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Küçük O, Sarı E, Zengin M, Ülger G, Öztürk Yalçın F, Baldemir R, Tunç M, Alagöz A. The Effect of Preprocedural Low-Dose Ketamine for Pain and Anxiety in Patients during Thoracic Epidural Catheterization. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:679. [PMID: 38674325 PMCID: PMC11052147 DOI: 10.3390/medicina60040679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Thoracic epidural catheterization (TEC) can be both uncomfortable and fearful for patients when performed awake with the thought that the procedure may be painful. The aim of this study was to assess the effect of low-dose intravenous ketamine administration on pain and anxiety during the TEC procedure. Materials and Methods: Sixty patients were randomly divided into two groups to receive intravenous (IV) placebo (Group P) and IV low-dose (0.15 mg/kg) ketamine (LDK) (Group K) 3 min before the procedure in a double-blind manner. A visual analog scale (VAS) was used to measure anxiety (VAS-A) and pain (VAS-P) scores. Vital parameters were monitored before premedication (T1), 20 min after premedication (T2), during skin anesthesia (T3), during TEC (T4), and 5 min after TEC (T5). VAS-A values were recorded at T1, T3, T4, and T5 periods, and VAS-P levels were noted at T3, T4, and T5 periods. Results: During TEC (T4), both VAS-P and VAS-A were significantly lower in Group K (p < 0.001). The mean VAS-A value was 10.6 mm lower, and the mean VAS-P value was 9 mm lower in Group K than in Group P at the T4 time point. Additionally, the mean VAS-P value was 7.7 mm lower in Group K compared to Group P at the T3 time point (p < 0.001). Both groups showed a statistically significant difference in VAS-A measurements when compared at their respective time points (p < 0.001). However, only Group P demonstrated a statistically significant difference in VAS-P measurements (p < 0.001). VAS-P values remained stable in Group K. The number of patients who did not recall the procedure was significantly higher in Group K (p < 0.001). Furthermore, the number of patients who would consent to the same procedure in the future was significantly higher in Group K (p = 0.007). Conclusions: A preprocedural LDK (0.15 mg/kg) can effectively prevent anxiety and pain experienced by patients during the TEC procedure. Administration of LDK may provide a more comfortable procedure process without causing ketamine-induced side effects (hemodynamic, respiratory, and psychological).
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Affiliation(s)
- Onur Küçük
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Esra Sarı
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Musa Zengin
- Department of Anesthesiology and Reanimation, Ankara Etlik City Hospital, Ministry of Health, 06170 Ankara, Turkey
| | - Gülay Ülger
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Fatma Öztürk Yalçın
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Ramazan Baldemir
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Mehtap Tunç
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Ali Alagöz
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
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Zhou X, Zhao J, Tu H, Chen K, Hu Y, Jin Y. The effect of age on outpatient pediatric procedural sedation with intranasal dexmedetomidine and oral midazolam. Eur J Pediatr 2024; 183:169-177. [PMID: 37855928 PMCID: PMC10858144 DOI: 10.1007/s00431-023-05240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/29/2023] [Accepted: 09/23/2023] [Indexed: 10/20/2023]
Abstract
Procedural sedation for diagnostic examination is a common practice in children. The study aims to analyze the sedative effect and safety of intranasal dexmedetomidine combined with oral midazolam in outpatient pediatric procedural sedation across different age groups and to assess the incidence of sedation failure. From February 2021 to September 2021, children who underwent procedural sedation were retrospectively enrolled. The children were divided into 4 groups based on age: the infant group (0 to 1 year old), toddler group (1 to 3 years old), preschool group (3 to 6 years old), and school-age group (6 to 12 years old). Two-mcg/kg intranasal dexmedetomidine and 0.5-mg/kg oral midazolam were used for sedation. The sedation success rate after rescue, sedation success rate, onset time of sedation, and the sedation time were recorded. The incidence of adverse events and the risk factors for sedation failure were also analyzed. A total of 4758 patients were identified. After exclusion, 3149 patients were ultimately enrolled. The combination of 2-mcg/kg