601
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Abstract
Flexible bronchoscopy is commonly performed by respiratory physicians and is the gold standard for directly visualising the airways, allowing for numerous diagnostic and therapeutic interventions. With the widespread use of flexible bronchoscopy and the evolution of interventional bronchoscopy with more complex and longer procedures, physicians are placing increasing importance on the use of sedation as a necessary adjunct to topical anaesthesia. There is no standardised practice for the use of sedation in bronchoscopy with a good deal of variation among physicians regarding the use of pre-procedure medication and pharmacological sedatives. In addition, there is ongoing debate and controversy about proceduralist-administered versus anaesthetist-administered sedation whilst at the same time there is a growing body of evidence that nonanaesthetist administered sedation is safe and cost-effective. In this review we summarise the evidence for the use of sedation as an adjunct to topical anaesthesia in bronchoscopy and provide the clinician with up-to-date concise guidance for the use of pharmacological sedatives in bronchoscopy and future directions for sedation in the bronchoscopy suite.
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Affiliation(s)
- Ricardo J José
- Dept of Thoracic Medicine, University College Hospital, London, UK.
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602
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Bavullu EN, Aksoy E, Abdullayev R, Göğüş N, Dede D. Comparison of Dexmedetomidine and Midazolam in Sedation for Percutaneous Drainage of Hepatic Hydatid Cysts. Turk J Anaesthesiol Reanim 2013; 41:195-9. [PMID: 27366371 DOI: 10.5152/tjar.2013.40] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 04/01/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Hydatid cyst still continues to be a public health problem. The basic treatment for the disease is surgery, but ultrasound-guided percutaneous drainage has become an important treatment alternative. Agents preferred for sedation during drainage performed under local anaesthesia must also preserve respiration and hemodynamic stability while providing adequate sedation. We compared the sedative properties of midazolam, which has a short duration of action, and a selective α2 adrenergic receptor agonist, dexmedetomidine, and the intraoperative complications. METHODS After approval by the clinical trials ethics committee, 40 patients with similar demographic data were randomized into two groups. All patients received 10 mg metoclopramide and 45.5 mg pheniramine before the procedure. Then, midazolam (0.07 mg kg(-1) IV bolus followed by 0.01 mg kg(-1) h(-1) infusion) was administered to Group 1, and dexmedetomidine (1 μg kg(-1) loading dose in 10 minutes, followed by 0.2 μg kg(-1) h(-1) continuous infusion) was administered to Group 2 for sedation. Just before the surgical procedure, all patients received IV propofol in a subhypnotic dose of 0.5 mg kg(-1); the dose was repeated if adequate sedation could not be achieved. Observer's assessment of alertness/sedation (OAA/S) scale and Bispectral index (BIS) were used to evaluate the sedation level during the procedure. Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide pressure (ETCO2) were monitored before and after induction and every 5 minutes thereafter. Propofol requirement was noted for each group. RESULTS Sedation in the dexmedetomidine group was as effective and adequate as that observed in the midazolam group. BIS values were significantly lower in the dexmedetomidine group, especially after 10 minutes and thereafter. RR, SpO2, and ETCO2 were similar in both groups, whereas clinically insignificant decreases in HR and MAP were observed in the dexmedetomidine group. Propofol requirements were similar in both groups. CONCLUSION We conclude that dexmedetomidine, providing adequate sedation without respiratory depression, can be considered as an appropriate agent for sedation in surgical procedures performed under local anaesthesia.
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Affiliation(s)
- Emine Nilgün Bavullu
- Department of Anaesthesiology and Reanimation, Çaycuma State Hospital, Zonguldak, Turkey
| | - Esra Aksoy
- Department of Anaesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ruslan Abdullayev
- Department of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Nermin Göğüş
- Department of Anaesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Doğan Dede
- Department of Radiology, Ankara Numune Training and Research Hospital, Ankara, Turkey
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603
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Bagchi D, Mandal MC, Das S, Basu SR, Sarkar S, Das J. Bispectral index score and observer's assessment of awareness/sedation score may manifest divergence during onset of sedation: Study with midazolam and propofol. Indian J Anaesth 2013; 57:351-7. [PMID: 24163448 PMCID: PMC3800326 DOI: 10.4103/0019-5049.118557] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Correlation between the clinical and electroencephalogram-based monitoring has been documented sporadically during the onset of sedation. Propofol and midazolam have been studied individually using the observer's assessment of awareness/sedation (OAA/S) score and Bispectral index score (BIS). The present study was designed to compare the time to onset of sedation for propofol and midazolam using both BIS and OAA/S scores, and to find out any correlation. Methods: A total of 46 patients (18-60 years, either sex, American Society of Anesthesiologists (ASA) I/II) posted for infraumbilical surgeries under spinal anaesthesia were randomly allocated to receive either injection propofol 1 mg/kg bolus followed by infusion 3 mg/kg/h (Group P, n=23) or injection midazolam 0.05 mg/kg bolus followed by infusion 0.06 mg/kg/h (Group M, n=23). Spinal anaesthesia was given with 2.5 ml to 3.0 ml of 0.5% bupivacaine heavy. When sensory block reached T6 level, sedation was initiated. The time to reach BIS score 70 and time to achieve OAA/S score 3 from the start of study drug were noted. OAA/S score at BIS score 70 was noted. Data from 43 patients were analyzed using SPSS 12 for Windows. Results: Time to reach BIS score 70 using propofol was significantly lower than using the midazolam (P<0.05). Time to achieve OAA/S score 3 using propofol was comparable with midazolam (P=0.358). Conclusion: A divergence exists between the time to reach BIS score 70 and time to achieve OAA/S score 3 using midazolam, compared with propofol, during the onset of sedation.
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Affiliation(s)
- Dipanjan Bagchi
- Department of Anaesthesiology, North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal, India
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604
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Korth-Bradley JM, Parks V, Wagner F, Chalon S, Gourley I, Matschke K, Gossart S, Ripp SL, Fleckenstein L. Effect of moxidectin on CYP3A4 activity as evaluated by oral midazolam pharmacokinetics in healthy subjects. Clin Pharmacol Drug Dev 2013; 3:151-7. [PMID: 27128460 DOI: 10.1002/cpdd.81] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 09/19/2013] [Indexed: 11/11/2022]
Abstract
In order to evaluate the potential for CYP3A4 induction by moxidectin, midazolam pharmacokinetic (PK) parameters were compared before and after moxidectin administration. Healthy subjects received a single 8 mg dose of moxidectin and 3 single 7.5 mg doses of midazolam 3 days before, and 7 and 89 days after the moxidectin. Blood samples were taken for 24 hours to measure midazolam and metabolites in plasma, and for 89 days to measure moxidectin in plasma after dose administration. Noncompartmental PK analyses were performed for each analyte. Analysis of variance was performed on log-transformed midazolam parameters with treatment day as a fixed effect. Adverse events were recorded and laboratory tests, physical examinations, pulse oximetry monitoring, vital sign measurement, and electrocardiograms performed. Thirty-nine subjects were enrolled in the study; PK data were available for 37 subjects. Moxidectin PK parameters were similar to previous studies. There were no significant changes in PK for midazolam or its metabolites 7 or 89 days after moxidectin administration. Adverse events were generally mild and there were no relevant changes in safety assessments. Thus, 8 mg moxidectin does not induce CYP3A4 activity and other CYP3A4 substrates are unlikely to be affected by moxidectin co-administration.
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Affiliation(s)
| | | | - Frank Wagner
- Charité Research Organisation GmbH, Berlin, Germany
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605
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Hopster K, Müller C, Hopster-Iversen C, Stahl J, Rohn K, Kästner S. Effects of dexmedetomidine and xylazine on cardiovascular function during total intravenous anaesthesia with midazolam and ketamine and recovery quality and duration in horses. Vet Anaesth Analg 2013; 41:25-35. [PMID: 24127757 DOI: 10.1111/vaa.12095] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 02/20/2013] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To compare cardiovascular effects and recovery quality and duration of total intravenous anaesthesia (TIVA) with xylazine-ketamine-midazolam or dexmedetomidine-ketamine-midazolam. STUDY DESIGN Prospective, randomized experimental cross-over trial. ANIMALS Eight adult warmblood horses. METHODS After sedation with acepromazine and either xylazine [0.5 mg kg(-1) , intravenously (IV)] or dexmedetomidine (3.5 μg kg(-1) IV) anaesthesia was induced with ketamine and midazolam and maintained with a constant rate infusion (CRI) of xylazine (1 mg kg(-1) hour(-1) ) [XKM] or dexmedetomidine (7 μg kg(-1) hour(-1) ) [DKM] in combination with midazolam (0.1 mg kg(-1) hour(-1) ), and ketamine infusion (initially 3 mg kg(-1) hour(-1) ) for 120 minutes. Ketamine infusion rate was increased in response to positive reactions to electrical nociceptive stimulation performed every 30 minutes. Heart rate (HR), mean arterial blood pressure (MAP) and cardiac output (Q˙t) were measured before treatment (baseline), after sedation (not Q˙t), and during anaesthesia. Xylazine, dexmedetomidine, midazolam and ketamine kinetics were calculated, from plasma drug concentrations. Twenty minutes after end of TIVA, flumazenil (0.01 mg kg(-1) IV) was administered. Recovery quality and duration were assessed. Two-way analysis of variance with repeated measurements or Wilcoxon signed rank test as relevant were used to analyse data with an alpha of 5%. RESULTS Compared to baseline, MAP did not change, while similar, but limited, decreases in HR and Q˙t were observed in both TIVA's. Mean ketamine doses of 3.7 mg kg(-1) hour(-1) were required with both treatments. Plasma concentrations of dexmedetomidine and xylazine showed high intra- and inter-individual changes with elimination half-lifes of 46 ± 7 minutes and 64 ± 13 minutes, respectively. Recovery quality was good to excellent with mean duration of 37 ± 16 and 46 ± 21 minutes after stopping TIVA with XKM and DKM, respectively. CONCLUSIONS AND CLINICAL RELEVANCE Both drug combinations are suitable to maintain anaesthesia for two hours, with good cardiovascular and good to excellent recovery conditions.
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Affiliation(s)
- Klaus Hopster
- Equine Clinic, University of Veterinary Medicine Hanover, Foundation, Hanover, Germany
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606
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Zhang C, Li J, Zhao D, Wang Y. Prophylactic midazolam and clonidine for emergence from agitation in children after emergence from sevoflurane anesthesia: a meta-analysis. Clin Ther 2013; 35:1622-31. [PMID: 24075150 DOI: 10.1016/j.clinthera.2013.08.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/26/2013] [Accepted: 08/21/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergence agitation (EA) after emergence from sevoflurane anesthesia is a common phenomenon in children. The efficacy of prophylactic midazolam or clonidine in preventing EA is controversial. OBJECTIVE We performed a meta-analysis of clinical trials of the 2 drugs to evaluate their ability to prevent EA in pediatric patients after emergence from sevoflurane anesthesia. METHODS A comprehensive literature search was conducted to identify clinical trials that observed the effect of midazolam and clonidine on preventing EA in children after their emergence from sevoflurane anesthesia. All data were examined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% CI. I(2) was used to assess heterogeneity. Subgroup analysis was used to assess the effects of preoperative analgesics, routes of administration, and dose, and funnel plots were used to check publication bias. RESULTS After a comprehensive literature search, we found 12 papers that met the criteria for inclusion in this analysis, with a total of 447 children in the midazolam group and 767 children in the clonidine group. We found that both midazolam and clonidine decreased the incidence of EA (OR = 0.45 [95% CI, 0.29-0.70], P = 0.0004, I(2) = 46%; and OR = 0.24 [95% CI, 0.13-0.43], P < 0.00001, I(2) = 48%, respectively). Subgroup analysis indicated that preoperative analgesia may decrease the effect of midazolam against EA, whereas for clonidine, neither the route of administration (intravenous or caudal) nor the dose affected the results. Funnel plots did not detect publication bias in the midazolam group, but a bias was detected in the clonidine group. CONCLUSIONS This meta-analysis suggests that prophylactic administration of midazolam or clonidine could significantly decrease the incidence of sevoflurane-induced EA in pediatric patients.
