular vein access. A micropuncture access kit is used to place a 5 or 6 Fr sheath using the modified Seldinger technique. Manual compression is applied for 10-15 min and the patient is observed for at least 2 hours after the procedure. In a retrospective analysis, we investigated the risk of bleeding complications associated with RHC via the internal jugular vein in patients with and without full anticoagulation.

METHODS AND RESULTS

Our catheterization laboratory database was searched for adult patients who underwent RHC by a single operator between January 2012 and December 2015. A total of 571 patients were included in the analysis. Baseline characteristics, labs, relevant invasive hemodynamics, co-morbid conditions, and incidence of access-site hematoma are presented. Multivariable binary logistic regression was performed using IBM SPSS v. 23.0 software. Statistically significant associations with access-site hematoma were observed with body mass index (P=.02; 95% confidence interval [CI], 1.0-1.1), right atrial pressure (P=.03; 95% CI, 0.7-0.9), and dialysis dependence (P<.01; 95% CI, 0.1-0.6). There was no association of access-site hematoma with the use of anticoagulants (P>.99).

CONCLUSION

The incidence of internal jugular vein access-site hematoma is small when using careful access techniques for RHC even with the continued use of novel oral anticoagulants and warfarin. Patient characteristics and co-morbid conditions are related to bleeding complications.

The Effect of Oral Dexmedetomidine Premedication on Preoperative Cooperation and Emergence Delirium in Children Undergoing Dental Procedures

INTRODUCTION

The aim of this study was to detect the effect of 1 μg/kg of oral dexmedetomidine (DEX) as premedication among children undergoing dental procedures.

MATERIALS AND METHODS

The study involved 100 children between 2 and 6 years of age, ASA I, who underwent full-mouth dental rehabilitation. The DEX group (n = 50) received 1 μg/kg DEX in apple juice, and the control group (n = 50) received only apple juice. The patients' scores on the Ramsay Sedation Scale (RSS), parental separation anxiety scale, mask acceptance scale, and pediatric anesthesia emergence delirium scale (PAEDS) and hemodynamic parameters were recorded. The data were analyzed using chi-square test, Fisher's exact test, Student's t-test, and analysis of variance in SPSS.

RESULTS

RSS scores were significantly higher in the DEX group than group C at 15, 30, and 45 min (p < 0.05). More children (68% easy separation, 74% satisfactory mask acceptance) in the DEX group showed satisfactory ease of parental separation and mask acceptance behavior (p < 0.05). There was no significant difference in the PAEDS scores and mean hemodynamic parameters of both groups.

CONCLUSIONS

Oral DEX administered at 1 μg/kg provided satisfactory sedation levels, ease of parental separation, and mask acceptance in children but was not effective in preventing emergence delirium. The trial was registered (Protocol Registration Receipt NCT03174678) at clinicaltrials.gov.

The Effect of Pre-operative Lornoxicam and Ketoprofen Application on the Morphine Consumption of Post-operative Patient-controlled Analgesia

We compared the efficacy of preoperative intramuscular lornoxicam and ketoprofen for post-operative analgesia in patients undergoing abdominal hysterectomy. This randomized, double-blind, placebo-controlled, parallel-group study investigated 60 patients who received lornoxicam (group L, 8 mg), ketoprofen (group K, 100 mg) or saline (group C) 60 min before standard anaesthesia. All patients received patient-controlled analgesia (intravenous morphine) during the post-operative period. Visual analogue scale (VAS) scores recorded 2, 4, 6 and 12 h after surgery in groups L and K patients were significantly lower than in group C patients, and VAS scores at 2, 4 and 6 h in group L patients were significantly lower than those in group K patients. Morphine consumption in groups L and K was significantly lower than in group C. Pre-emptive administration of lornoxicam and ketoprofen effectively reduced post-operative pain and morphine consumption, and lornoxicam was more effective than ketoprofen in the early post-operative period.

Anticholinergic premedication-induced fever in paediatric ambulatory ketamine anaesthesia

Objective

A randomized, double-blind, prospective study to evaluate the effect of anticholinergic drugs on thermoregulation in paediatric patients undergoing ambulatory anaesthesia with ketamine.

Methods

Patients were randomized to receive either 0.005 mg/kg glycopyrrolate or the equivalent volume of normal saline (placebo) at 30 min before ketamine anaesthesia. Body temperature was measured tympanically at baseline and at 0, 30, 60 and 90 min postoperatively. The quantity of saliva prodiced during surgery and incidence of fever were recorded.

