Premedication with sublingual triazolam compared with oral diazepam

Comparative study of hemodynamic changes caused by diazepam and midazolam during third molar surgery: a randomized controlled trial

The aim of the present study was to compare hemodynamic changes using midazolam 7.5 mg and diazepam 10.0 mg during the surgical removal of symmetrically positioned third molars. A prospective, randomized, double-blind, clinical trial was carried out involving 120 patients divided into three groups: Group 1 (diazepam and placebo), Group 2 (midazolam and placebo), and Group 3 (diazepam and midazolam). Each subject underwent two surgeries on separate occasions under local anesthesia. The following parameters were assessed at five different times (T0, T1, T2, T3, and T4): systolic, diastolic, and mean blood pressure (SBP, DBP, and MBP, respectively); heart rate (HR); oxygen saturation (SpO(2)); rate pressure product (RPP); and pressure rate quotient (PRQ). Statistically significant differences were found regarding heart rate at T2 and T3 (p < 0.005) in Group 2, with a higher rate occurring during midazolam administration. Moreover, significant differences in rate pressure product were found at T2, T3, and T4 in this group, with higher values also occurring during midazolam administration. In Group 3, significant differences in diastolic blood pressure were found at T3 and T4, with higher values occurring during diazepam administration, whereas a higher heart rate occurred at T3 with midazolam. Midazolam 7.5 mg and diazepam 10.0 mg exert an influence on some hemodynamic parameters without perceptible clinical changes in healthy patients undergoing lower third molar surgery.

The Effects of Melatonin Premedication on Propofol and Thiopental Induction Dose–Response Curves: A Prospective, Randomized, Double-Blind Study

BACKGROUND

The effect of melatonin on the intraoperative requirements for i.v.anesthetics has not been documented. We studied the effect of melatonin premedication on the propofol and thiopental dose-response curves for abolition of responses to verbal commands and eyelash stimulation.

METHODS

This prospective, randomized, double-blind study included 200 adults with ASA physical status I. Patients received either 0.2 mg/kg melatonin or a placebo orally for premedication (n = 100 per group). Approximately 50 min later, subgroups of 10 melatonin and 10 placebo patients were administered various doses of propofol (0.5, 1.0, 1.5, 2.0, or 2.4 mg/kg) or thiopental (2.0, 3.0, 4.0, 5.0, or 6.0 mg/kg) for anesthetic induction. The ability of each patient to respond to the command, "open your eyes," and the disappearance of the eyelash reflex were assessed 60 s after the end of the injection of propofol or thiopental. Dose-response curves were determined by probit analysis.

RESULTS

Melatonin premedication decreased thiopental ED50 values for loss of response to verbal command and eyelash reflex from 3.4 mg/kg (95% confidence interval, 3.2-3.5 mg/kg) and 3.7 mg/kg (3.5-3.9 mg/kg) to 2.7 mg/kg (2.6-2.9 mg/kg) and 2.6 mg/kg (2.5-2.7 mg/kg), respectively (P < 0.05). Corresponding propofol ED50 values decreased from 1.5 mg/kg (1.4-1.6 mg/kg) and 1.6 mg/kg (1.5-1.7 mg/kg) to 0.9 mg/kg (0.8-0.96 mg/kg) and 0.9 mg/kg (0.8-0.95 mg/kg), respectively (P < 0.05).

CONCLUSIONS

Melatonin premedication significantly decreased the doses of both propofol and thiopental required to induce anesthesia.

GABAA/alpha1 receptor agonists and antagonists: effects on species-typical and heightened aggressive behavior after alcohol self-administration in mice

RATIONALE

The positive modulation of gamma-aminobutyric acid type-A (GABAA) receptors is a putative mechanism via which alcohol escalates aggressive behavior. Broad-spectrum benzodiazepine antagonists block alcohol-heightened aggression in rats and monkeys. However, the degree to which GABAA subunit composition plays a role in heightened aggressive behavior induced by self-administration of a moderate alcohol dose remains unresolved.

OBJECTIVE

Beta-carboline-3-carboxylate-t-butyl ester (beta-CCt) and zolpidem act preferentially at GABAA receptors containing the alpha1 subunit as antagonist and agonist, respectively, and serve as useful tools to evaluate the role of GABAA receptor subtypes in self-administered alcohol on aggression.

METHODS

Male resident mice, housed in breeding pairs, were conditioned to nose-poke in a removable panel in their home cage, with each fifth poke being reinforced by the delivery of 0.05 ml of 6% ethanol (EtOH). After consuming EtOH, the resident mice were given the antagonists beta-CCt and flumazenil or agonists zolpidem and triazolam, and then confronted an intruder male in their home cage for a 5-min period.

RESULTS

Following self-administration of EtOH (1.0 g/kg, 1.7 g/kg), 14 of 37 resident mice displayed unusually large increases in the frequency of attack bites and sideways threats. Flumazenil or beta-CCt decreased alcohol-heightened and non-heightened aggression in a dose-dependent manner. Administration of 3 mg/kg beta-CCt lowered the aggression-heightening effects of 1 g/kg and 1.7 g/kg EtOH, but did not antagonize the sedative effects of 3.0 g/kg EtOH. Triazolam and zolpidem decreased alcohol-heightened and non-heightened aggressive behavior, and these antiaggressive effects were accompanied by reduced motor activity, indicating sedation.