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Affiliation(s)
- Chengmi Zhang
- Department of Anesthesiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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607
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Olsson A, Phalen D. Comparison of biochemical stress indicators in juvenile captive estuarine crocodiles (Crocodylus porosus) following physical restraint or chemical restraint by midazolam injection. J Wildl Dis 2013; 49:560-7. [PMID: 23778605 DOI: 10.7589/2012-06-160] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Using a prospective, randomized study design we demonstrate that midazolam sedation minimizes acidosis compared with physical restraint in captive juvenile estuarine crocodiles during handling or noninvasive procedures at preferred body temperature. A dose of midazolam (5.0 mg/kg) was administered intramuscularly into the forelimb of 20 male estuarine crocodiles weighing 2-3.5 kg. Their heart and respiratory rate and degree of sedation were monitored until recovery and then daily for 7 subsequent days. Blood samples were taken at 30, 60, 90, 180, and 360 min. We recorded lactate, partial pressure of carbon dioxide (CO2), hematocrit, glucose, and blood pH. A second group (1.9-2.6 kg) was physically restrained for 5 min and the same parameters recorded. Physically restrained animals demonstrated elevated heart rate, respiratory rate, glucose, lactate, and anion gap compared with the midazolam-treated group. Physically restrained animals had lower pH, bicarbonate, and partial pressure of CO2 compared with the midazolam-treated group. Behavior in the physically restrained group in the days following the study was disrupted, with reluctance to feed and bask, compared with midazolam-treated animals whose behavior was normal. We conclude that midazolam administered in the forelimb of captive estuarine crocodiles of 2-3.5 kg provides predictable onset and duration of sedation enabling physical examination, sample collection, and translocation of the animals with minimal disturbance to lactate, pH, and CO2. Behavior following recovery appears normal.
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608
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Mishra SK, Kang JH, Lee CW, Oh SH, Ryu JS, Bae YS, Kim HM. Midazolam induces cellular apoptosis in human cancer cells and inhibits tumor growth in xenograft mice. Mol Cells 2013; 36:219-26. [PMID: 24008365 PMCID: PMC3887981 DOI: 10.1007/s10059-013-0050-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 07/03/2013] [Accepted: 07/03/2013] [Indexed: 12/18/2022] Open
Abstract
Midazolam is a widely used anesthetic of the benzodiazepine class that has shown cytotoxicity and apoptosisinducing activity in neuronal cells and lymphocytes. This study aims to evaluate the effect of midazolam on growth of K562 human leukemia cells and HT29 colon cancer cells. The in vivo effect of midazolam was investigated in BALB/c-nu mice bearing K562 and HT29 cells human tumor xenografts. The results show that midazolam decreased the viability of K562 and HT29 cells by inducing apoptosis and S phase cell-cycle arrest in a concentration-dependent manner. Midazolam activated caspase-9, capspase-3 and PARP indicating induction of the mitochondrial intrinsic pathway of apoptosis. Midazolam lowered mitochondrial membrane potential and increased apoptotic DNA fragmentation. Midazolam showed reactive oxygen species (ROS) scavenging activity through inhibition of NADPH oxidase 2 (Nox2) enzyme activity in K562 cells. Midazolam caused inhibition of pERK1/2 signaling which led to inhibition of the anti-apoptotic proteins Bcl-XL and XIAP and phosphorylation activation of the pro-apoptotic protein Bid. Midazolam inhibited growth of HT29 tumors in xenograft mice. Collectively our results demonstrate that midazolam caused growth inhibition of cancer cells via activation of the mitochondrial intrinsic pathway of apoptosis and inhibited HT29 tumor growth in xenograft mice. The mechanism underlying these effects of midazolam might be suppression of ROS production leading to modulation of apoptosis and growth regulatory proteins. These findings present possible clinical implications of midazolam as an anesthetic to relieve pain during in vivo anticancer drug delivery and to enhance anticancer efficacy through its ROS-scavenging and pro-apoptotic properties.
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Affiliation(s)
| | - Ju-Hee Kang
- Division of Cancer Biology, National Cancer Center, Goyang 410-769, Korea
- Department of Food and Nutrition, Division of Natural Sciences, Chung-Ang University, Ansung 456-756, Korea
| | - Chang Woo Lee
- Bioevaluation Center, Korea Research Institute of Bioscience and Biotechnology, Cheongwon 363-883, Korea
| | - Seung Hyun Oh
- Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon 406-840, Korea
| | - Jun Sun Ryu
- Head and Neck Oncology Clinic, Center for Specific Organs Cancer, Center for Thyroid Cancer, National Cancer Center, Goyang 410-769, Korea
| | - Yun Soo Bae
- Department of Life Science, College of Natural Sciences, Ewha Womans University, Seoul 120-750, Korea
| | - Hwan Mook Kim
- Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon 406-840, Korea
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609
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Stoll F, Burhenne J, Lausecker B, Weiss J, Thomsen T, Haefeli WE, Mikus G. Reduced exposure variability of the CYP3A substrate simvastatin by dose individualization to CYP3A activity. J Clin Pharmacol 2013; 53:1199-204. [PMID: 23939663 DOI: 10.1002/jcph.161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 08/02/2013] [Indexed: 01/03/2023]
Abstract
This study aimed to demonstrate that the dose of a CYP3A substrate (simvastatin) can be adapted individually on the basis of CYP3A activity as assessed by midazolam metabolic clearance. In 18 healthy participants individual CYP3A activity was quantified using midazolam metabolic clearance both alone and during CYP3A inhibition with 40 mg ritonavir. Thereafter, simvastatin acid exposure was determined after a simvastatin standard dose (40 mg) and doses adapted to individual CYP3A activity at baseline and during CYP3A inhibition. Interindividual variability of CYP3A activity and simvastatin acid AUC0-24 was large and both correlated (r(2) = 0.745, P < .001). The adapted simvastatin doses ranged from 25 to 80 mg and their administration reduced simvastatin variability fivefold. Despite the low adapted simvastatin dose of 12 mg during CYP3A inhibition with ritonavir, exposure increased (point estimate of 4.2 [90% CI: 3.15-5.61]) probably caused by additional OATP1B1 inhibition. CYP3A activity-based dose adaptation can be used to reduce interindividual variability in simvastatin exposure.
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Affiliation(s)
- Felicitas Stoll
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, 69120, Heidelberg, Germany
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610
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Abstract
BACKGROUND THE GOAL OF THIS INVESTIGATION WAS TO COMPARE THE BEHAVIORAL AND PHYSIOLOGICAL EFFECTS OF THREE SEDATIVE DRUG REGIMENS: oral meperidine (OM), submucosal meperidine (SM) and oral midazolam (M) in healthy pediatric patients. MATERIALS AND METHODS This study sample consisted of thirty children aged 24-72 months (mean = 41.1) exhibiting definitely negative behavior. Three sedative regimens including: Oral meperidine/hydroxyzine, oral midazolam/hydroxyzine and submucosal meperidine/oral hydroxyzine were administered randomly during three consecutive appointments with a crossover design. Houpt behavioral scale was employed for evaluating the sedation effect of each regimen by a calibrated independent Pediatric dentist. Physiologic parameters were also recorded including blood oxygen saturation and pulse rate. Data was analyzed using Wilcoxon-signed ranked test, Mc-Nemar, GEE Logistic regression, Friedman, Fisher exact and Cochran tests for significance. RESULTS Overall success rates were 50%, 46.7% and 26.7% for submucosal meperidine, oral meperidine and oral midazolam, respectively (P = 0.03). The probability of achieving a success in behavior control was more in 48-72 month olds. Child's age and drug type were the two main predictors of altered behavior. Evaluating the differences between the effects of three tested regimens on recorded physiological parameters showed no significant differences. CONCLUSION All three regimens were proved safe within the limits of the current study. Meperidine sedation in both routes was considered to be more effective. Although there was less sleep and more head/oral resistance in midazolam group, the difference between groups was not significant.
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Affiliation(s)
- Lida Toomarian
- Department of Pedodontics, Dental School, Shahid Beheshti Medical University, Tehran
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611
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Gündüz M, Sakalli S, Güneş Y, Kesiktaş E, Ozcengiz D, Işik G. Comparison of effects of ketamine, ketamine-dexmedetomidine and ketamine- midazolam on dressing changes of burn patients. J Anaesthesiol Clin Pharmacol 2013; 27:220-4. [PMID: 21772684 PMCID: PMC3127303 DOI: 10.4103/0970-9185.81823] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: The aim of this randomized, controlled study was to compare the sedoanalgesic effects of ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients. Materials and Methods: Following Ethics Committee approval and informed patient consent, 90 ASA physical statuses I and II adult burn patients were included in the study. Patients were randomly divided into three groups. Ten minutes before dressing change, the dexmedetomidine group (group KD) (n = 30) received a continuous infusion of dexmedetomidine at a rate of 1 μg kg-1, the midazolam group (group KM) (n = 30) received a continuous infusion of midazolam at a rate of 0.05 mg kg-1 and the saline group (group KS) (n = 30) received a continuous infusion of saline intravenously. One minute before dressing change, each patient was administered 1 mg kg-1 ketamine intravenously. Hemodynamic variables, pain and sedation scores, the number of patients requiring additional ketamine, time to dressing change and recovery time were recorded. Results: Systolic blood pressure (SBP) values were significantly lower at, before and after ketamine administration; and 5, 10 and 15 minutes after the procedure in group KD in comparison with the other groups (P <0.05). There was no significant difference in pain scores among the groups during the study period. Sedation scores were significantly higher in group KD than in groups KM and KS at the end of the first hour (P <0.05). Time to dressing change and recovery time were similar in all the groups Conclusion: In burn patients undergoing dressing changes, although both combinations ketamine-dexmedetomidine and ketamine-midazolam offered an effective sedoanalgesia without causing any significant side effect, the former resulted in higher sedation and lower hemodynamic discrepancy.
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Affiliation(s)
- Murat Gündüz
- Department of Anesthesiology, Çukurova University Faculty of Medicine, Çukurova State Hospital, Department of Plastic and Reconstructive Surgery, Adana, Turkey
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612
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Adams R, Brown GT, Davidson M, Fisher E, Mathisen J, Thomson G, Webster NR. Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: a systematic review. Br J Anaesth 2013; 111:703-10. [PMID: 23748199 DOI: 10.1093/bja/aet194] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients in Intensive Care Unit (ICU) often require sedatives which commonly include midazolam and the more recently developed α2-receptor agonist, dexmedetomidine. It was our aim to compare the sedative and clinical effectiveness of dexmedetomidine vs midazolam in adults admitted to ICU, using an objective appraisal of randomized control trials. Medline, Embase, SCOPUS, Web of Knowledge, Cinhal, the United States National Library of Medicine, and the Cochrane Database of Systematic Reviews were searched using keywords: 'dexmedetomidine', 'midazolam', and 'intensive care'. These were limited to human studies and adults (>18 yr old). Six randomized controlled trials were found and were critically appraised using a standardized appraisal method. Two papers described the time spent by each intervention group within a specified target sedation range and both found no statistically significant difference between midazolam and dexmedetomidine (P=0.18 and P=0.15). A third paper found no statistically significant difference in the length of time that patients were sedated within a target zone (P=0.445). Two additional pilot studies did not report P values as they were insufficiently statistically powered. A final paper found that, of the eight occasions measured, patients on dexmedetomidine were more often within the target sedation range than patients on midazolam. The sedative benefits of dexmedetomidine vs midazolam remain inconclusive. While some secondary outcomes showed clinical effectiveness of dexmedetomidine, more research is needed to validate the findings of these studies.