Results

Body temperature was significantly higher in the glycopyrrolate group (n = 42) than the placebo group (n = 42) at 30, 60 and 90 min after surgery, and higher than baseline at 0, 30, 60 and 90 min after surgery. In the placebo group, body temperature was significantly higher than baseline at 0 and 30 min after surgery. Saliva secretion was significantly lower in the glycopyrrolate group than the placebo group.

Conclusion

Routine premedication with adjunctive anticholinergics should not be considered in paediatric patients receiving ketamine sedation due to the increased risk of fever.

Trial registration number, Clinicaltrials.gov: NCT02430272

[Acute kidney failure and renal replacement therapy after colonoscopy in a 63-year-old woman]

A 63-year-old woman presented with intestinal disorder, alternating between obstipation and diarrhoea. Sodium phosphate/diphosphate (Fleet®) was used in preparation for colonoscopy. Within 24 h the patient developed severe hyperphosphatemia and oliguric acute kidney failure with the need of renal replacement therapy. This case illustrates the rare event of phosphate nephropathy after colonoscopy.

A randomized trial of misoprostol versus laminaria before dilation and evacuation in South Africa

OBJECTIVE

To compare complication rates, efficacy and acceptability of buccal misoprostol to laminaria for cervical preparation before dilation and evacuation (D&E) in South Africa.

STUDY DESIGN

We performed a randomized, single-blind trial comparing buccal misoprostol 400 mcg (1-2 doses, administered at least 3 h before D&E) to laminaria inserted the day before D&E among women at 13-19 weeks gestation. The primary outcome was expulsion of the fetus prior to surgery; secondary outcomes included other complications, need for mechanical dilation, procedure duration, side effects and satisfaction. Required sample size was 176 to detect a difference in expulsion of 20% to 5%, with a two-sided alpha of 0.05 and 80% power.

RESULTS

Due to slow enrollment and low incidence of primary outcome, the study was stopped early. One hundred fifty-nine women were randomized, and 156 received treatment (78 in each group). Mean gestational age was 14.8 weeks (range, 13.0-18.6 weeks). Complications were rare and did not differ by group [three in each group; odds ratio (OR), 1; 95% confidence interval (CI), 0.20-5.11]; this included two expulsions in the misoprostol group (2.6%). Misoprostol participants were more likely to require mechanical dilation compared to those receiving laminaria (35% vs. 8%; OR, 6.4; 95% CI, 2.4-16.5). The proportion of women reporting each side effect was similar except for diarrhea (21.3% in misoprostol group vs. 5.2% in laminaria group, p=0.004). Procedure time and satisfaction did not differ between groups.

CONCLUSIONS

Both misoprostol and laminaria are associated with a low complication rate in this setting, although misoprostol requires more mechanical dilation and causes more diarrhea.

IMPLICATIONS

Cervical preparation using either laminaria or misoprostol can be safely used before D&E up to at least 19 weeks. Physicians using misoprostol must be skilled at mechanical dilation, since this is commonly required.

[Factors involved in the development of vasoplegia after cardiac surgery with extracorporeal circulation. A prospective observational study]

OBJECTIVE

The incidence and risk factors for vasoplegia in the early postoperative period and at 24h are investigated in patients subjected to cardiopulmonary bypass surgery. Vasoplegia following cardiac surgery with cardiopulmonary bypass is associated with a high morbimortality. The risk factors described emerged from retrospective, non-controlled studies.

METHODS

Observational prospective study of 188 consecutive patients subjected to cardiac surgery with cardiopulmonary bypass in a single hospital between November 2011 and May 2012. Emergency surgery or complex procedures were excluded. Vasoplegia was assessed during the immediate postoperative period, and at 24h after surgery, and was defined as a mean arterial pressure below 50mmHg, and the need for a noradrenaline perfusion of more than 0.08μg/kg/min, monitored by cardiac output and systemic vascular resistances. The anaesthetic and cardiopulmonary bypass protocols, as well as haemodynamic management, were the same in all patients.

RESULTS

Almost half (48%) of patients had vasoplegia in the immediate postoperative period, and 34% at 24h. Risk factors for immediate vasoplegia development were preoperative use of angiotensin converting enzyme inhibitor drugs, a mean arterial pressure<50mmHg immediately after beginning cardiopulmonary bypass, duration of aortic clamping as well as the cardiopulmonary bypass, and minimum temperature in cardiopulmonary bypass. Vasoplegia at 24h after surgery was correlated to preoperative angiotensin converting enzyme inhibitor drug treatment and cardiopulmonary bypass duration.