intranasal dexmedetomidine and 0.5-mg/kg oral midazolam resulted in a total success rate of 99.7% and a sedation success rate of 91.4%. The sedation success rate varied among the four groups: 90.2% in the infant group, 93.1% in the toddler group, 92.7% in the preschool group, and 78.4% in the school-age group. The sedation success rate was significantly lower in the school-age group compared to the other three groups (P < 0.001). The onset time of sedation was shorter in infant (22 min, IQR: 18-28 min, P < 0.001) and longer in the school-age group (30 min, IQR: 25-35 min, P < 0.05). Additionally, the infants had a longer sedation time (110 min, IQR: 90-135 min, P < 0.001) and a higher rate of delayed recovery (27.5%, all P < 0.001). The incidence of adverse events was low (4.70%), which bradycardia (2.03%) being the most common. Age (0-1 year and > 6 years), weight, ASA class II, and history of failed sedation were identified as risk factors of sedation failure. Conclusion: Intranasal administration of 2-mcg/kg dexmedetomidine combined with oral administration of 0.5-mg/kg midazolam was found to be efficient and safety for pediatric procedural sedation. Different age groups of children exhibited distinct sedation characteristics, and age was identified as a risk factor affecting the efficacy of sedation. What is Known: • Procedural sedation for diagnostic examination is a common practice in children. • The combination of dexmedetomidine with midazolam can improve sedative effects. What is New: • The success rate of sedation using a combination of 2-mcg/kg intranasal dexmedetomidine and 0.5-mg/kg oral midazolam was significantly lower in school-age children as compared to infants, toddlers, and preschoolers. • The onset time of sedation increased with age, and the sedation time was found to be longer in infant patients.
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Affiliation(s)
- Xiaqing Zhou
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jialian Zhao
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiya Tu
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kunwei Chen
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yaoqin Hu
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Yue Jin
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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Yıldırım MY, Ülgey A, Talih G, Doğan H, Güneş I. Evaluation of the Perioperative Effects of Dexmedetomidine and Midazolam-Ketamine Premedication in Strabismus Surgery. J Pediatr Ophthalmol Strabismus 2023; 60:427-434. [PMID: 36803239 DOI: 10.3928/01913913-20221219-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
PURPOSE To evaluate the effects of intranasal dexmedetomidine and midazolam-ketamine combination for premedication on sedation quality, oculocardiac reflex development, mask tolerance, and separation from parents in children who would undergo strabismus surgery. METHODS A total of 74 patients aged 2 to 11 years, were divided into two groups. The dexmedetomidine group (n = 37) received 1 mcg/kg of dexmedetomidine and the midalozam-ketamine group (n = 37) received 0.1 mg/kg of midazolam and 7.5 mg/kg of ketamine combination intranasally. Mean arterial pressure, peripheral oxygen saturation, Ramsay Sedation Scale values, and heart rate were recorded before and after the premedication. The children's separation from the family scores were evaluated and recorded. The mask compliance was evaluated and recorded. Patients who developed oculocardiac reflex and were administered atropine were recorded. In the postoperative period, nausea and vomiting, recovery times, and postoperative agitation were evaluated. RESULTS Ramsay Sedation Scale scores, mask acceptance, and family separation scores were similar in both groups (P > .05). Oculocardiac reflex was observed more in the dexmedetomidine group (P = .048). Atro-pine requirement and postoperative nausea and vomiting rates were similar in both groups (P > .05). Mean arterial pressures and heart rates were significantly lower in the dexmedetomidine group during the pre-medication period. The recovery time was longer in the midazolam-ketamine group (P < .001). The incidence of postoperative agitation was significantly lower in the midazolam-ketamine group (P = .001). CONCLUSIONS The sedation efficacy of intranasal dexmedetomidine and midazolam-ketamine combination that were given in premedication was similar. Oculocardiac reflex was observed more with dexmedetomidine. The recovery time was prolonged in the midazolam-ketamine group, but postoperative agitation was observed less. [J Pediatr Ophthalmol Strabismus. 2023;60(6):427-434.].