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Affiliation(s)
- R Adams
- University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK
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613
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Grimsley A, Gallagher R, Hutchison M, Pickup K, Wilson ID, Samuelsson K. Drug-drug interactions and metabolism in cytochrome P450 2C knockout mice: application to troleandomycin and midazolam. Biochem Pharmacol 2013; 86:529-38. [PMID: 23732297 DOI: 10.1016/j.bcp.2013.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 12/11/2022]
Abstract
Drug-drug interactions (DDIs) may cause serious drug toxicity and delay development of candidate drugs. Screening using human liver microsomes and hepatocytes can help predict DDIs but do not always provide the degree of certainty required for confident progression of a candidate drug. Thus a suitable in vivo test system could be of great value. Here a Cyp2c knockout (KO) mouse was investigated for studying DDIs using midazolam (MDZ) a standard human CYP3A4 substrate and troleandomycin (TAO) a potent human CYP3A4 inhibitor. Pharmacokinetics (PK) and biotransformation of MDZ were investigated following dosing to Cyp2c KO and wild type mice before and after TAO treatment. The noteworthy differences in the metabolism of MDZ in Cyp2c KO compared to wild type mice confirms the important role that Cyp2c enzymes play in the murine metabolism of MDZ in vivo. The impact of Cyp3a inhibition produced a further increase in circulating MDZ concentrations in all individuals from both strains of mice though the impact of the elimination of the Cyp2c pathway in the KO mice on the AUC was less than perhaps expected. We have shown that TAO produces an increase in the MDZ concentration and a reduction in the 1'hydroxymidazolam/midazolam formation ratio but the expected difference in the magnitude of this effect between the wild type and the Cyp2c KO mice was not seen. The magnitude of the TAO effect was also smaller than is reported in humans. Hence further work is required before this animal model could be used to predict clinical interactions.
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Affiliation(s)
- Aidan Grimsley
- Global DMPK, AstraZeneca UK Ltd., Alderley Park, Macclesfield SK10 4TG, United Kingdom
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614
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Wang JJ, Huan SKH, Hsieh KH, Chou HC, Hsiao G, Jayakumar T, Sheu JR. Inhibitory effect of midazolam on MMP-9, MMP-1 and MMP-13 expression in PMA-stimulated human chondrocytes via recovery of NF-κB signaling. Arch Med Sci 2013; 9:332-9. [PMID: 23671446 PMCID: PMC3648813 DOI: 10.5114/aoms.2012.30949] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 11/15/2011] [Accepted: 12/05/2011] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Midazolam, a benzodiazepine, has a hypnotic effect and is widely used as an intravenous sedative. Past studies have clearly established that midazolam has beneficial effects in attenuating ischemia-reperfusion injury more than other currently used sedative drugs. However, the role of midazolam on chondroprotection via inhibition of matrix metalloproteinases (MMPs) is warrant investigation. The aim of this study was to examine the mechanisms of action of midazolam on MMP expression via nuclear factor κB (NF-κB) signaling in activated chondrosarcoma cells maintained in vitro. MATERIAL AND METHODS Chondrocytes, SW1353 cells, were stimulated with phorbol 12-myristate 13-acetate (PMA) in the absence or presence of various concentrations of midazolam (5-20 µM). Release of MMP-9 into the culture media was determined by gelatin zymography. The expressions of MMP-1, MMP-9 and MMP-13, phosphorylation of extracellular signal-regulated kinase (ERK), p38 mitogen-activated protein kinases and degradation of IκB-α were determined by western blotting assay. RESULTS Midazolam significantly down-regulated PMA-induced MMP-9 protein expression at concentrations of 5, 10 and 20 µM, the values were 1.95 ±0.09 (p < 0.01), 1.71 ±0.12 (p < 0.01) and 1.35 ±0.20 (p < 0.001), respectively. At concentrations of 5, 10 and 20 µM, it was significantly inhibited the PMA-induced expressions of MMP-1 (2.27 ±0.10, 1.98 ±0.11 and 1.56 ±0.15; p < 0.001) and MMP-13 (0.89 ±0.04, 0.81 ±0.07, and 0.74 ±0.09; p < 0.001), respectively. Midazolam at concentrations of 10 and 20 µM for 15 min significantly reversed the rate of degradation (0.895 ±0.051; p < 0.05 and 0.926 ±0.060; p < 0.01, respectively) of IκB-α in PMA-chondrocyte cells. In addition, this sedative drug inhibited PMA-induced levels of phos-ERK (1.243 ±0.12, 1.108 ±0.16 and 0.903 ±0.19, respectively) and phos-p38 (1.146 ±0.10, 1.063 ±0.13 and 0.946 ±0.18, at concentrations of (5, 10 and 20 µM), respectively. CONCLUSIONS These results are important for understanding the mechanism of midazolam in inhibiting PMA-induced MMP expression through the signaling pathways of either NF-κB or ERK/p38 MAPKs down-regulation.
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Affiliation(s)
- Jen-Jui Wang
- Department of Anesthesiology, West Garden Hospital, Taipei, Taiwan
| | - Steven Kuan-Hua Huan
- Division of Urology, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
| | | | - Hsiu-Chu Chou
- Department of Anatomy, and Graduate Institute of Medical Sciences, Taipei Medical University, Taiwan
| | - George Hsiao
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taiwan
| | - Thanasekaran Jayakumar
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taiwan
| | - Joen-Rong Sheu
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taiwan
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615
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Yi Y, Heo D, Son HJ, Joo Y, Lee SJ, Hwang B. Association between bispectral index and age and use of sedative drugs in high spinal anaesthesia. J Int Med Res 2013; 41:378-85. [PMID: 23569021 DOI: 10.1177/0300060513476437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES A prospective, randomized, double-blind study using bispectral index values to objectively quantify the sedative effect of high spinal anaesthesia in patients stratified according to age, and to determine whether sedative drugs are associated with additional adverse respiratory and haemodynamic effects in older patients. METHODS Patients who were electively scheduled for lower limb or abdominal surgery were recruited and allocated into one of three groups according to their age and whether midazolam and fentanyl were used: younger (20-40 years); and older (61-80 years) with or without midazolam and fentanyl intravenous infusion. RESULTS The study recruited a total of 90 patients (n = 30 per group). Intraoperative bispectral index values were significantly lower than preoperative values in all groups. Patients in the older age group had significantly lower intraoperative bispectral index values than younger patients. Older patients were significantly more likely to experience respiratory depression (arterial oxyhaemoglobin saturation <90%) than younger patients. CONCLUSIONS The sedative effect of high spinal anaesthesia is greater in older patients than in younger patients, with an increase in respiratory instability.
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Affiliation(s)
- Yuri Yi
- Department of Anaesthesia and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
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616
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Misra S, Koshy T. A review of the practice of sedation with inhalational anaesthetics in the intensive care unit with the AnaConDa(®) device. Indian J Anaesth 2013; 56:518-23. [PMID: 23325934 PMCID: PMC3546236 DOI: 10.4103/0019-5049.104565] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The intensive care unit (ICU) environment is often perceived to be hostile and frightening by patients due to unfamiliar surroundings coupled with presence of numerous personnel, monitors and other equipments as well as a loss of perception of time. Mechanical ventilation and multiple painful procedures that often need to be carried out in these critically ill patients add to their overall anxiety. Sedation is therefore required not only to allay the stress and anxiety, but also to allow for mechanical ventilation and other invasive therapeutic and diagnostic procedures to be performed. The conventional intravenous sedative agents used in ICUs suffer from problems of over sedation, tachyphylaxis, drug accumulation, organ specific elimination and often lead to patient agitation on withdrawal. All this tend to prolong the ventilatory as well as ICU and hospital discharge time, which increase the risk for infection and add to the overall increase in morbidity, mortality and hospital costs. In 2005, the anaesthetic conserving device (AnaConDa(®)) was marketed for ICU sedation with volatile anaesthetic agents. A number of trials have shown the effectiveness of using volatile anaesthetic agents for ICU sedation with the AnaConDa device. Compared with intravenous sedatives, use of volatile anaesthetic agents have resulted in shorter wake up and extubation time, lesser duration of mechanical ventilation and faster discharge from hospitals. This review shall focus on the benefits, technical pre-requisites and status of sedation with volatile anaesthetic agents in ICUs with the AnaConDa(®) device.
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Affiliation(s)
- Satyajeet Misra
- Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, Kerala, India
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617
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Abstract
The ideal sedative–hypnotic drug would be a rapidly titratable intravenous agent with a high therapeutic index and minimal side effects. The current efforts to develop such agents are primarily focused on modifying the structures of existing drugs to improve their pharmacodynamic and pharmacokinetic properties. Drugs currently under development using this rational design approach include analogues of midazolam, propofol, and etomidate, such as remimazolam, PF0713, and cyclopropyl methoxycarbonyl-etomidate (MOC-etomidate), respectively. An alternative approach involves the rapid screening of large libraries of molecules for activity in structural or phenotypic assays that approximate anesthetic and target receptor interactions. Such high-throughput screening offers the potential for identifying completely novel classes of drugs. Anesthetic drug development is experiencing a resurgence of interest because there are new demands on our clinical practice that can be met, at least in part, with better agents. The goal of this review is to provide the reader with a glimpse of the novel anesthetic drugs and new developmental approaches that lie on the horizon.
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Affiliation(s)
- Hovig V Chitilian
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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618
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Yadav G, Pratihary BN, Jain G, Paswan AK, Mishra LD. A prospective, randomized, double blind and placebo-control study comparing the additive effect of oral midazolam and clonidine for postoperative nausea and vomiting prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystecomy. J Anaesthesiol Clin Pharmacol 2013; 29:61-5. [PMID: 23493482 PMCID: PMC3590545 DOI: 10.4103/0970-9185.105800] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Reduction of postoperative nausea and vomiting (PONV) continues to be a major challenge in perioperative care in spite of introduction of newer antiemetics with better efficacy and safety profiles. Therefore, we evaluated the additive effect of oral midazolam and clonidine for PONV prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystectomy. Materials and Methods: In a prospective, randomized fashion, 120 selected cases were randomized into three groups: I, II or III to receive a tablet of midazolam (15 mg, n = 36), clonidine (150 mcg, n = 40), or glucose as placebo (5 g, n = 44) orally, 1 h before anesthesia. Occurrence of PONV along with need for rescue antiemetic during the first postoperative day was compared between groups as a primary outcome. Results: Episodes of PONV reduced significantly in Group II (15%) as compared to group I and III (22.2%, 59%) at various time points during the period of observation (P = 0.002). Need for rescue antiemetic was significantly lower in group I (13.88%) and II (5%) as compared to group III (52.27%, P < 0.001). Conclusion: Oral clonidine is better adjuvant for PONV prophylaxis, as compared to midazolam, in granisetron premedicated patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Ghanshyam Yadav
- Department of Anesthesiology, Sir Sunder Lal Hospital, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
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619
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Abstract
Pharmacologic treatment options for neonatal seizures have expanded over the past 2 decades, and there is no consensus on optimal treatment strategy. We systematically reviewed the published literature to determine which medication(s) are most effective for treating neonatal seizures, by retrieving trials and observational investigations via PubMed (through August 2011) that focused on pharmacological seizure treatment of neonates (≤ 28 days old) and utilized continuous or amplitude-integrated EEG to confirm seizure diagnosis and cessation. Our search identified 557 initial articles and 14 additional studies after reference reviews, with 16 meeting inclusion criteria. Of these, 2 were randomized trials and only 3 additional investigations included comparison groups. We found limited evidence regarding the best pharmacologic treatment for neonatal seizures, but were able to devise a treatment algorithm from available data. These findings have the potential to serve as a clinical reference and to inform the design of comparative effectiveness investigations for neonatal antiepileptics.
