A comparison of triazolam and diazepam as premedication agents for minor gynaecological surgery

The effect of triazolam premedication on anxiety, sedation, and amnesia in general anesthesia

BACKGROUND

Benzodiazepines have been used preoperatively as part of an anesthesia regimen to attenuate the anxiety of patients. In this study, we aimed to examine the effect of oral triazolam, a short-acting benzodiazepine, on anxiety, sedation, and amnesia.

METHODS

Ninety patients, aged 20-55 years, were randomly assigned to receive no premedication, or to receive triazolam 0.25 mg or 0.375 mg 1 h before anesthesia. Anxiety score, sedation score, blood pressure, heart rate and psychomotor performance were measured on the evening before surgery and on the day of surgery. Additional tests of psychomotor performance were performed in the postanesthesia care unit and on the next day of surgery. The occurrence of amnesia, bispectral index (BIS), recovery profiles and patient satisfaction with overall anesthesia care were also evaluated.

RESULTS

Changes in the anxiety and sedation scores on the day of surgery were not significantly different among groups, whereas the increases in systolic blood pressure and heart rate were significantly less in both triazolam groups. The triazolam groups both showed a higher incidence of high satisfaction scores (≥ 2). The two triazolam groups also showed similar outcomes, except for a dose-dependent increase in the number of patients with amnesia and BIS values < 90. Delayed recovery from general anesthesia and psychomotor impairment were not observed in the triazolam groups.

CONCLUSIONS

Triazolam 0.25 mg or 0.375 mg reduced the hemodynamic changes associated with anxiety, produced potent amnesia, and improved patient satisfaction. We suggest that triazolam can be used effectively as anesthetic premedication in adults.

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.

Using triazolam to reduce dental anxiety

Triazolam, commonly prescribed to treat insomnia, also can be used to reduce dental anxiety. Despite controversial reports in the lay press, triazolam can be used safely at low doses for short periods. The authors review research concerning the drug's safety and discuss its use in dentistry.

Premedication with sublingual triazolam compared with oral diazepam

The clinical effects of a new administration form of triazolam, 0.2 mg sublingual (sl) tablet, were compared with those of a 10 mg tablet of diazepam in a double-blind study, in 100 ASA I-II patients scheduled for ophthalmic surgery under local anaesthesia. The sedative and anxiolytic effects of the study drugs were followed at 15 min intervals by plotting the patient's assessments on a visual analogue scale and by a trained observer. The onset of sedative and anxiolytic effect was similar. At 75 min after premedication and after the operation triazolam 0.2 mg caused deeper sedation than diazepam 10 mg according to the observer (P < 0.001, P < 0.01) and according to the patient (P < 0.01, P < 0.05). Ten patients (20%) in the triazolam group and one in the diazepam group were assessed to be too sedated during the operation. All these patients were 61-70 yr old. The study drugs resulted in equal reduction of anxiety during the preoperative period. Both premedications provided good patient comfort but caused total amnesia only to one patient in each group. Neither caused any severe cardiorespiratory or other side effects. It is concluded that 0.2 mg triazolam sl produces deeper sedation than 10 mg oral diazepam. For elderly patients this dose is excessive for intraocular surgery.

Oral benzodiazepines and conscious sedation: A review

A large number of benzodiazepines have been studied for use as sedatives and for their anxiolytic potential as premedicants for outpatient surgery. Potent, new, orally-administered drugs with short half-lives, rapid onset, and minimal residual effects have been developed. Dose-dependent amnesia is also produced by some of these agents. Advances in understanding receptor physiology have shed light on specific pharmacologic activities and aided the discovery of benzodiazepine antagonists with antidote properties. While these drugs have relatively low toxicity, dose-related oversedation remains a risk in susceptible patients, especially when combined with other sedatives.

A comparison of propranolol and diazepam for preoperative anxiolysis

The effectiveness of propranolol, a nonsedating anxiolytic premedication, was studied by monitoring preoperative anxiety and postoperative recovery of cognitive function in 92 healthy ASA physical status I females aged 15-42 yr undergoing outpatient dilatation and curettage (D&C) for therapeutic abortion. In a randomized double-blind design, patients received one of the following oral medications 1-1.5 hr preoperatively: (1) diazepam 10 mg (n = 31); (2) propranolol 80 mg (n = 31); (3) placebo (n = 30). Anxiety throughout the hospital stay was monitored using the State-Trait Anxiety Inventory (STAI). Postoperative cognitive recovery was assessed using the digit span and Trieger tests. STAI anxiety levels were recorded on admission to hospital, immediately before entering the operating room, and two hours postoperatively. There was no difference among the anxiolytic properties of the three medications and all three patient groups showed a significant decrease in anxiety levels after administration of the medication. Tests of cognitive function after anaesthesia showed the fastest return to baseline status in patients receiving propranolol, possibly because beta adrenergic blockade blunted the autonomic signs of light anaesthesia and less anaesthetic was administered. None of the study premedications was demonstrated to have an anxiolytic advantage, but propranolol did offer a faster return of cognitive function in the postoperative period.