CONCLUSIONS

Benzodiazepine antagonists, particularly those acting preferentially at GABAA/alpha1 subunit-containing receptors, decrease alcohol-heightened and species-typical aggressive behavior, but are ineffective in attenuating the sedative effects of alcohol.

The Misericordia Health Centre cataract comfort study

BACKGROUND

All surgery provokes various degrees of anxiety for patients. The environment leading up to surgery can affect anxiety levels. We performed a prospective randomized study to compare environmental factors around the time of cataract surgery in order to identify interventions that would minimize stress for patients.

METHODS

Patients scheduled to undergo cataract surgery at a university-affiliated hospital in Winnipeg were randomly assigned to 1) receive orally administered lorazepam or a placebo before surgery; 2) listen to relaxing music through headphones or routine background noise before surgery; 3) walk (or go by wheelchair if unable to walk) to the operating room or go by stretcher; and 4) listen to relaxing music through headphones or routine background noise during surgery. Randomization for part 1 was double blind; for parts 2 and 3 the surgeon and anesthetist were blinded, but the patient was not. Patients were asked to rate their anxiety, sedation, nausea and pain on arrival at the preoperative area, about 30 minutes after arrival, on arrival in the operating room and on arrival in the postoperative area, on a visual analogue scale graded from 0 ("None" [or "Wide awake" in the case of sedation]) to 10 ("Worst possible" [or "Asleep" in the case of sedation]). Patient satisfaction and willingness to repeat the exact same form of treatment were also rated.

RESULTS

Of the 19 surgeons in the department 18 agreed to participate; I withdrew during the study. Data were collected for 144 patients aged 26 to 93 years. Anxiety was highest on arrival at the institution and decreased progressively thereafter. Oral sedation and listening to music before surgery were associated with decreased anxiety and increased levels of sedation (p = 0.002). Walking to the operating room provided no benefit over going by stretcher. Listening to music through headphones during surgery was not accepted by many patients and, when used, negatively affected the surgeon's assessment of the patient's ability to cooperate. Surgeons reported movement more often among patients who received oral sedation than among those who did not (chi2 = 0.01). Levels of pain and nausea were extremely low in all patients, and satisfaction was very high. Patients who received regional local anesthesia had less pain and higher satisfaction than those who received topical anesthesia. Willingness to repeat the same treatment was extremely high.

INTERPRETATION

For patients undergoing cataract surgery, efforts should be directed toward reducing anxiety on arrival at the institution, when it is highest, and not just during surgery. Oral sedation and listening to music before surgery appear to be beneficial. Listening to music through headphones during surgery was not found to be advantageous.

The comparative dose-response effects of melatonin and midazolam for premedication of adult patients: a double-blinded, placebo-controlled study

We designed this prospective, randomized, double-blinded, placebo-controlled study to compare the perioperative effects of different doses of melatonin and midazolam. Doses of 0.05, 0.1, or 0. 2 mg/kg sublingual midazolam or melatonin or placebo were given to 84 women, approximately 100 min before a standard anesthetic. Sedation, anxiety, and orientation were quantified before, 10, 30, 60, and 90 min after premedication, and 15, 30, 60, and 90 min after admission to the recovery room. Psychomotor performance of the patient was evaluated at these times also, by using the digit-symbol substitution test and Trieger dot test. Patients who received premedication with either midazolam or melatonin had a significant decrease in anxiety levels and increase in levels of sedation preoperatively compared with control subjects. Patients in the three midazolam groups experienced significant psychomotor impairment in the preoperative period compared with melatonin or placebo. After operation, patients who received 0.2 mg/kg midazolam premedication had increased levels of sedation at 90 min compared with 0.05 and 0. 1 mg/kg melatonin groups. In addition, patients in the three midazolam groups had impairment of performance on the digit-symbol substitution test at all times compared with the 0.05 mg/kg melatonin group. Premedication with 0.05 mg/kg melatonin was associated with preoperative anxiolysis and sedation without impairment of cognitive and psychomotor skills or affecting the quality of recovery.

IMPLICATIONS

Premedication with 0.05 mg/kg melatonin was associated with preoperative anxiolysis and sedation without impairment of cognitive and psychomotor skills or affecting the quality of recovery.

Premedication with midazolam is more effective by the sublingual than oral route

PURPOSE

This study compared the sedative effects of sublingual tablet midazolam (Roche Dormicum 7.5 mg) with the oral route as premedication.

METHODS

One hundred ASA physical status I and II gynaecological patients were randomly selected to receive a 7.5 mg tablet of midazolam either sublingually or orally as premedication about one hour before elective surgery. There were 50 patients in each group. The degree of sedation was assessed according to the Ramsay scale initially and then at 20, 30, 45 and 60 min intervals by a second observer blinded to the route of administration. The time for complete drug dissolution was studied in the sublingual group by the inspection of tablet residue under the tongue every five minutes for 20 min, 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 60 min after drug administration. (P = 0.0054 and P = 0.008) Seventy-two percent of the sublingual group had complete drug dissolution within 10 min and 64% of the patients in the sublingual group found the tablet acceptable with regard to its taste.