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Bagheri M, Soltani AE, Qorbani M, Sureda A, Faghihi T. Efficacy and safety of low dose oral ketamine for controlling pain and distress during intravenous cannulation in children: a double-blind, randomized, placebo-controlled trial. Korean J Pain 2022; 35:311-318. [PMID: 35768986 PMCID: PMC9251395 DOI: 10.3344/kjp.2022.35.3.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/05/2022] Open
Abstract
Background Ketamine is widely used in infants and young children for procedural sedation and anesthesia. The aim of this study was to evaluate the efficacy and safety of low dose oral ketamine to control pain and distress in children during intravenous (IV) cannulation. Methods This is a prospective, randomized, double-blind study, including children aged between 3 and 6 years requiring a non-emergent IV-line placement. Children were randomly assigned to two groups, treated either with oral ketamine or a placebo. All patients were monitored for vital signs. Pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wong-Baker Faces Pain Rating Scale (WBFS) scales and sedation using a 5-point sedation score. The facility of IV-line placement was measured by a 3-point scale. Adverse effects were recorded after 1 and 24 hours. Results A total of 79 and 81 children were entered in the ketamine and placebo groups, respectively. The heart and respiratory rates increased significantly in the placebo group. The median CHEOPS 4 (95% confidence interval [CI]: 3, 4, P < 0.001) and WBFS 6 (95% CI: 4, 6, P < 0.001) scores decreased statistically in the ketamine group. IV-line placement was 50% easier in the ketamine group (95% CI: 37%, 63%, P < 0.001). No serious adverse effects were observed in all cases. Conclusions Low dose oral ketamine effectively decreased the pain and distress during IV cannulation in children without any significant adverse reactions.
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Affiliation(s)
- Mahdi Bagheri
- Department of Clinical Pharmacy, School of Pharmacy & Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Ebrahim Soltani
- Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Anesthesiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Antoni Sureda
- Research Group in Community Nutrition and Oxidative Stress and Health Research Institute of the Balearic Islands (IdISBa), University of Balearic Islands, Palma de Mallorca, Spain.,CIBER Physiopathology of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Toktam Faghihi
- Department of Clinical Pharmacy, School of Pharmacy & Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran.,Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Oliveira Filho GRD, Castilhos CM, Kriegl JP, Bianchi GN. Oral preanesthetic medication in children - comparison between midazolam alone and in combination with ketamine: a systematic review and meta-analysis. Braz J Anesthesiol 2021:S0104-0014(21)00315-8. [PMID: 34411631 PMCID: PMC10362461 DOI: 10.1016/j.bjane.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 07/18/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Up to 60% of pediatric surgical patients develop high levels of preoperative anxiety. This study compared the effects of oral combinations of midazolam and ketamine with oral midazolam alone for pediatric preanesthetic medication. METHODS The study protocol was registered in PROSPERO as CRD42020172920. A systematic literature search was conducted using Medline, Cochrane, EMBASE, CENTRAL, and Web of Science for randomized controlled trials comparing oral combinations of midazolam and ketamine with midazolam alone as preanesthetic medication in elective surgical pediatric patients. Meta-analyses included the following outcomes: anxiety and sedation levels, child's behavior during separation from parents, face mask acceptance, and venipuncture. The quality of evidence was assessed using GRADE criteria. RESULTS Twenty studies were included. The following effects (RR (95% CI)) were observed for combinations of ketamine and midazolam relative midazolam alone: anxiolysis (1.2 (0.94-1.52); p = 0.15; I2 = 80%; GRADE = very low); satisfactory sedation (1.2 ( 1.10-1.31); p < 0.001; I2 = 71%; GRADE = very low); behavior during parental separation (1.2 (1.06-1.36); p = 0.003; I2 = 88%; GRADE = very low); facial mask acceptance (1.13 (1.04-1.24); p = 0.007; I2 = 49%; GRADE = very low); behavior during venipuncture (1.32 (1.11-1.57); p = 0.002; I2 = 66%; GRADE = very low). CONCLUSIONS While similar probabilities of obtaining anxiolysis were found, adequate sedation, calm behavior during child's separation from parents, low levels of fear during face mask adaptation, and cooperative behavior during peripheral venous cannulation were more likely with midazolam-ketamine combinations.