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Affiliation(s)
- Laurel A. Slaughter
- Division of Child Neurology, Nationwide Children’s Hospital, Columbus, Ohio,The Ohio State University, Department of Pediatrics, Columbus, Ohio
| | - Anup D. Patel
- Division of Child Neurology, Nationwide Children’s Hospital, Columbus, Ohio,The Ohio State University, Department of Pediatrics, Columbus, Ohio
| | - Jonathan L. Slaughter
- Division of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio,Center for Perinatal Research, Nationwide Children’s Hospital, Columbus, Ohio,The Ohio State University, Department of Pediatrics, Columbus, Ohio
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620
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Arpaci AH, Bozkırlı F. Comparison of sedation effectiveness of remifentanil-dexmedetomidine and remifentanil- midazolam combinations and their effects on postoperative cognitive functions in cystoscopies: A randomized clinical trial. J Res Med Sci 2013; 18:107-14. [PMID: 23914211 PMCID: PMC3724369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 04/14/2012] [Accepted: 05/26/2012] [Indexed: 11/03/2022]
Abstract
BACKGROUND The aim of the study is to compare the effects of remifentanil/dexmedetomidine and remifentanil/midazolam combinations in monitored anesthesia care (MAC) during cystoscopies. MATERIALS AND METHODS Forty patients who received remifentanil infusion of 0.05 μg kg(-1) min(-1) for cytoscopy procedure were randomized into two groups: Either dexmedetomidine 1 mg kg(-1) (Group D) or midazolam 0.2 mg kg(-1) h(-1) (Group M) was administered intravenously for the first 10 min. Subsequently, anesthesia was maintained by using the bispectral index as a continuous infusion of dexmedetomidine (0.2-0.7 μg kg(-1) h(-1)) or midazolam (0.05-0.15 μg kg(-1) h(-1)). Heart rate, mean arterial pressure, mini-mental state examination findings, levels of sedation andanalgesia, and the patient's and surgeon's satisfaction were recorded. RESULTS Successful sedation and analgesia were achieved in all the patients. We were able to reach the target sedation level faster in Group D (P<0.0001). In Group D, the cognitive functions were less affected than in Group M (P<0.0001). Patient's and surgeon's satisfaction were significantly higher in Group D. CONCLUSION The targeted sedation levels were achieved in a shorter period with dexmedetomidine-remifentanil compared to midazolam-remifentanil. The dexmedetomidine-remifentanil combination was observed to affect the cognitive functions less than midazolam-remifentanil did with shorter recovery times. Besides, patient's and surgeon's satisfaction rates were superior with dexmedetomidine-remifentanil. It was concluded that dexmedetomidine-remifentanil may be a combination of choice for monitored anesthesia care applications in outpatient surgical procedures of short duration.
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Affiliation(s)
- Ayse Hande Arpaci
- Department of Anaesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Turkey,Address for correspondence: Dr. Ayşe HandeArpacı, Department of Oral and Maxillofacial, Faculty of Dentistry, Ankara University, Besevler, Ankara, Turkey. E-mail:
| | - Fusun Bozkırlı
- Department of Anaesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Turkey
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621
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Hedenqvist P, Edner A, Fahlman Å, Jensen-Waern M. Continuous intravenous anaesthesia with sufentanil and midazolam in medetomidine premedicated New Zealand White rabbits. BMC Vet Res 2013; 9:21. [PMID: 23351150 PMCID: PMC3568725 DOI: 10.1186/1746-6148-9-21] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 01/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaesthesia in rabbits is associated with a high mortality rate, compared to that in cats and dogs. Total intravenous anaesthesia (TIVA) with drugs that provide cardiovascular stability and are rapidly metabolised could be of benefit for use in rabbits. The aim was to evaluate cardiorespiratory effects of TIVA with sufentanil-midazolam in eight New Zealand White rabbits. Subcutaneous premedication with medetomidine (0.1 mg/kg BW) was followed by IV administration of a mixture of 2.5 μg/mL sufentanil and 0.45 mg/mL midazolam at a rate of 0.3 mL/kg BW/h for anaesthetic induction. Additionally, intravenous boluses of 0.1 mL of the mixture were administered every 20 s until the righting reflex was lost. Following endotracheal intubation, anaesthesia was maintained for 60 min with an infusion rate adjusted to supress the pedal withdrawal reflex. Air and oxygen (1:2) were delivered at 3 L/min. Physiological variables were recorded before induction and at predefined time points during and after anaesthesia. RESULTS Righting and pedal withdrawal reflexes were lost within 3 and 5 min, respectively. Doses of sufentanil and midazolam were 0.48 μg/kg BW and 0.09 mg/kg BW for induction, and 0.72 μg/kg BW/h and 0.13 mg/kg BW/h for maintenance. Apnoea occurred in two rabbits. Induction of anaesthesia caused a significant increase in heart rate, cardiac output and arterial CO2 partial pressure and a decrease in mean arterial pressure, respiratory rate and pH. Mean time from stopping the infusion to endotracheal extubation was 5 min, and to return of the righting reflex 7 min. Anaesthesia was characterized by induction and recovery without excitation, with muscle relaxation, and absence of the pedal withdrawal reflex. CONCLUSIONS TIVA with sufentanil-midazolam provided smooth induction and recovery of anaesthesia in rabbits but with marked hypotension and respiratory depression, requiring mechanical ventilation. Further evaluation is needed to establish if the protocol is useful for rabbits undergoing surgery.
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Affiliation(s)
- Patricia Hedenqvist
- Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, Swedish University of Agricultural Sciences, P.O. Box 7054, SE, 750 07, Uppsala, Sweden
| | - Anna Edner
- Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, Swedish University of Agricultural Sciences, P.O. Box 7054, SE, 750 07, Uppsala, Sweden
| | - Åsa Fahlman
- Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, Swedish University of Agricultural Sciences, P.O. Box 7054, SE, 750 07, Uppsala, Sweden
| | - Marianne Jensen-Waern
- Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, Swedish University of Agricultural Sciences, P.O. Box 7054, SE, 750 07, Uppsala, Sweden
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622
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Dou Y, Li Y, Chen J, Wu S, Xiao X, Xie S, Tang L, Yan M, Wang Y, Lin J, Zhu W, Yan G. Inhibition of cancer cell proliferation by midazolam by targeting transient receptor potential melastatin 7. Oncol Lett 2013; 5:1010-1016. [PMID: 23426784 PMCID: PMC3576402 DOI: 10.3892/ol.2013.1129] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 12/12/2012] [Indexed: 12/17/2022] Open
Abstract
Transient receptor potential melastatin 7 (TRPM7), a Ca2+-permeable channel, has been demonstrated to be present in cancer cells and involved in their growth and proliferation. The present study used midazolam, a benzodiazepine class anesthesic, to pharmacologically intervene in the expression of TRPM7 and to inhibit cancer cell proliferation. Midazolam significantly inhibited the growth and proliferation of FaDu human hypopharyngeal squamous cell carcinoma cells, concurring with the induction of G0/G1 cell cycle arrest and blockage of Rb activation. Central-type and peripheral-type benzodiazepine receptor antagonists did not abrogate proliferation inhibition by midazolam, while the specific TRPM7 agonist bradykinin reversed this effect. In addition, other benzodiazepines, diazepam and clonazepam also exhibited anti-proliferative activities. The inhibitory activity on cancer cell growth and proliferation, combined with the TRPM-dependent mechanism, reveals the anticancer potential of midazolam as a TRPM7 inhibitor and supports the suggestion that TRPM7 is a valuable target for pharmaceutical intervention.
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Affiliation(s)
- Yunling Dou
- Department of Pharmacology, Zhongshan School of Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, P.R. China ; Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, P.R. China
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623
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Kirihara Y, Takechi M, Kurosaki K, Kobayashi Y, Kurosawa T. Anesthetic effects of a mixture of medetomidine, midazolam and butorphanol in two strains of mice. Exp Anim 2013; 62:173-80. [PMID: 23903051 PMCID: PMC4160945 DOI: 10.1538/expanim.62.173] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 01/07/2013] [Indexed: 12/05/2022] Open
Abstract
The combination of ketamine and xylazine is a widely used anesthetic for laboratory animals. However, due to an abuse problem in Japan, ketamine has been specified as a narcotic since 2007. Instead of using ketamine, Kawai et al. reported an injectable formula with an equivalent effect to the mixture of ketamine and xylazine [11]. The mixture of 0.3 mg/kg body weight (b.w.) medetomidine (Med.), 4.0 mg/kg b.w. midazoram (Mid.), and 5.0 mg/kg b.w. butorphanol (But.) produced an anesthetic duration of around 40 min in outbred ICR mice. However, the anesthetic effect of the mixture for inbred mice strains remains unknown. Therefore, we examined anesthetic effects of the mixture of Med., Mid., and But. in the BALB/c and C57BL/6J strains. After intraperitoneal injection into mice, right front paw, left hind paw, and tail pinch reflexes as well as corneal and righting reflexes were observed. Every 5 min, we scored each reflex category as 0 for reaction or 1 for no reaction. As long as the total score was at least 4 out of 5, we considered the mixture as putting a mouse in a surgical anesthetic state. The mixture produced an anesthetic duration of more than 45 min in both strains of mice. These results indicate that the mixture of Med., Mid., and But. can be a useful and effective anesthesia for the BALB/c and C57BL/6J strains of inbred mice as well as outbred ICR mice.
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Affiliation(s)
- Yumiko Kirihara
- Department of Experimental Animals, Center for Integrated Research in Science, Shimane University, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
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624
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Honarmand A, Safavi M, Khalili G, Mohammadnejad F. Prophylactic administration of haloperidol plus midazolam reduces postoperative nausea and vomiting better than using each drug alone in patients undergoing middle ear surgery. Saudi J Anaesth 2012; 6:145-51. [PMID: 22754441 PMCID: PMC3385257 DOI: 10.4103/1658-354x.97028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims: The efficacy of using midazolam or haloperidol for prevention of postoperative nausea and vomiting (PONV) has been investigated before. The main object of the present study was to evaluate the anti-emetic effects of combining administration of intravenous haloperidol with intravenous midazolam on PONV in patients underwent middle ear surgery in comparison with using each drug alone. Methods: Study design was randomized, double-blind, placebo-controlled. 80 patients, aged 18-60 years, scheduled for middle ear surgery in Kashani Hospital Medical Center under general anesthesia were enrolled in this randomized, double-blind, placebo-controlled study. Patients were divided into 4 groups of 20 each and received haloperidol 2 mg i.v. (Group H); midazolam 2 mg i.v. (Group M); haloperidol 2 mg plus midazolam 2 mg i.v. (Group HM); saline i.v. (Group C). The incidences of PONV and complete response were evaluated at 0-2 hours after arrival to the PACU and 2-24 hours after arrival to the ward in 4 groups. Results: Patients in group HM had significantly lower incidence of PONV compared with groups H, M, and C throughout 0-24 h (P<00.5). The HM group had the lowest incidence of PONV (0-2, 2-24, and 0-24 h) and the highest incidence of complete response. Postoperative anti-emetic requirement was significantly less in group HM compared with group M or H (P<0.05). Conclusion: Combine administration of haloperidol 2 mg plus midazolam 2 mg significantly reduced PONV better than using each drug alone in patients underwent middle ear surgery under general anesthesia.
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Affiliation(s)
- Azim Honarmand
- Departments of Anesthesiology and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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625
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Abstract
Background: Relieving preoperative anxiety is an important concern for the pediatric anesthesiologist. Midazolam has become the most frequently used premedication in children. However, new drugs such as the α2 -agonists have emerged as alternatives for premedication in pediatric anesthesia. Methods: One hundred and twenty children scheduled for adenotonsillectomy were enrolled in this prospective, double-blind, randomized study. The children were divided into two equal groups to receive either intranasal dexmedetomidine 1 μg/kg (group D), or oral midazolam 0.5 mg/kg (group M) at approximately 60 and 30 mins, respectively, before induction of anesthesia. Preoperative sedative effects, anxiety level changes, and the ease of child-parent separation were assessed. Also, the recovery profile and postoperative analgesic properties were assessed. Results: Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation levels (P=0.042), lower anxiety levels (P=0.036), and easier child-parent separation (P=0.029) than children who received oral midazolam at the time of transferring the patients to the operating room. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both the groups (P=0.067). Also, the number of children who required fentanyl as rescue analgesia medication was significantly less (P=0.027) in the dexmedetomidine group. Conclusion: Intranasal dexmedetomidine appears to be a better choice for preanesthetic medication than oral midazolam in our study. Dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child-parent separation at the time of transferring patients to the operating room than children who received oral midazolam. Moreover, intranasal dexmedetomidine has better analgesic property than oral midazolam with discharge time from postanesthetic care unit similar to oral midazolam.