CONCLUSION

Midazolam 7.5 mg sublingual is a more effective pre-anaesthetic sedative than by the oral route.

Oral clonidine reduces postoperative PCA morphine requirements

PURPOSE

The purpose of this study was to evaluate the effect of perioperative oral clonidine on postoperative analgesia and PCA morphine requirements in adult patients after major orthopaedic knee surgery.

METHODS

In this prospective, double blind, placebo-controlled study 44 patients undergoing either total knee replacement or hemiarthroplasty of the knee were randomly assigned to receive oral placebo or clonidine (5 micrograms . kg-1) 1.5 hr before surgery, and at 12 hr, and 24 hr after the initial dose. Five patients were subsequently withdrawn from study. No other preoperative drugs were given. Preoperative sedation score was recorded. A standardized general anaesthetic was administered to all patients. Postoperative blood pressure, heart rate, PCA morphine use, visual analogue score (VAS) for pain, sedation, nausea, and pruritus were recorded for 36 hr postoperatively.

RESULTS

The cumulative PCA morphine used was 37% lower after clonidine 57.3 +/- 26.8 mg (mean +/- SD) compared with placebo 91 +/- 31.6 mg (P = 0.031). There was no difference in pain or sedation scores postoperatively but patients who received clonidine were more sedated preoperatively (P < 0.001) and had a lower mean arterial blood pressure throughout the period of study by 10 to 26 mmHg (P < 0.0001). Clonidine reduced the incidence of postoperative nausea (25% vs 74%) (P < 0.01) and vomiting compared with placebo (10% vs 53%) (P < 0.01) and required less antiemetic (dimenhydrinate 37.5 +/- 20.9 mg vs 82.1 +/- 49.4 mg) but not statistically significant (P = 0.065).

CONCLUSIONS

Oral clonidine is a useful component to postoperative balanced analgesia as it decreases PCA morphine requirements and decreases the incidence of nausea and vomiting.

Intravenous sedation for retrobulbar injection and eye surgery: diazepam and/or propofol?

Principle goals of sedation for eye surgery are to provide patient comfort and to allow the patient to stay calm during both retrobulbar injection and surgery. Insufficient sedation may not prevent the patient from moving during retrobulbar injection, whereas very deep sedation may result in respiratory complications during surgery. The aim of the present study was to evaluate the effectiveness and suitability of a combination of diazepam and propofol for sedation for both application of retrobulbar block and subsequent elective eye surgery. One-hundred and fifty patients were randomly allocated to receive either diazepam, propofol or a combination of both drugs before retrobulbar injection. Tolerance of retrobulbar injection and comfort during the surgical procedure were assessed by comfort scores using a nominal analogue scale between 1 (worst possible condition) and 6 (best conceivable condition). Side effects related to sedation were recorded. The combination of diazepam and propofol resulted in the highest comfort scores for both retrobulbar block (5.3 +/- 0.3) and the surgical procedure (5.4 +/- 0.4). Diazepam alone did not produce adequate sedation for retrobulbar block (3.1 +/- 0.3), whereas comfort scores during surgery were significantly higher (5.3 +/- 0.3) compared to propofol alone (3.6 +/- 0.4). No severe side effects induced by sedation were noted in any of the study groups. The combination of diazepam and propofol proved able to provide a reliable degree of sedation with minimal side effects for both retrobulbar block and surgery. The combination was clearly superior to the sedation induced by propofol or diazepam alone.

Sublingual triazolam versus peroral diazepam as a premedication for general anaesthesia

Sublingual triazolam 0.2 mg (T) was compared with peroral diazepam 10 mg (D) as a premedicant in a randomised, double-blind study. Eighty-one ASA I-III patients aged 18-70 yr, scheduled for elective surgery and general anaesthesia were studied. The patients were premedicated about one hour preoperatively. The T-group subjects (n = 41) received triazolam sl after a placebo po and the D-group subjects (n = 40) diazepam po before a sl placebo. Anxiety and sedation were evaluated before premedication, every 15 min after that until the patient was removed to the operating room, just before the induction of anaesthesia and both 30 and 60 min after operation. Anxiety and sedation were evaluated by the patient using a visual analogue scale (VAS) and by the anaesthetist with a scale of 0-3 for anxiety and 0-4 for sedation. The patients' experience with regards to their premedication and visit to the operating unit were investigated after the operation. In both groups sedation and anxiolysis became different at 30-45 min after premedication, but at the time just before the induction of anaesthesia there was sedation and anxiolysis only in the T-group. There was no difference between the groups at any time. The T-group patients were more satisfied with their premedication and visit to the operating unit. The study drugs did not cause any cardiorespiratory or other side effects. We conclude that triazolam 0.2 mg sl is at least as effective a premedication as diazepam 10 mg po, that is suitable for patients that cannot swallow, and that the patients were more satisfied with it than with diazepam.