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Affiliation(s)
| | | | - Jean Philippe Kriegl
- Universidade Federal de Santa Catarina, Departamento de Cirurgia, Florianópolis, SC, Brazil
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Manso MA, Guittet C, Vandenhende F, Granier L. Efficacy of oral midazolam for minimal and moderate sedation in pediatric patients: A systematic review. Paediatr Anaesth 2019; 29:1094-1106. [PMID: 31538393 PMCID: PMC6900062 DOI: 10.1111/pan.13747] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/27/2019] [Accepted: 09/17/2019] [Indexed: 11/29/2022]
Abstract
One of the most widely used options for minimal/moderate sedation in pediatric patients is oral midazolam, as it presents an alternative to less well-accepted routes of administration (eg, intravenous or intranasal) of this well-known efficacious and well-tolerated short-acting benzodiazepine. A systematic review of the literature was conducted in order to identify clinical studies evaluating the effectiveness of oral midazolam for sedation in pediatric patients in the context of premedication before anesthesia or during diagnostic/treatment procedures. The percentage of responders (response rate) after single administration of oral midazolam was evaluated and compared versus placebo in a subset of placebo-controlled studies. The range of oral midazolam doses providing effective sedation in the different pediatric age subsets was analyzed in order to assess optimum dosing strategies. A total of 25 pediatric clinical studies, utilizing a variety of measures of sedation effectiveness, were selected. These studies included a total of 1472 patients (aged 4 months-18 years) treated with midazolam (0.25-1.5 mg/kg) and 138 patients treated with placebo. The response rates [95% confidence interval] with oral midazolam ranged from 36.7% [21.6%, 54.9%] to 97.8% [86.1%, 99.7%], while with placebo response rates ranged from 4.0% [0.6%, 23.5%] to 41.0% [29.4%, 53.6%]. When considering the 4 placebo-controlled studies, the odds ratios [95% confidence interval] for the comparison of midazolam vs. placebo ranged from 13.4 [5.0, 36.0] to 25.9 [6.7, 100.6]. The analysis of subgroups by context of sedation showed response rates [95% confidence interval] with oral midazolam ranging from 36.7% [21.6%, 54.9%] to 97.0% [94.8%, 98.3%] for anesthetic premedication and from 56.1% [43.1%, 68.4] to 97.8% [86.1%, 99.7%] for medical procedures. The efficacy of midazolam for pediatric minimal/moderate sedation from a dose of 0.25 mg/kg and above was demonstrated. The probability of occurrence of adverse events and over-sedation increases with increasing doses.