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Affiliation(s)
- Ashraf M Ghali
- Department of Anesthesia, Magrabi Eye & Ear Hospital, Muscat, Sultanate of Oman
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626
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Jang JS, Lee JH, Lee JJ, Park WJ, Hwang SM, Lee SK, Lim SY. Postoperative nausea and vomiting after myringoplasty under continuous sedation using midazolam with or without remifentanil. Yonsei Med J 2012; 53:1010-3. [PMID: 22869486 PMCID: PMC3423846 DOI: 10.3349/ymj.2012.53.5.1010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This prospective study evaluated the effects of continuous sedation using midazolam, with or without remifentanil, on postoperative nausea and vomiting (PONV) in patients undergoing myringoplasty. MATERIALS AND METHODS Sixty patients undergoing myringoplasty were sedated with midazolam in the presence of remifentanil (group MR), or after saline injection instead of remifentanil (group M). RESULTS Three patients (10%) in group M complained of nausea; two vomited. Four patients (13%) in group MR complained of nausea and vomited within 24 h after surgery. Rescue drugs were given to the six patients who vomited. No significant difference was detected between the two groups regarding the incidence or severity of nausea, incidence of vomiting, or need for rescue drugs. CONCLUSION Midazolam-based continuous sedation can reduce PONV after myringoplasty. Compared with midazolam alone, midazolam with remifentanil produced no difference in the incidence or severity of nausea, incidence of vomiting, or need for rescue drugs.
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Affiliation(s)
- Ji Su Jang
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Jun Ho Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Hallym University, Chuncheon, Korea
| | - Jae Jun Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Won Jae Park
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Sung Mi Hwang
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - So Young Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
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627
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Abstract
Midazolam can induce acute dystonia in childhood. We report the development of acute dystonia in a 6-year-old girl after receiving midazolam as a sedative. Dystonic contractions persisted despite flumazenil and biperiden lactate injections and the patient was treated with diazepam. Acute dystonia was rapidly abolished after the administration of diazepam intravenously. Diazepam may be an effective treatment option in patients who are unresponsive to flumazenil.
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Affiliation(s)
- Mustafa Komur
- Department of Pediatric Neurology, Mersin University School of Medicine, Mersin, Turkey
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628
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Stern CA, Gazarini L, Takahashi RN, Guimarães FS, Bertoglio LJ. On disruption of fear memory by reconsolidation blockade: evidence from cannabidiol treatment. Neuropsychopharmacology 2012; 37:2132-42. [PMID: 22549120 DOI: 10.1038/npp.2012.63] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The search for reconsolidation blockers may uncover clinically relevant drugs for disrupting memories of significant stressful life experiences, such as those underlying the posttraumatic stress disorder. Considering the safety of systemically administered cannabidiol (CBD), the major non-psychotomimetic component of Cannabis sativa, to animals and humans, the present study sought to investigate whether and how this phytocannabinoid (3-30 mg/kg intraperitoneally; i.p.) could mitigate an established memory, by blockade of its reconsolidation, evaluated in a contextual fear-conditioning paradigm in rats. We report that CBD is able to disrupt 1- and 7-days-old memories when administered immediately, but not 6 h, after their retrieval for 3 min, with the dose of 10 mg/kg being the most effective. This effect persists in either case for at least 1 week, but is prevented when memory reactivation was omitted, or when the cannabinoid type-1 receptors were antagonized selectively with AM251 (1.0 mg/kg). Pretreatment with the serotonin type-1A receptor antagonist WAY100635, however, failed to block CBD effects. These results highlight that recent and older fear memories are equally vulnerable to disruption induced by CBD through reconsolidation blockade, with a consequent long-lasting relief in contextual fear-induced freezing. Importantly, this CBD effect is dependent on memory reactivation, restricted to time window of <6 h, and is possibly dependent on cannabinoid type-1 receptor-mediated signaling mechanisms. We also observed that the fear memories disrupted by CBD treatment do not show reinstatement or spontaneous recovery over 22 days. These findings support the view that reconsolidation blockade, rather than facilitated extinction, accounts for the aforementioned CBD results in our experimental conditions.
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629
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Abstract
Acute seizure and status epilepticus constitute major medical emergencies in children. Four to six percent of children will have at least one seizure in the first 16 years of life. Status epilepticus is a common neurological emergency in childhood and is associated with significant morbidity and mortality. The early application of antiepileptic treatment is very important. Because early treatment prevents the status epilepticus formation and shortens the duration of seizure activity. For this reason administration of anticonvulsant therapy in the prehospital setting is very important. Seizures generally begin outside the hospital, and thus parents and caregivers need simple, safe and effective treatment options to ensure early intervention. The only special preparation used for this purpose is rectal diazepam but has some disadvantages. Midazolam is a safe, short-acting benzodiazepin. It is suitable to use oral, buccal, nasal, im and iv routes. This provides a wide area for clinical applications. Recently there are many clinical studies about the usage of nasal and buccal midazolam for treatment of pediatric epileptic seizures. The nasal and buccal applications in pediatric seizures are very practical and effective. Parents and caregivers can apply easily outside the hospital.
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Affiliation(s)
- Ayşe Ulgey
- Medical Faculty, Erciyes University, 38039 Kayseri, Turkey
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630
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Zhao S, Zhu Y, Xue R, Li Y, Lu H, Mi W. Effect of midazolam on the proliferation of neural stem cells isolated from rat hippocampus. Neural Regen Res 2012; 7:1475-82. [PMID: 25657682 PMCID: PMC4308778 DOI: 10.3969/j.issn.1673-5374.2012.19.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 06/13/2012] [Indexed: 02/03/2023] Open
Abstract
In many recent studies, the inhibitory transmitter gamma-aminobutyric acid has been shown to modulate the proliferation, differentiation and survival of neural stem cells. Most general anesthetics are partial or allosteric gamma-aminobutyric acid A receptor agonists, suggesting that general anesthetics could alter the behavior of neural stem cells. The neuroprotective efficacy of general anesthetics has been recognized for decades, but their effects on the proliferation of neural stem cells have received little attention. This study investigated the potential effect of midazolam, an extensively used general anesthetic and allosteric gamma-aminobutyric acid A receptor agonist, on the proliferation of neural stem cells in vitro and preliminarily explored the underlying mechanism. The proliferation of neural stem cells was tested using both Cell Counting Kit 8 and bromodeoxyuridine incorporation experiments. Cell distribution analysis was performed to describe changes in the cell cycle distribution in response to midazolam. Calcium imaging was employed to explore the molecular signaling pathways activated by midazolam. Midazolam (30–90 μM) decreased the proliferation of neural stem cells in vitro. Pretreatment with the gamma-aminobutyric acid A receptor antagonist bicuculline or Na-K-2Cl cotransport inhibitor furosemide partially rescued this inhibition. In addition, midazolam triggered a calcium influx into neural stem cells. The suppressive effect of midazolam on the proliferation of neural stem cells can be partly attributed to the activation of gamma-aminobutyric acid A receptor. The calcium influx triggered by midazolam may be a trigger factor leading to further downstream events.
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Affiliation(s)
- Sanjun Zhao
- Department of Anesthesiology, the General Hospital of Chinese PLA, Beijing 100853, China
| | - Yajing Zhu
- Department of Obstetrics and Gynecology, Luhe Teaching Hospital, Capital Medical University, Beijing 101100, China
| | - Rui Xue
- Beijing Institute of Pharmacology and Toxicology, Beijing 100853, China
| | - Yunfeng Li
- Beijing Institute of Pharmacology and Toxicology, Beijing 100853, China
| | - Hui Lu
- The 254 Hospital of Chinese PLA, Tianjin 300142, China
| | - Weidong Mi
- Department of Anesthesiology, the General Hospital of Chinese PLA, Beijing 100853, China
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631
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Kher S, Roberts RJ, Garpestad E, Kunkel C, Howard W, Didominico D, Fergusson A, Devlin JW. Development, implementation, and evaluation of an institutional daily awakening and spontaneous breathing trial protocol: a quality improvement project. J Intensive Care Med 2012; 28:189-97. [PMID: 22596087 DOI: 10.1177/0885066612444255] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION While one controlled trial found that a daily awakening and spontaneous breathing trial (DA-SBT) decreases time on mechanical ventilation (MV), there is a paucity of real-world data surrounding the development, implementation, and impact of DA-SBT protocols. We describe a multidisciplinary process improvement effort in 2, 10-bed medical intensive care units (MICUs) at a 330-bed academic medical center that focused on the development, implementation, and evaluation of a new DA-SBT protocol. METHODS A DA-SBT protocol, developed using results from a nursing survey literature and available institutional resources, was implemented after extensive clinician education and institution of quality reminders to boost use. Postprotocol compliance was evaluated. Use of sedation, DA and SBT practices, and clinical outcomes were retrospectively compared between the before and after DA-SBT protocol groups (ie, consecutive MICU patients requiring a continuously infused sedative [CIS] ≥24 hours). RESULTS In the after group (n = 32), the DA and SBT compliances were 44% and 84%, respectively. Compared with the before group (n = 33), after group patients received CIS on fewer days of MV (100% vs 67%, P = .003) and had their CIS down-titrated by ≥25% on more days of CIS (40% vs 71%, P = .006). Neither total CIS dose (P = .49), total MV days (P = .75), days of MV where a SBT occurred (P = .38), nor episodes of self-extubation (15% vs 6%, P = .43) differed between the 2 groups. CONCLUSION Despite the implementation of a DA-SBT protocol that was individualized to clinician preferences and institutional resources and accompanied by substantial education and reminders for use, compliance to the DA component of this protocol was low and duration of MV remained unchanged. Additional quality improvement strategies are needed to overcome barriers to DA-SBT protocol use that may not exist in controlled clinical trials.
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Affiliation(s)
- Sucharita Kher
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA 02115, USA
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632
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Heidari SM, Talakoub R, Yaraghi Z. Comparing the preventive effect of midazolam and midazolam-dexamethasone on postoperative nausea and vomiting in elective middle ear surgery. Adv Biomed Res 2012; 1:9. [PMID: 23210068 PMCID: PMC3507039 DOI: 10.4103/2277-9175.96052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 02/18/2012] [Indexed: 11/24/2022] Open
Abstract
Background: Nausea and vomiting are common postoperative complications with incidence of 20–80% depends on the surgery type, anesthetic drugs, age, sex, etc. This complication may lead to patient discomfort, intraocular, and intracerebral pressures increase, sutures rupture, esophageal injury, and rarely death. Many studies reported that midazolam and dexamethasone alone can decrease postoperative nausea and vomiting (PONV), but their combination has never been studied yet. The aim of this study was to compare the effect of midazolam and midazolam-dexamethasone on PONV after middle ear surgery. Materials and Methods: 66 ASA I and II patients aged 15–65 year scheduled for elective middle ear surgery under general anesthesia randomly divided into two groups. Immediately after induction of the anesthesia group one (M) received midazolam 0.075 mg/kg and group two (M+D) received combination of midazolam (0.075 mg/kg) plus dexamethasone (0.05 mg/kg). Then the severity of nausea was measured by visual analog scales 0–10 (VAS) in recovery room at 6, 12, and 24 h after surgery. Metoclopramid (0.1 mg/kg) was administrated I.V. slowly if nausea score was above 3 or patient had vomiting. The postoperative need for antiemetics and the duration of stay in recovery room were recorded. Values of P<0.05 were considered statistically significant. Results: There were no significant differences in age, gender, and weight between the two groups. There was no significant difference in the mean nausea scores between two groups except after 12 h postoperatively (1.39 ± 3.19 in M group vs. 0.42 ± 1.71 in M+D group). The mean vomiting frequency was significantly less in midazolam-dexamethasone group in the recovery room (0.9 ± 0.29 vs. 0 ± 0) and at 6–12 h (1.09 ± 2.41 vs. 0.3 ± 0.8), and 12–24 h (0.42 ± 1.32 vs. 0.03 ± 0.17) postoperatively. During the first 24 h postoperatively, the metoclopramid consumption was significantly less in combination therapy (6.48 ± 9.54) than in the midazolam group (12.9 ± 23.44) (Value<0.5). Conclusion: The combination of midazolam-dexametazone is more effective than midazolam alone in prevention of postoperative vomiting after middle ear surgery. Therefore, we recommend combination therapy for patients who are prone to PONV.