Attenuation of anxiety in ambulatory oral surgery patients with oral triazolam

The purpose of this investigation was to determine if the preoperative administration of an oral anxiolytic agent (triazolam) is beneficial in reducing the cardiovascular response to stress and anxiety. Twelve consecutive patients, six who received the drug and six who received a placebo, were monitored from the night before surgery at home until the morning with a Holter monitor. On presentation for surgery, levels of anxiety as well as heart rate and presence of cardiac arrhythmias were determined for the two groups. Patients who received the study medication had an anxiety level on the day of surgery similar to that recorded at an earlier consultation visit, whereas the placebo group showed a tendency toward an increase in anxiety on the day of surgery. There was a significant difference for resting heart rate between the two groups at various intervals associated with the preparation for the surgery. There were no complications related to the medication and, therefore, on the basis of this study, it appears that the administration of an oral anxiolytic agent prior to the patient presenting for surgery is beneficial in reducing the stress and anxiety associated with the operation as well as in reducing some of the cardiac manifestations of this stress.

The effectiveness of flurazepam as night sedation prior to the removal of third molars

Anxiety prior to dental treatment is a well-recognized problem. Although oral sedation has been recommended the night before appointments to reduce this anxiety, there are no well-controlled studies to support this claim. The present double-blind cross-over study investigated the effect of 30 mg of flurazepam taken the night before the removal of impacted third molars. Preoperative anxiety, visuomotor performance and sleep patterns were investigated in 20 adult patients with similarly impacted third molars. While preoperative flurazepam led to a statistically significant improvement in sleep patterns, there was no reduction in pre-operative anxiety on the morning of surgery. In addition, the flurazepam-treated group demonstrated significantly impaired visuo-motor performance 60 min after intravenous sedation compared to this group where intravenous sedation was used only preceded by placebo. Patients had a significant preference for flurazepam over placebo as a night-time sedative.

Placebo controlled comparison of midazolam, triazolam and diazepam as oral premedicants for outpatient anaesthesia

Two short-acting benzodiazepines, midazolam 15 mg and triazolam 0.25 mg, were compared with diazepam 10 mg and placebo as oral premedicants in 120 patients presenting for minor urological surgery. Midazolam was found to produce the greatest degree of amnesia and sedation at the time of anaesthetic induction and triazolam was found to have the greatest degree of residual sedation at the time of discharge, four hours postoperatively. These effects are consistent with the greater potency and more rapid onset of action of midazolam at this dose compared with triazolam. The relative merits of the compounds as anxiolytics varied depending upon the observer, time and method of assessment. It was considered that the doses of midazolam and triazolam used were excessive for routine day case anaesthesia.

Assessment of a new hypnotic imidazo-pyridine (zolpidem) as oral premedication

1 A new imidazo-pyridine hypnotic (zolpidem 10 mg and 20 mg) was compared with placebo as premedication before general anaesthesia in female patients undergoing minor gynaecological surgery. Efficacy and tolerance before and after anaesthesia were assessed. Psychomotor testing was used to study recovery from anaesthesia. 2 Both doses of zolpidem produced good sedation pre-operatively but only the higher dose was associated with anterograde amnesia. 3 Premorbid anxiety scores were low in the group of patients studied and were unaffected by either dose of zolpidem. 4 There were no significant effects on the course of anaesthesia. However, postoperatively there was a tendency for wake-up to be delayed in those patients who received either dose of zolpidem. 5 Postoperative recovery, as indicated by tests of psychomotor performance, was noticeably delayed with a dose of 20 mg compared with placebo whilst psychomotor performance had returned towards baseline levels 3 h after wake-up in those patients who had received placebo. The zolpidem 10 mg group was intermediate. 6 Zolpidem may be a suitable premedicant when hypnosis and amnesia only are required.

Triazolam premedication. A comparison with lorazepam and placebo in gynaecological patients

A randomised, double blind study, of 58 female patients undergoing laparoscopic investigation was carried out to compare triazolam 0.25 mg, lorazepam 2 mg, or placebo as oral premedication. Each patient was assessed by only one of the authors both pre- and postoperatively with regard to anxiolysis, sedation and rapidity of recovery. Triazolam and lorazepam were each associated with a significant reduction in anxiety compared to the initial assessment, whereas placebo had no anxiolytic effect. Sixty minutes after premedication, patients who had received triazolam were significantly more sleepy than patients given placebo or lorazepam. Two hours after the operation, the patients who had had triazolam or lorazepam were significantly more sleepy than those who received placebo. However, at 6 hours postoperatively there was no difference between triazolam and placebo, whilst those who had been given lorazepam were still significantly more sleepy than those given placebo. Triazolam appears to offer advantages over either lorazepam or placebo in patients who require rapid recovery, sedation and reduction in pre-operative anxiety.

Comparison of oral slow release morphine (MST) with intramuscular morphine for premedication

Oral morphine sulphate slow-release (MST) 40 mg and intramuscular morphine sulphate 10 mg, each administered with intramuscular atropine 0.6 mg, were compared in a randomised double-blind trial as premedication agents in 30 patients undergoing abdominal hysterectomy. Both formulations produced sedation but no anxiolysis in the anaesthetic room, as measured by 10 cm, horizontal linear analogue scales. There was no significant difference between the preparations in terms of postoperative pain, recorded either by the linear analogue scales or using a patient questionnaire. The usage of analgesics and anti-emetics postoperatively was comparable in both groups.

A comparison of nalbuphine and morphine as premedication agents for minor gynaecological surgery

Nalbuphine 10 mg and morphine 10 mg were compared in a randomised double-blind trial as intramuscular premedication in 50 patients undergoing minor gynaecological surgery. Both nalbuphine and morphine produced significant sedation without anxiolysis as assessed by patient linear analogue scales, but there were no significant differences between the two drugs. Observer ratings demonstrated that nalbuphine produced calm/sleepy patients to a greater extent than morphine. There were no differences in untoward effects produced by each drug.