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Rayala S, Kyander M, Haridass V, Palat G, Ström A, Wiebe T, Brun E, Segerlantz M. Low-dose Oral Ketamine as a Procedural Analgesia in Pediatric Cancer Patients Undergoing Bone Marrow Aspirations at a Resource-limited Cancer Hospital in India. Indian J Palliat Care 2019; 25:501-507. [PMID: 31673202 PMCID: PMC6812415 DOI: 10.4103/ijpc.ijpc_110_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: Many pediatric cancer patients undergo repeated bone marrow aspirations (BMAs) for diagnostic and treatment evaluation purposes. Full anesthesia is the standard of care during this procedure in high-income countries. At hospitals with low resources in low/middle-income countries many children undergo these painful procedures without sufficient pain relief. This study aimed to evaluate the usefulness of low-dose oral ketamine as a procedural analgesic in a low-resource pediatric cancer care department. Materials and Methods: Pediatric patients, 4–15 years of age, who underwent BMAs between September 31 and November 30, 2018, were invited to participate. The study was designed as a placebo-controlled, single-blinded trial with three trial groups. Group K received 1.0 mg/kg of ketamine and Group KM received 1.0 mg/kg ketamine with an addition of 0.2 mg/kg midazolam, mixed in juice 30 min before procedures. Group P received placebo consisting of plain juice. All three groups also received the hospital's current standard treatment for procedural pain in BMAs. Patients and caregivers assessed the procedural pain, as did the performing doctors. For the patients, Faces Pain Scale – Revised was used and the Numeric Rating Scale-11 for caregivers and doctors. Results: A total of 87 patients were included in the study distributed with 29 in Group K, 29 in Group KM, and 29 in Group P. Seven patients were excluded, one patient denied participation and the remaining did not meet the inclusion criteria. There was no significant difference between the pain reported by the groups. A total of 69% patients in Group KM and 35% in Group K had somnolence reported as a side effect compared to 14% in Group P. Conclusion: We found no significant effects on the procedural pain in any of the treatment groups compared to placebo. There were only mild side effects. The doses of ketamine might be insufficient for this painful and stressful procedure.
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Affiliation(s)
- Spandana Rayala
- Department of Medical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | | | - Vikranth Haridass
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - Gayatri Palat
- Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India.,Two Worlds Cancer Collaboration-INCTR, Vancouver, British Columbia, Canada.,Department of Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - Axel Ström
- Skane University Hospital, Clinical Studies Sweden-Forum South, Lund, Sweden
| | - Thomas Wiebe
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | - Eva Brun
- Department of Clinical Sciences, Oncology, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Radiotherapy and Radiophysics, Skane University Hospital, Lund, Sweden
| | - Mikael Segerlantz
- Department of Clinical Sciences, Oncology and Pathology, Institute for Palliative Care, Faculty of Medicine, Lund University, Region Skane, Lund, Sweden.,Palliative Care and Advanced Home Health Care, Primary Health Care Skane, Region Skane, Lund, Sweden
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Liu Y, Friesen JB, McAlpine JB, Lankin DC, Chen SN, Pauli GF. Natural Deep Eutectic Solvents: Properties, Applications, and Perspectives. JOURNAL OF NATURAL PRODUCTS 2018; 81:679-690. [PMID: 29513526 PMCID: PMC5913660 DOI: 10.1021/acs.jnatprod.7b00945] [Citation(s) in RCA: 432] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
As functional liquid media, natural deep eutectic solvent (NADES) species can dissolve natural or synthetic chemicals of low water solubility. Moreover, the special properties of NADES, such as biodegradability and biocompatibility, suggest that they are alternative candidates for concepts and applications involving some organic solvents and ionic liquids. Owing to the growing comprehension of the eutectic mechanisms and the advancing interest in the natural eutectic phenomenon, many NADES applications have been developed in the past several years. However, unlike organic solvents, the basic structural unit of NADES media primarily depends on the intermolecular interactions among their components. This makes NADES matrices readily influenced by various factors, such as water content, temperature, and component ratio and, thus, extends the metabolomic challenge of natural products (NPs). To enhance the understanding of the importance of NADES in biological systems, this review focuses on NADES properties and applications in NP research. The present thorough chronological and statistical analysis of existing report adds to the recognition of the distinctiveness of (NA)DES, involves a discussion of NADES-related observations in NP research, and reportes applications of these eutectic mixtures. The work identifies potential areas for future studies of (NA)DES by evaluating relevant applications, including their use as extraction and chromatographic media as well as their biomedical relevance. The chemical diversity of natural metabolites that generate or participate in NADES formation highlights the growing insight that biosynthetically primordial metabolites (PRIMs) are as essential to the biological function and bioactivity of unrefined natural products as the biosynthetically more highly evolutionary metabolites (HEVOs) that can be isolated from crude mixtures.