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Affiliation(s)
- Sayed Morteza Heidari
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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633
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Empey PE, Miller TM, Philbrick AH, Melick JA, Kochanek PM, Poloyac SM. Mild hypothermia decreases fentanyl and midazolam steady-state clearance in a rat model of cardiac arrest. Crit Care Med 2012; 40:1221-8. [PMID: 22067624 PMCID: PMC3307845 DOI: 10.1097/ccm.0b013e31823779f9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Therapeutic hypothermia is widely employed for neuroprotection after cardiac arrest. However, concern regarding elevated drug concentrations during hypothermia and increased adverse drug reaction risk complicates concurrent pharmacotherapy. Many commonly used medications in critically ill patients rely on the cytochrome P450 3A isoform for their elimination. Therefore, our study objectives were to determine the effect of mild hypothermia on the in vivo pharmacokinetics of fentanyl and midazolam, two clinically relevant cytochrome P450 3A substrates, after cardiac arrest and to investigate the mechanisms of these alterations. DESIGN Prospective, randomized, controlled study. SETTING University research laboratory. SUBJECTS Thirty-two adult male Sprague-Dawley rats. INTERVENTIONS An asphyxial cardiac arrest rat model was used and mild hypothermia (33°C) was induced 1 hr post injury by surface cooling and continued for 10 hrs to mimic the prolonged clinical application of hypothermia accompanied by intensive care interventions. Fentanyl and midazolam were independently administered by intravenous infusion and plasma and brain concentrations were analyzed using ultraperformance liquid chromatography tandem mass spectrometry. Cytochrome P450 3a2 protein expression was measured and a Michaelis-Menten enzyme kinetic analysis was performed at 37°C and 33°C using control rat microsomes. MEASUREMENTS AND MAIN RESULTS Mild hypothermia decreased the systemic clearance of both fentanyl (61.5 ± 11.5 to 48.9 ± 8.95 mL/min/kg; p < .05) and midazolam (89.2 ± 12.5 to 73.6 ± 12.1 mL/min/kg; p < .05) after cardiac arrest. The elevated systemic concentrations did not lead to parallel increased brain exposures of either drug. Mechanistically, no differences in cytochrome P450 3a2 expression was observed, but the in vitro metabolism of both drugs was decreased at 33°C vs. 37°C through reductions in enzyme metabolic capacity rather than substrate affinity. CONCLUSIONS Mild hypothermia reduces the systemic clearances of fentanyl and midazolam in rats after cardiac arrest through alterations in cytochrome P450 3a2 metabolic capacity rather than enzyme affinity as observed with other cytochrome P450s. Contrasting effects on blood and brain levels further complicates drug dosing. Consideration of the impact of hypothermia on medications whose clearance is dependent on P450 3A metabolism is warranted.
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Affiliation(s)
- Philip E Empey
- Department of Pharmacy and Therapeutics, School of Medicine, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
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634
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Mattoo SK, Kate N, Verma AK. Refractory delirium tremens: a case report and brief review. Innov Clin Neurosci 2012; 9:19-22. [PMID: 22567606 PMCID: PMC3342992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Delirium tremens is a common presentation in tertiary care hospitals. Severe and/or refractory delirium tremens is not as common, is potentially lethal, and requires intensive management. Usually delirium tremens responds to management with standard doses of benzodiazepines. Limited literature is available, however, for the management of refractory delirium tremens. We describe a case of refractory delirium tremens in which the patient was successfully managed with a combination of high doses of lorazapam, midazolam, and phenytoin.
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Affiliation(s)
- Surendra Kumar Mattoo
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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635
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Golpayegani MV, Dehghan F, Ansari G, Shayeghi S. Comparison of oral Midazolam-Ketamine and Midazolam-Promethazine as sedative agents in pediatric dentistry. Dent Res J (Isfahan) 2012; 9:36-40. [PMID: 22363361 PMCID: PMC3283976 DOI: 10.4103/1735-3327.92925] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Investigation was designed to evaluate the behavioral changes in children receiving dental treatment while they have been administered combination of Midazolam/Ketamine or Midazolam/Promethazine. MATERIALS AND METHODS This was a randomized double blind clinical trial with cases being selected from those uncooperative children aged 2 to 6 years from those referred for treatment under general anesthesia. Anxiety score of all cases were recorded before any attempt using Frankel's anxiety scoring system with those in negative category being included. Cases with at least a pair of similar size cavities on similar teeth were selected with each tooth being randomly allocated for one sedative regimen group. To avoid sequence effect, half of the patients received one regimen at the first visit while the other half received the other regimen as the first. Each case served as control for him or herself to reduce influencing factors. Child's reaction was recorded before, during, and at the end of dental procedure. SO2 as well as Pulse rate were recorded as the most critical vital signs. Collected data were then analyzed using analysis of variance (ANOVA) and paired t-test. RESULTS Patients' mean age was 3.5 years with 43% being male. Only 10% of the Ketamine/Midazolam group showed considerable amount of change in their behavior with a statistical significant difference being presented (P=0.029). CONCLUSION Under the current circumstances, Ketamine/Midazolam combination provided sufficient sedative effect in lower doses. However, Midazolam/Promethazine combination did not produce similar results.
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Affiliation(s)
| | - Fereshteh Dehghan
- Department of Pediatric Dentistry, Dental School, Islamic Azad University, Tehran, Iran
| | - Ghassem Ansari
- Department of Pediatric Dentistry, Dental School, Shahid Beheshti Medical University, Tehran, Iran
| | - Shahnaz Shayeghi
- Department of Anesthesiology, Mofid Children's Hospital, Shahid Beheshti Medical University, Tehran, Iran
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636
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Eren G, Cukurova Z, Demir G, Hergunsel O, Kozanhan B, Emir NS. Comparison of dexmedetomidine and three different doses of midazolam in preoperative sedation. J Anaesthesiol Clin Pharmacol 2011; 27:367-72. [PMID: 21897510 PMCID: PMC3161464 DOI: 10.4103/0970-9185.83684] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: This study was conducted to compare the efficacy and effects of dexmedetomidine and midazolam in preoperative sedation. Materials and Methods: A total of 125 patients in American Society of Anaesthesiologists (ASA) I-II were divided into three groups: Group I (n = 40) for controls, Group II (n = 40) for Dexmedetomidine (1 μg/kg), and group III was the midazolam group (n = 45). Group III was further divided into three subgroups according to the doses of midazolam: Group IIIA (n = 15) received 0.02 mg/kg, group IIIB (n = 15) received 0.04 mg/kg, and group IIIC (n = 15) received 0.06 mg/kg of midazolam. Drugs were infused over a 10-minute period with appropriate monitoring. Ramsay and visual analog scores, for sedation and anxiety, respectively, and mean arterial pressure, heart rate, and SpO2 measurement, including respiratory rates were recorded, every 5 minutes for 30 minutes following infusion. Results: There was marked sedation and a decrease in anxiety in groups II and IIIC (P < 0.01). Mean arterial pressure (MAP) and heart rate (HR) decreased significantly in group II (P < 0.01 and P < 0.05, respectively), but there was no associated hypotension (MAP <60 mm Hg) or bradycardia (HR <50 bpm) (P < 0.05). Respiratory rates and SpO2 values decreased in groups II, IIIA, IIIB, and IIIC. The differences in respiratory rates were not significant (P > 0.05); however, decrease in SpO2 was significant in group IIIC (P < 0.01). Conclusions: Dexmedetomidine was as effective as higher doses of midazolam in sedation. The hemodynamic and respiratory effects were minimal. Although dexmedetomidine caused significant decrease in the blood pressure and heart rate, it probably just normalized increased levels caused by preoperative stress.
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Affiliation(s)
- Gulay Eren
- Department of Anaesthesiology and Intensive Care, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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637
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Bai X, France CP, Gerak LR. The discriminative stimulus effects of midazolam are resistant to modulation by morphine, amphetamine, dizocilpine, and γ-butyrolactone in rhesus monkeys. Psychopharmacology (Berl) 2011; 217:495-504. [PMID: 21503606 DOI: 10.1007/s00213-011-2302-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 04/06/2011] [Indexed: 10/18/2022]
Abstract
RATIONALE Although abuse of benzodiazepines alone is uncommon, it is high in polydrug abusers, including those who primarily use opioids or stimulants. OBJECTIVES This study investigated whether drugs that are abused (e.g., amphetamine) or drugs that have mechanisms of action similar to abused drugs (e.g., morphine) alter the discriminative stimulus effects of the benzodiazepine midazolam. METHODS Three rhesus monkeys discriminated 0.56 mg/kg of midazolam while responding under a fixed-ratio 10 schedule of food presentation. Dose-effect curves were determined for midazolam alone and in the presence of morphine (opioid receptor agonist), amphetamine (dopamine receptor indirect agonist), dizocilpine (N-methyl-D: -aspartic acid receptor antagonist), or γ-butyrolactone (prodrug of γ-hydroxybutyrate, which acts primarily at GABA(B) receptors). RESULTS Doses of midazolam larger than 0.32 mg/kg produced ≥80% midazolam-lever responding. When administered alone, morphine, amphetamine, dizocilpine, and γ-butyrolactone did not produce midazolam-lever responding, although large doses of each drug eliminated responding; when administered in combination with midazolam, they did not alter the discriminative stimulus effects of midazolam up to doses that markedly decreased response rates. CONCLUSIONS The current study demonstrates a lack of modulation of the discriminative stimulus effects of midazolam by morphine, amphetamine, dizocilpine, and γ-butyrolactone. Other effects of benzodiazepines, such as their reinforcing effects, might be altered by these other drugs, or benzodiazepines might modulate the discriminative stimulus or reinforcing effects of the other drugs, which might contribute to the relatively high incidence of benzodiazepine abuse among polydrug abusers.
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638
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Robinson MJF, Armson M, Franklin KBJ. The effect of propranolol and midazolam on the reconsolidation of a morphine place preference in chronically treated rats. Front Behav Neurosci 2011; 5:42. [PMID: 21866225 PMCID: PMC3149442 DOI: 10.3389/fnbeh.2011.00042] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 07/08/2011] [Indexed: 11/13/2022] Open
Abstract
A stable memory can be disrupted if amnestic treatment is applied in conjunction with memory reactivation. Recent findings in the conditioned place preference (CPP) model suggest that blocking reconsolidation attenuates the ability of environmental cues to induce craving and relapse in drug addicts, but the impact of prior physical dependence has not been described. We examined the effect of post-reactivation amnestic treatment on reconsolidation of a CPP for morphine, in animals naïve to morphine, under chronic morphine experience or abstinent. Chronic morphine experience was induced by escalating doses of morphine from 10 mg/kg/day (s.c.), and maintained on 30 mg/kg/day during the course of conditioning and reactivation procedures, or conditioning alone. Naïve and morphine-experienced animals were trained in a three-compartment apparatus by four morphine (5 mg/kg, s.c.) and four saline experiences paired with either of two large conditioning compartments. The memory was then reactivated by a CPP test, and immediately afterward animals received an injection of the beta-adrenergic antagonist propranolol (10 mg/kg, s.c.), the GABAa agonist midazolam (1 mg/kg, i.p.), or saline. Morphine-naïve rats received only a single reconsolidation-blocking treatment (Experiment 1), while chronic morphine rats were given eight reactivation sessions each followed by amnestic treatment, either before (Experiment 2) or after 10 days of withdrawal (Experiment 3). Propranolol and midazolam disrupted reconsolidation in morphine-naïve rats, but failed to disrupt the CPP when rats were trained under chronic morphine treatment, even if they were recovered from chronic opiate exposure before reactivation. In fact, propranolol increased the preference for the drug-paired context in animals trained while maintained on chronic morphine. Midazolam had little effect. Morphine experience may produce neurochemical changes which alter memory storage processes and reduce the impact of amnestic treatments on reconsolidation.