CONCLUSION

The incidence of vasoplegia after cardiac surgery with cardiopulmonary bypass is high during the first 24 postoperative hours. Preoperative treatment with angiotensin converting enzyme inhibitor and the mean arterial pressure at the beginning of cardiopulmonary bypass are the more easily controllable risk factors. In patients arriving to surgery with those drugs, treatment or prevention of vasoplejia should be planned.

[Chronic myelogenous leukemia complicated by drug-induced agranulocytosis]

We describe a patient with chronic myelogenous leukemia (CML) who developed drug-induced agranulocytosis. A 75-year-old female was diagnosed with CML in December 2001. She had been receiving imatinib therapy for more than five years. In August 2007, she was hospitalized due to a severe neutropenia 10 days after colonoscopy. She was diagnosed as having agranulocytosis induced by colonoscopy premedication including scopolamine butylbromide and flumazenil. Severe neutropenia was resolved by G-CSF treatment without CML progression. Agranulocytosis in patients with CML is rare, but potentially lethal. Here, we report the clinical course in this patient.

Endotracheal intubation in a neonatal population remains associated with a high risk of adverse events

INTRODUCTION

There has been a significant increase in premedication use for neonatal intubation in the UK over the past decade. We aimed to determine the adverse events during neonatal intubation using the most commonly used premedication regimen in the UK.

DISCUSSION

We prospectively studied all intubations performed using morphine, suxamethonium and atropine during a 3-month period in three UK tertiary neonatal units. Premedication was administered for 87/93 (94%) of intubations. Median time taken to prepare premedication was 16 min (IQR 10-35). Median time to successful intubation was 5 min (IQR 2-9) following premedication. Median lowest recorded oxygen saturation after administration of premedication was 65% (IQR 39-85). A bradycardia in the range 61-99/min accompanied the procedure in 24/93 (26%) intubations, with a median duration of bradycardia of 8 s (IQR 1-10).

CONCLUSION

Despite the widespread move to premedication for neonatal intubation, many deficiencies in everyday practice remain. The rate of haemodynamic complications is high in this commonly used premedication regimen. This study shows that there are important factors to control at the local level in terms of timely preparation and administration of premedication drugs, training and supervision of staff carrying out this high-risk procedure.

[A case of advanced breast cancer with anaphylaxis-like reaction after intravenous administration of dexamethasone]

The patient was a 74-year-old woman who was diagnosed with advanced breast cancer, T4aN0M0, stage IV. She was placed on chemotherapy of weekly paclitaxel (PTX) (60 mg/m(2) day 1, 8, 15 with 1 course consisting of 28 days). We used dexamethasone (8 mg/body) as premedication for chemotherapy every time. Three courses were performed with no severe adverse reaction. On the fourth course, day 8, she complained of nausea, vomiting, paroxysmal cough and fecal incontinence after a few minutes of dexamethasone administration. Her blood pressure dropped to a minimum of 64 mmHg (systolic pressure) and she soon became drowsy. We diagnosed the anaphylaxis-like reaction for dexamethasone, immediately discontinued dexamethasone infusion, and treated her successfully. Forty minutes after the episode had occurred, she recovered. The few reports on anaphylaxis or anaphylaxis-like reaction to dexamethasone must be taken into account when we use these drugs.

[Perioperative risk in patients with sleep apnoea]

Patients with upper airway obstruction during sleep are at constant risk of hypoxic and hypercarbic episodes and are especially vulnerable during anaesthesia and sedation as the abnormal anatomy is compounded by drug-related respiratory depression. Elective procedures in patients with the obstructive sleep apnoea (OSA) should be usually delayed, allowing for the preoperative home treatment (diet, alcohol abstinence, nasal CPAP/BiPAP during night). Respiratory supportive techniques, started at home, should be continued in the hospital, both in preoperative and postoperative periods. Patients with OSA should be also thoroughly examined for possible anatomic abnormalities of the upper airway that may complicate laryngoscopy and/or intubation. Heavy premedication should be avoided; in special cases of very nervous patients oral clonidine may be used. Careful preoxygenation is mandatory, opioids should be used sparingly. Muscle relaxant should be calculated for an ideal body weight. Isoflurane should be avoided. The OPS and obese patients are usually extubated in the sitting or lateral positions to avoid limitation of FRC by elevated diaphragm. In selected cases, prolonged intubation and/or ventilation are recommended. Regional anaesthesia are usually safe in these patients, however, opioids should be used carefully. When sedation is required, ketamine or dexmedetomidine may be used.