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Affiliation(s)
- Yang Liu
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- UIC/NIH Botanical Center for Botanical Dietary Supplements Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
| | - J. Brent Friesen
- UIC/NIH Botanical Center for Botanical Dietary Supplements Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Center for Natural Product Technologies (CENAPT), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Institute for Tuberculosis Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Department of Physical Sciences, Rosary College of Arts and Sciences, Dominican University, River Forest, Illinois 60305, United States
| | - James B. McAlpine
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Center for Natural Product Technologies (CENAPT), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Institute for Tuberculosis Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
| | - David C. Lankin
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- UIC/NIH Botanical Center for Botanical Dietary Supplements Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Center for Natural Product Technologies (CENAPT), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Institute for Tuberculosis Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
| | - Shao-Nong Chen
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- UIC/NIH Botanical Center for Botanical Dietary Supplements Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Center for Natural Product Technologies (CENAPT), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Institute for Tuberculosis Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
| | - Guido F. Pauli
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- UIC/NIH Botanical Center for Botanical Dietary Supplements Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Center for Natural Product Technologies (CENAPT), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Institute for Tuberculosis Research, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois 60612, United States
- Corresponding Author. Tel: (312) 355-1949. Fax: (312) 355-2693.
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Kussman BD, Laussen PC, Benni PB, McGowan FX, McElhinney DB. Cerebral Oxygen Saturation in Children With Congenital Heart Disease and Chronic Hypoxemia. Anesth Analg 2017; 125:234-240. [PMID: 28514318 DOI: 10.1213/ane.0000000000002073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Increased hemoglobin (Hb) concentration accompanying hypoxemia is a compensatory response to maintain tissue oxygen delivery. Near infrared spectroscopy (NIRS) is used clinically to detect abnormalities in the balance of cerebral tissue oxygen delivery and consumption, including in children with congenital heart disease (CHD). Although NIRS-measured cerebral tissue O2 saturation (ScO2) correlates with arterial oxygen saturation (SaO2), jugular bulb O2 saturation (SjbO2), and Hb, little data exist on the interplay between these factors and cerebral O2 extraction (COE). This study investigated the associations of ScO2 and ΔSaO2-ScO2 with SaO2 and Hb and verified the normal range of ScO2 in children with CHD. METHODS Children undergoing cardiac catheterization for CHD were enrolled in a calibration and validation study of the FORE-SIGHT NIRS monitor. Two pairs of simultaneous arterial and jugular bulb samples were drawn for co-oximetry, calculation of a reference ScO2 (REF CX), and estimation of COE. Pearson correlation and linear regression were used to determine relationships between O2 saturation parameters and Hb. Data were also analyzed according to diagnostic group defined as acyanotic (SaO2 ≥ 90%) and cyanotic (SaO2 < 90%). RESULTS Of 65 children studied, acceptable jugular bulb samples (SjbO2 absolute difference between samples ≤10%) were obtained in 57 (88%). The ΔSaO2-SjbO2, ΔSaO2-ScO2, and ΔSaO2-REF CX were positively correlated with SaO2 and negatively correlated with Hb (all P < .001). Although by diagnostic group ScO2 differed statistically (P = .002), values in the cyanotic patients were within the range considered normal (69% ± 6%). COE estimated by the difference between arterial and jugular bulb O2 content (ΔCaO2-CjbO2, mL O2/100 mL) was not different for cyanotic and acyanotic patients (P = .10), but estimates using ΔSaO2-SjbO2, ΔSaO2-ScO2, or ΔSaO2-ScO2/SaO2 were significantly different between the cyanotic and acyanotic children (P < .001). CONCLUSIONS Children with adequately compensated chronic hypoxemia appear to have ScO2 values within the normal range. The ΔSaO2-ScO2 is inversely related to Hb, with the implication that in the presence of reduced Hb, particularly if coupled with a decreased cardiac output, the ScO2 can fall to values associated with brain injury in laboratory studies.