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639
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Schneider P, Ho YJ, Spanagel R, Pawlak CR. A novel elevated plus-maze procedure to avoid the one-trial tolerance problem. Front Behav Neurosci 2011; 5:43. [PMID: 21845176 PMCID: PMC3146044 DOI: 10.3389/fnbeh.2011.00043] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 07/08/2011] [Indexed: 11/13/2022] Open
Abstract
The elevated plus-maze (EPM) test is one of the most commonly used behavioral assays to evaluate anxiety-related behavior in rodents. It is an economic test (5 min duration) without prior conditioning of the animals. The critical measure for anxiety is the time spent in the open arms of the maze. A confounding problem of the EPM is the so called one-trial tolerance (OTT), characterized by a marked decrease of open arm exploration in spite of treatment with anxiolytic acting benzodiazepines upon re-exposure to the EPM. This consistent finding is often raised as an evidence for the inappropriateness to re-test rodents in the EPM. However, a reliable re-test paradigm would broaden the usability and effectiveness of this test. Therefore, we tested how an extension of the inter-trial interval to 28 days (instead of the usual 24 h), and an additional change of the testing room would affect the open arm time and other behaviors on the EPM. In two experiments, drug-naive Wistar rats were exposed to the EPM on trial 1, and treated intraperitoneally with either vehicle or midazolam (0.25 mg/kg) 30 min before trial 2. Then, trial 2 (28 days after trial 1) was carried out in either the same testing room (Experiment 1) or in another unfamiliar room (Experiment 2). Twenty-eight days after trial 1 the open arm time of the rats in the vehicle treated control rats of both experimental groups was comparable to that of the first trial, independent of the testing room. Most importantly, we found that the treatment with the benzodiazepine midazolam had a significantly anxiolytic-like (i.e., increase of open arm time) effect in trial 2 only when conducted in the previously unfamiliar testing room (Experiment 2). We suggest that in order to reliably re-test the EPM and to prevent confounding effects due to the OTT, an inter-trial interval of 28 days and a change in testing rooms reinstates anxiolytic-like actions of benzodiazepines.
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Affiliation(s)
- Peggy Schneider
- Institute of Psychopharmacology, Central Institute of Mental Health Mannheim, Germany
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640
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Bobade S, Kulkarni V, Dhumne S, Barde S, Chauhan J, Sharma A. Drug interaction leading to prolonged sedation in a postoperative high risk coronary bypass surgery patient. Indian J Crit Care Med 2011; 15:55-7. [PMID: 21633550 PMCID: PMC3097546 DOI: 10.4103/0972-5229.78230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Use of midazolam infusion in mechanically ventilated patient is an established practice in critical care. In our case, the use of erythromycin as a prokinetic agent for better tolerance of enteral feeding and paralytic ileus led to an interaction between midazolam and erythromycin, which resulted in prolonged and deeply sedated patient. In a critically ill patient, there is always a possibility of multiple drug interactions. It is important to understand them and they should be considered before starting new medication.
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Affiliation(s)
- Shrikant Bobade
- Department of Anaesthesiology and Critical Care, CARE Hospital, Nagpur, India
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641
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Abstract
Status epilepticus (SE) is a medical emergency associated with significant morbidity and mortality. SE is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them. Based on recent understanding of the pathophysiology, it is now considered that any seizure that lasts more than 5 min probably needs to be treated as SE. GABAergic mechanisms play a crucial role in terminating seizures. When the seizure persists, GABA-mediated mechanisms become ineffective and several other putative mechanisms of seizure suppression have been recognized. Early treatment of SE with benzodiazepines, followed if necessary by fosphenytoin administration, is the most widely followed strategy. About a third of patients with SE may have persistent seizures refractory to the first-line medications. They require aggressive management with second-line medications such as barbiturates, propofol, or other agents. In developing countries where facilities for assisted ventilation are not readily available, it may be helpful to use nonsedating antiepileptic drugs (such as sodium valproate, levetiracetam, or topiramate) at this stage. It is important to recognize SE and institute treatment as early as possible in order to avoid a refractory state. It is equally important to attend to the general condition of the patient and to ensure that the patient is hemodynamically stable. This article reviews current knowledge regarding the management of convulsive SE in adults.
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Affiliation(s)
- Ajith Cherian
- Department of General Medicine, Medical College, Trivandrum, Kerala, India
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Khattab AM, El-Seify ZA. Sevoflurane-emergence agitation: Effect of supplementary low-dose oral ketamine premedication in preschool children undergoing dental surgery. Saudi J Anaesth 2011; 3:61-6. [PMID: 20532105 PMCID: PMC2876942 DOI: 10.4103/1658-354x.57878] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The use of sevoflurane in pediatric anesthesia, which could enable a more rapid emergence and recovery, is complicated by the frequent occurrence of post-anesthesia agitation. This study aims to test the efficacy of adding a low dose of ketamine orally, as a supplement to the midazolam-based oral premedication for reducing sevoflurane-related emergence agitation. MATERIALS AND METHODS Ninety-two preschool children, aged between two and six years, with an American Society of Anesthesiologists physical status I or II, scheduled for elective dental filling and extractions under general anesthesia were included. The patients were allocated into two groups: Group M (46 patients) received oral midazolam 0.5 mg/kg, mixed with ibuprofen 10 mg/kg, while group KM (46 patients) received a similar premedication mixture, in addition to ketamine 2 mg/kg. The acceptance of the drug mixture, the onset of action, and the occurrence of vomiting were monitored over the next 30 minutes. Induction of anesthesia was carried out using sevoflurane 8 Vol% in 100% oxygen via face mask. Anesthesia was maintained with sevoflurane 1.5-2 Vol% in an oxygen-nitrous oxide mixture. After extubation, the standard scoring scale was used for assessing the quality of emergence. Agitation parameters were measured using a five-point scale. Agitated children were managed by giving intravenous increments of fentanyl 1 mug/ kg. The time of hospital discharge allowance was recorded. RESULTS Drug palatability, vomiting, and onset of action of premedication; showed no significant differences between both groups. Time of eye opening after discontinuation of sevoflurane showed no significant differences between both groups. Postoperative agitation score and rescue fentanyl consumption were higher in group M than in group KM on admission to the PACU (P < 0.01). The time of hospital discharge allowance in group M was longer than in group KM (P < 0.05). CONCLUSION Adding a low dose of oral ketamine to midazolam-based oral premedication in preschool children undergoing dental surgery reduced sevoflurane-related emergence agitation without delaying discharge.
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Affiliation(s)
- Ahmed Metwally Khattab
- Ain Shams University, Cairo, Egypt, Doha Clinic Hospital, Department of Anesthesia, Doha, Qatar
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Ceran C, Pampal A, Goktas O, Pampal HK, Olmez E. Commonly used intravenous anesthetics decrease bladder contractility: An in vitro study of the effects of propofol, ketamine, and midazolam on the rat bladder. Indian J Urol 2011; 26:364-8. [PMID: 21116355 PMCID: PMC2978435 DOI: 10.4103/0970-1591.70570] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Aim: This study was designed to test the hypothesis that propofol, ketamine, and midazolam could alter the contractile activity of detrusor smooth muscle. Materials and Methods: Four detrusor muscle strips isolated from each rat bladder (n = 12) were placed in 4 tissue baths containing Krebs-Henseleit solution. The carbachol (10
−8to 10−4mol/L)-induced contractile responses as well as 5, 10, 20, 30, 40, 50 Hz electrical field stimulation (EFS)-evoked contractile responses of the detrusor muscles were recorded using isometric contraction measurements. After obtaining basal responses, the in vitro effects of propofol, ketamine, midazolam (10−5 to 10−3 mol/L), and saline on the contractile responses of the detrusor muscle strips were recorded and evaluated. Results: All the 3 drugs reduced the carbachol-induced and/or EFS-evoked contractile responses of rat detrusor smooth muscles in different degrees. Midazolam (10−4 to 10−3 mol/L) caused a significant decrease in the contractile responses elicited by either EFS or carbachol (P=0.000−0.013). Propofol (10−3mol/L) caused a decrease only in EFS-evoked contractile responses (P=0.001−0.004) and ketamine (10−3mol/L) caused a decrease only in carbachol-induced contractile responses (P=0.001−0.034). Conclusion: We evaluated the effects of the 3 different intravenous anesthetics on detrusor contractile responses in vitro and found that there are possible interactions between anesthetic agents and detrusor contractile activity. The depressant effects of midazolam on the contractile activity were found to be more significant than ketamine and propofol. Despite the necessity of further studies, it could be a piece of wise advice to clinicians to keep the probable alterations due to intravenous anesthetics in mind, while evaluating the results of urodynamic studies in children under sedation.
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Affiliation(s)
- Canan Ceran
- Department of Pediatric Surgery, Inonu University, Malatya
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Bai X, Gerak LR. Comparing the discriminative stimuli produced by either the neuroactive steroid pregnanolone or the benzodiazepine midazolam in rats. Psychopharmacology (Berl) 2011; 214:427-35. [PMID: 20972551 DOI: 10.1007/s00213-010-2047-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 10/02/2010] [Indexed: 10/18/2022]
Abstract
RATIONALE Neuroactive steroids might be therapeutic alternatives for benzodiazepines because they have similar anxiolytic, sedative, and anticonvulsant effects, and their actions at different modulatory sites on γ-aminobutyric acid(A) (GABA(A)) receptors might confer differences in adverse effects. OBJECTIVES This study used drug discrimination to compare discriminative stimuli produced by positive GABA(A) modulators that vary in their site of action on GABA(A) receptors. METHODS Two groups of rats discriminated either 3.2 mg/kg of pregnanolone or 0.56 mg/kg of midazolam from vehicle while responding under a fixed ratio 10 schedule of food presentation. RESULTS Pregnanolone, midazolam, and flunitrazepam produced ≥ 80% drug-lever responding in both groups; each drug was more potent in rats discriminating pregnanolone. Pentobarbital produced ≥ 80% drug-lever responding in all rats discriminating pregnanolone, and in 1/3 of the rats discriminating midazolam with larger doses decreasing response rates to <20% of control. Morphine and ketamine produced predominantly saline-lever responding in both groups. Flumazenil antagonized midazolam and flunitrazepam in both groups; slopes of Schild plots were not different from unity, and pA (2) values for flumazenil ranged from 5.86 to 6.09. Flumazenil did not attenuate the discriminative stimulus effects of pregnanolone. CONCLUSIONS The midazolam and pregnanolone discriminative stimuli were qualitatively similar, although the effects of pentobarbital were not identical in the two groups. Although acute effects of midazolam and pregnanolone are similar, suggesting that neuroactive steroids might retain the therapeutic effects of benzodiazepines, differences emerge during chronic treatment, indicating that neuroactive steroids might produce fewer adverse effects than benzodiazepines.