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Affiliation(s)
- Barry D Kussman
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; †Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; ‡CAS Medical Systems Inc, Branford, Connecticut; §Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and ‖Department of Cardiothoracic Surgery, Stanford Medical Center, Palo Alto, California
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Ghai B, Jain K, Saxena AK, Bhatia N, Sodhi KS. Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study. Paediatr Anaesth 2017; 27:37-44. [PMID: 27734549 DOI: 10.1111/pan.13010] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children undergoing computerized tomography (CT) frequently require sedation to allay their anxiety, and prevent motion artifacts and stress of intravenous (IV) cannulation. AIMS The aim of this trial was to compare the effectiveness of oral midazolam and intranasal dexmedetomidine as sole premedicants in children for carrying out both IV cannulation as well as CT scanning, without the need for additional IV sedatives. METHODS Fifty-nine children, aged 1-6 years, scheduled to undergo CT imaging under sedation were randomized to receive either 0.5 mg·kg-1 oral midazolam (group M) or 2.5 mcg·kg-1 intranasal dexmedetomidine (group D). After 20-30 min, intravenous cannulation was performed and response to its placement was graded using the Groningen Distress Rating Scale (GDRS). After cannulation, children were transferred on the CT table, and assessed using the Ramsay sedation score (RSS). CT imaging was performed without any further sedative if the RSS was ≥4. If there was movement or decrease in sedation depth (RSS ≤ 3), ketamine 1 mg·kg-1 IV was given as an initial dose, followed by subsequent doses of 0.5 mg·kg-1 IV if required. RESULTS A Significantly higher proportion of children in group D (67%) achieved RSS ≥ 4 as compared to group M (24%) (P-0.002). The risk ratio (95% CI) was 2.76 (1.38-5.52). Significantly lower GDRS scores were noted in group D (1(1-2)) as compared to group M (2(1-2)) at the time of venipuncture (P = 0.04). CONCLUSION In the doses and time intervals used in our study, intranasal dexmedetomidine (2.5 μg·kg-1 ) was found to be superior to oral midazolam (0.5 mg·kg-1 ) for producing satisfactory sedation for CT imaging.
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Affiliation(s)
- Babita Ghai
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Kajal Jain
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Nidhi Bhatia
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
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11
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Rubinstein O, Barkan S, Breitbart R, Berkovitch S, Toledano M, Weiser G, Karadi N, Nassi A, Kozer E. Efficacy of oral ketamine compared to midazolam for sedation of children undergoing laceration repair: A double-blind, randomized, controlled trial. Medicine (Baltimore) 2016; 95:e3984. [PMID: 27368000 PMCID: PMC4937914 DOI: 10.1097/md.0000000000003984] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [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
OBJECTIVE To assess the efficacy of oral ketamine versus oral midazolam for sedation during laceration repair at a pediatric emergency department. METHODS Children between 1 and 10 years requiring laceration repair were randomly assigned to 2 groups, treated either with oral midazolam (0.7 mg/kg) or with oral ketamine (5 mg/kg).Main outcomes measured were level of pain during local anesthesia, as assessed by the parent on a 10-cm visual analog scale (VAS) and the number of children who required intravenous sedation. Secondary outcomes included VAS by physician, pain assessment by child, maximal sedation depth assessed by the University of Michigan Sedation Scale, time until University of Michigan Sedation Scale 2 or more, general satisfaction of a parent and treating physician, length of procedure, total sedation time, and the incidence of any adverse events. RESULTS Sixty-eight children were recruited of which 33 were girls. Average age was 5.08 ± 2.14 years. Thirty-seven children were treated with ketamine and 31 with midazolam. Parent-assessed VAS in ketamine treated patients was 5.07 ± 0.75 compared with 3.68 ± 0.7 in midazolam treated patients [mean difference = 1.39 95% confidence interval (CI) -0.47 to 3.26]. Twelve (32%) of the children treated with ketamine required the addition of IV sedation compared to only 2 children (6%) of the children treated with midazolam [odds ratio (adjusted for age and gender) 6.1, 95% CI: 1.2 to 30.5]. The rest of the measured variables were similar between the groups, with no statistical significance. DISCUSSION No difference in the level of pain was found between ketamine and midazolam treated patients. Compared with oral midazolam (0.7 mg/kg), oral ketamine (5 mg/kg) was associated with higher rates of sedation failure, and thus is not recommended as a single agent for oral sedation in children requiring laceration repair.
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Affiliation(s)
- Orit Rubinstein
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Shiri Barkan
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Rachelle Breitbart
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Michal Toledano
- Department of Pharmacy, Assaf Harofeh Medical Center, Zerifin
| | - Giora Weiser
- Pediatric Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Natali Karadi
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Anat Nassi
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Eran Kozer
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
- Correspondence: Eran Kozer, MD, Assaf Harofeh Mediacl Center Zerifin, Israel (e-mail: )
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Salem K, Kamranzadeh S, Kousha M, Shaeghi S, AbdollahGorgi F. Two Oral Midazolam Preparations in Pediatric Dental Patients: A Prospective Randomised Clinical Trial. Int J Pediatr 2015; 2015:349795. [PMID: 26120325 PMCID: PMC4452871 DOI: 10.1155/2015/349795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/27/2015] [Indexed: 11/17/2022] Open
Abstract
Pharmacological sedation is an alternative behavior management strategy in pediatric dentistry. The aim of this study was to compare the behavioral and physiologic effects of "commercially midazolam syrup" versus "orally administered IV midazolam dosage form (extemporaneous midazolam (EF))" in uncooperative pediatric dental patients. Eighty-eight children between 4 to 7 years of age received 0.2-0.5 mg/kg midazolam in this parallel trial. Physiologic parameters were recorded at baseline and every 15 minutes. Behavior assessment was conducted objectively by Houpt scale throughout the sedation and North Carolina at baseline and during injection and cavity preparation. No significant difference in behavior was noted by Houpt or North Carolina scale. Acceptable behavior (excellent, very good, and good) was observed in 90.9% of syrup and 79.5% of EF subjects, respectively. Physiological parameters remained in normal range without significant difference between groups and no adverse effect was observed. It is concluded that EF midazolam preparation can be used as an acceptable alternative to midazolam syrup.
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Affiliation(s)
- Katayoun Salem
- Department of Pediatric Dentistry and Oro-Maxillofacial Developmental Disease Research Center, Faculty of Dentistry, Guilan University of Medical Sciences, Rasht 4194173774, Iran
| | | | - Maryam Kousha
- Department of Pediatric Psychiatry, Shafa Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Shahnaz Shaeghi
- Department of Pediatric Anesthesiology, Mofid Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh AbdollahGorgi
- Medical Research Development Center, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Iran
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Barkan S, Breitbart R, Brenner-Zada G, Feldon M, Assa A, Toledano M, Berkovitch S, Shavit I, Kozer E. A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair. Emerg Med J 2013; 31:649-53. [DOI: 10.1136/emermed-2012-202189] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Torres FS, Jeddiyan S, Jiménez-Juan L, Nguyen ET. β-Blockers to Control Heart Rate during Coronary CT Angiography. Radiology 2011; 259:615-6; author reply 616-7. [DOI: 10.1148/radiol.11102288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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