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Xia WF, Liu Y, Zhou QS, Tang QZ, Zou HD. Comparison of the effects of propofol and midazolam on inflammation and oxidase stress in children with congenital heart disease undergoing cardiac surgery. Yonsei Med J 2011; 52:326-32. [PMID: 21319354 PMCID: PMC3051229 DOI: 10.3349/ymj.2011.52.2.326] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To investigate and compare the effects of propofol and midazolam on inflammation and oxidase stress in children with congenital heart disease undergoing cardiac surgery. MATERIALS AND METHODS Thirty-two ASA class I-II children with congenital heart disease undergoing cardiac surgery were randomly divided into two groups: propofol combined with low dose fentanyl (PF group, n = 16) and midazolam combined with low dose fentanyl (MF group, n = 16). Tracheal extubation time and length of Intensive Care Unit (ICU) stay were recorded. Blood samples were taken before operation (T₀), at 2 h after release of the aorta cross-clamp (T₃) and at 24 h after operation (T₄) to measure interleukin 6 (IL-6), IL-8, superoxide dismutase (SOD) and malondialdehyde (MDA) levels. Myocardium samples were collected at 10-20 min after aorta cross-clamp (T₁) and at 10-20 min after the release of the aorta cross-clamp (T₂) to detect heme oxygenase-1 (HO-1) expression. RESULTS Tracheal extubation time and length of ICU stay in PF group were significantly shorter than those of the MF group (p < 0.05, respectively). After cardiopulmonary bypass, IL-6, IL-8 and MDA levels were significantly increased, and the SOD level was significantly reduced in both two groups, but PF group exhibited lower IL-6, IL-8 and MDA levels and higher SOD levels than the MF group (p < 0.05, respectively). The HO-1 expression in the PF group was significantly higher than that in MF group at the corresponding time points (p < 0.05, respectively). CONCLUSION Propofol is superior to midazolam in reducing inflammation and oxidase stress and in improving post-operation recovery in children with congenital heart disease undergoing cardiac surgery.
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Affiliation(s)
- Wen-fang Xia
- Department of Critic Care Medicine, Renmin Hospital of Wuhan University, Wuhan, P.R. China
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China
| | - Yu Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China
- Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China
| | - Qing-shan Zhou
- Department of Critic Care Medicine, Renmin Hospital of Wuhan University, Wuhan, P.R. China
| | - Qi-zhu Tang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China
- Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China
| | - Han-dong Zou
- Department of Critic Care Medicine, Renmin Hospital of Wuhan University, Wuhan, P.R. China
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Abstract
Background: In this study, we compared the sedative effects of sublingual midazolam solution with the oral tablet as premedication. Sixty pediatric patients of ASA physical status I and II were randomly selected to receive either 0.5 mg/kg of tablet or 0.5 mg/kg of sublingual solution of midazolam as premedication, about 45 min before elective surgery. Materials and Methods: There were 30 patients in each group. In Group I, the patients received premedication in the form of oral midazolam tablet 0.5 mg/kg. In Group II, the patients received midazolam solution 0.5 mg/kg. The degree of sedation and ease of separation was assessed according to the Niall C. Wilton scale and the procedure of Davis Peter, respectively. The time for complete drug dissolution was noted in both the groups. Then, the patients were interviewed regarding their acceptance of taste. Results: The sedation scores in the sublingual group were higher than in the oral group at 30 and 45 min after drug administration (P=0.0134 and P=0.0157). 66.6% of the patients in the sublingual group found it satisfactory as compared to 53.3% in the case of group receiving tablet. Conclusion: Thus, from the present study, it is concluded that premedication with midazolam is more effective by the sublingual than the oral route in children.
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Affiliation(s)
- Shobhana Gupta
- Department of Anesthesiology, M. P. Shah Medical College, Guru Gobind Singh Hospital, Jamnagar, Gujarat, India
| | - Hina Gadani
- Department of Anesthesiology, M. P. Shah Medical College, Guru Gobind Singh Hospital, Jamnagar, Gujarat, India
| | - Shravan Kedia
- Department of Anesthesiology, M. P. Shah Medical College, Guru Gobind Singh Hospital, Jamnagar, Gujarat, India
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Kim S, Seo J, Jeon Y. Antiemetic effects of midazolam added to fentanyl-ropivacaine patient-controlled epidural analgesia after subtotal gastrectomy: A prospective, randomized, double-blind, controlled trial. Curr Ther Res Clin Exp 2010; 71:298-308. [PMID: 24688151 DOI: 10.1016/j.curtheres.2010.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2010] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Nausea and vomiting are frequent adverse effects of patient-controlled epidural analgesia (PCEA) with opioids. OBJECTIVE This study was designed to assess the antiemetic effect of midazolam added to fentanyl-ropivacaine PCEA. METHODS In a prospective, randomized, double-blind, controlled trial, smoking patients with gastric cancer undergoing elective subtotal gastrectomy were evenly allocated to 1 of 2 treatment groups to manage postoperative pain: 0.2% ropivacaine mixed with fentanyl 4 μg/mL and midazolam 0.2 mg/mL (test group) or 0.2% ropivacaine mixed with fentanyl 4 μg/mL (control group). The PCEA infusion was set to deliver 4 μL/h of the study solution, with a bolus of 2 mL per demand and a 15-minute lockout time. The incidence of postoperative nausea and vomiting (PONV), pain intensity, sedation score, usage of rescue analgesia and rescue antiemetic, respiratory depression, urinary retention, and pruritus were recorded at 2, 6, 12, 24, 48, and 72 hours after surgery. Total infused volume of PCEA at 72 hours after surgery was measured. RESULTS A total of 60 patients were approached and randomized to treatment. No patients were excluded by exclusion criteria and all enrolled patients completed this study. Incidence of nausea (7% vs 33%; P = 0.02) in the test group was significantly lower than in the control group. The overall frequency of PONV in the test group was significantly less than that of the control group (7% vs 40%; P = 0.006). In addition, the mean (SD) infused volume of PCEA in the test group was significantly lower than that in the control group (392.3 [68.9] vs 351.2 [49.8] mL; P = 0.01). However, there were no significant differences in pain intensity, usage of rescue antiemetics and rescue analgesics, and mild pruritus between groups. No patient reported moderate or severe sedation, respiratory depression, or hypoxemia. In addition, there were no severe adverse events. CONCLUSIONS Midazolam added to fentanyl-ropivacaine PCEA was associated with a significant reduction in the incidence of PONV compared with fentanyl-ropivacaine alone, and a significant decrease in the amount of PCEA administered without a significant increase in adverse events in these patients who underwent subtotal gastrectomy.
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Affiliation(s)
- Sioh Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jeongwon Seo
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Younghoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea
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Snyder HR, Hutchison N, Nyhus E, Curran T, Banich MT, O'Reilly RC, Munakata Y. Neural inhibition enables selection during language processing. Proc Natl Acad Sci U S A 2010; 107:16483-8. [PMID: 20813959 PMCID: PMC2944747 DOI: 10.1073/pnas.1002291107] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Whether grocery shopping or choosing words to express a thought, selecting between options can be challenging, especially for people with anxiety. We investigate the neural mechanisms supporting selection during language processing and its breakdown in anxiety. Our neural network simulations demonstrate a critical role for competitive, inhibitory dynamics supported by GABAergic interneurons. As predicted by our model, we find that anxiety (associated with reduced neural inhibition) impairs selection among options and associated prefrontal cortical activity, even in a simple, nonaffective verb-generation task, and the GABA agonist midazolam (which increases neural inhibition) improves selection, whereas retrieval from semantic memory is unaffected when selection demands are low. Neural inhibition is key to choosing our words.
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Affiliation(s)
- Hannah R. Snyder
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
| | - Natalie Hutchison
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
| | - Erika Nyhus
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
| | - Tim Curran
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
| | - Marie T. Banich
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
| | - Randall C. O'Reilly
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
| | - Yuko Munakata
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO 80309
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Bustos SG, Giachero M, Maldonado H, Molina VA. Previous stress attenuates the susceptibility to Midazolam's disruptive effect on fear memory reconsolidation: influence of pre-reactivation D-cycloserine administration. Neuropsychopharmacology 2010; 35:1097-108. [PMID: 20043007 PMCID: PMC3055408 DOI: 10.1038/npp.2009.215] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
It is well known that, under certain boundary conditions, the retrieval of a stable consolidated memory results into a labile one. During this unstable phase, memory can be vulnerable to interference by a number of pharmacological agents, including benzodiazepines. One of the goals of this study was to evaluate the vulnerability to midazolam (MDZ) after reactivation of recent and remote contextual fear memories in animals that experienced a stressful situation before learning. Animals were subjected to a restraint session and trained in a contextual fear paradigm the following day; consolidated memories were reactivated at different times after learning and different MDZ doses (1.5, 3.0 mg/kg) were administered to rats after reactivation. Our results show that MDZ did not affect memory reconsolidation in older-than-one-day memories of stressed animals, even after the administration of a higher MDZ dose and a longer reactivation session (5 min). In contrast, MDZ was effective in blocking reconsolidation at all memory ages in unstressed animals. In addition, the current research investigated whether activating NMDA sites before reactivation promotes the destabilization of resistant memories such as those of stressed animals. We tested the influence of pre-reactivation D-cycloserine (DCS), a partial NMDA agonist, on MDZ's effect on fear memory reconsolidation in stressed animals. Our findings indicate that DCS before reactivation promotes retrieval-induced lability in resistant memory traces, as MDZ-induced memory impairment in stressed rats became evident with pre-reactivation DCS but not after pre-reactivation sterile isotonic saline.
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Affiliation(s)
- Silvia Gabriela Bustos
- Departamento de Farmacología, IFEC-CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Haya de la Torre y Medina Allende, Ciudad Universitaria, Córdoba, Argentina
| | - Marcelo Giachero
- Departamento de Farmacología, IFEC-CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Haya de la Torre y Medina Allende, Ciudad Universitaria, Córdoba, Argentina
| | - Héctor Maldonado
- Laboratorio de Neurobiología de la Memoria, Departamento de Fisiología y Biología Molecular, IFIBYNE-CONICET, Pabellón II, Facultad de Ciencias Exactas y Naturales (C1428EHA), Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Víctor Alejandro Molina
- Departamento de Farmacología, IFEC-CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Haya de la Torre y Medina Allende, Ciudad Universitaria, Córdoba, Argentina,Departamento de Farmacología, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Haya de la Torre y Medina Allende, Ciudad Universitaria, Córdoba 5000, Argentina, Tel: +51 0351 4334437, Fax: +0351 433 4420, E-mail:
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Li JX, McMahon LR, Gerak LR, Becker GL, France CP. Interactions between Delta(9)-tetrahydrocannabinol and mu opioid receptor agonists in rhesus monkeys: discrimination and antinociception. Psychopharmacology (Berl) 2008; 199:199-208. [PMID: 18470505 DOI: 10.1007/s00213-008-1157-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 04/03/2008] [Indexed: 10/22/2022]
Abstract
RATIONALE Opioid receptor agonists can enhance some effects of cannabinoid receptor agonists, and cannabinoid receptor agonists can enhance some effects of opioid receptor agonists; however, the generality of these interactions is not established. OBJECTIVE This study examined interactions between the discriminative stimulus and antinociceptive effects of mu opioid receptor agonists and Delta(9)-tetrahydrocannabinol (THC) in rhesus monkeys. RESULTS Neither heroin nor morphine (intravenous (i.v.) or subcutaneous (s.c.)) altered the discriminative stimulus effects of THC in monkeys (n = 5) discriminating 0.1 mg/kg THC i.v. In contrast, THC (s.c.) markedly attenuated the discriminative stimulus effect of morphine and heroin in nondependent monkeys (n = 4) discriminating 1.78 mg/kg morphine s.c. Doses of THC that attenuated the discriminative stimulus effects of morphine in nondependent monkeys failed to modify the discriminative stimulus effects of morphine in morphine-dependent (5.6 mg/kg/12 h) monkeys (n = 4) discriminating 0.0178 mg/kg naltrexone s.c. THC also failed to modify the discriminative stimulus effects of naltrexone in morphine-dependent monkeys or the effects of midazolam in monkeys (n = 4) discriminating 0.32 mg/kg midazolam s.c. Doses of THC (s.c.) that attenuated the discriminative stimulus effects of morphine in nondependent monkeys enhanced the antinociceptive effects of morphine (s.c.) in nondependent monkeys. While mu receptor agonists did not alter the discriminative stimulus effects of THC, THC altered the effects of mu receptor agonists in a context-dependent manner. CONCLUSION That the same doses of THC enhance, attenuate, or do not affect morphine, depending on the condition, suggests that attenuation of morphine by THC can result from perceptual masking rather than common pharmacodynamic mechanisms or pharmacokinetic interactions.
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