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Peter JU, Dieudonné P, Zolk O. Pharmacokinetics, Pharmacodynamics, and Side Effects of Midazolam: A Review and Case Example. Pharmaceuticals (Basel) 2024; 17:473. [PMID: 38675433 PMCID: PMC11054797 DOI: 10.3390/ph17040473] [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: 02/22/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Midazolam, a short-acting benzodiazepine, is widely used to alleviate patient anxiety, enhance compliance, and aid in anesthesia. While its side effects are typically dose-dependent and manageable with vigilant perioperative monitoring, serious cardiorespiratory complications, including fatalities and permanent neurological impairment, have been documented. Prolonged exposure to benzodiazepines, such as midazolam, has been associated with neurological changes in infants. Despite attempts to employ therapeutic drug monitoring for optimal sedation dosing, its efficacy has been limited. Consequently, efforts are underway to identify alternative predictive markers to guide individualized dosing and mitigate adverse effects. Understanding these factors is crucial for determining midazolam's suitability for future administration, particularly after a severe adverse reaction. This article aims to elucidate the factors influencing midazolam's pharmacokinetics and pharmacodynamics, potentially leading to adverse events. Finally, a case study is presented to exemplify the complex investigation into the causative factors of midazolam-related adverse events.
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Affiliation(s)
- Jens-Uwe Peter
- Institute of Clinical Pharmacology, Immanuel Klinik Rüdersdorf, Brandenburg Medical School, 15562 Rüdersdorf, Germany;
| | - Peter Dieudonné
- Department of Anesthesiology, University Hospital Ulm, 89081 Ulm, Germany
| | - Oliver Zolk
- Institute of Clinical Pharmacology, Immanuel Klinik Rüdersdorf, Brandenburg Medical School, 15562 Rüdersdorf, Germany;
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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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Flores-Pérez C, Moreno-Rocha LA, Chávez-Pacheco JL, Noguez-Méndez NA, Flores-Pérez J, Ortiz-Marmolejo D, Sarmiento-Argüello LA. Pharmacokinetic-Pharmacodynamic Modeling of Midazolam in Pediatric Surgery. Pharmaceutics 2023; 15:2565. [PMID: 38004544 PMCID: PMC10674765 DOI: 10.3390/pharmaceutics15112565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 11/26/2023] Open
Abstract
Midazolam (MDZ) is used for sedation in surgical procedures; its clinical effect is related to its receptor affinity and the dose administered. Therefore, a pharmacokinetic-pharmacodynamic (PK-PD) population model of MDZ in pediatric patients undergoing minor surgery is proposed. A descriptive, observational, prospective, and longitudinal, study that included patients of both sexes, aged 2-17 years, ASA I/II, who received MDZ in IV doses (0.05 mg/kg) before surgery. Three blood samples were randomly taken between 5-120 min; both sedation by the Bispectral Index Scale (BIS) and its adverse effects were recorded. The PK-PD relationship was determined using a nonlinear mixed-effects, bicompartmental first-order elimination model using Monolix Suite™. Concentrations and the BIS were fitted to the sigmoid Emax PK-PD population and sigmoid Emax PK/PD indirect binding models, obtaining drug concentrations at the effect site (biophase). The relationship of concentrations and BIS showed a clockwise hysteresis loop, probably indicating time-dependent protein binding. Of note, at half the dose used in pediatric patients, adequate sedation without adverse effects was demonstrated. Further PK-PD studies are needed to optimize dosing schedules and avoid overdosing or possible adverse effects.
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Affiliation(s)
- Carmen Flores-Pérez
- Pharmacology Laboratory, National Institute of Pediatrics, Mexico City 04530, Mexico; (C.F.-P.); (J.L.C.-P.); (J.F.-P.)
| | - Luis Alfonso Moreno-Rocha
- Pharmacokinetics and Pharmacodynamics Laboratory, Division of Biological and Health Sciences, Universidad Autónoma Metropolitana, Mexico City 04960, Mexico
| | - Juan Luis Chávez-Pacheco
- Pharmacology Laboratory, National Institute of Pediatrics, Mexico City 04530, Mexico; (C.F.-P.); (J.L.C.-P.); (J.F.-P.)
| | - Norma Angélica Noguez-Méndez
- Molecular and Controlled Release Pharmacy Laboratory, Division of Biological and Health Sciences, Universidad Autónoma Metropolitana, Mexico City 04960, Mexico;
| | - Janett Flores-Pérez
- Pharmacology Laboratory, National Institute of Pediatrics, Mexico City 04530, Mexico; (C.F.-P.); (J.L.C.-P.); (J.F.-P.)
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Ridley A, Vial-Cholley E, Robert G, Jounis-Jahan F, Lervat C, Betremieux P, Viallard ML, Frache S, Cojean N. Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams. J Pain Symptom Manage 2023; 65:308-317. [PMID: 36528187 DOI: 10.1016/j.jpainsymman.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/16/2022]
Abstract
CONTEXT Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for health care teams and families. OBJECTIVES Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016. METHODS We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019. RESULTS Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, and sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n = 5 cases), Chlorpromazine (n = 3), Ketamine (n = 2), and Propofol (n = 2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction. CONCLUSION Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.
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Affiliation(s)
- Ashley Ridley
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France.
| | | | - Guillaume Robert
- Pediatric Palliative Care Team Bretagne (G.R.), Rennes, France; University of Rennes 1 (G.R.), Rennes, France
| | | | - Cyril Lervat
- Pediatric Palliative Care Team Hauts de France (C.L.), Lille, France; Pediatric, Adolescent and Young Adult Oncology Unit (C.L.), Oscar Lambret Centre, Lille, France
| | - Pierre Betremieux
- French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Marcel-Louis Viallard
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France
| | - Sandra Frache
- Pediatric Palliative Care Team Franche-Comté (S.F.), Besançon, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Nadine Cojean
- Pediatric Palliative Care Team Alsace (N.C.), Strasbourg, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
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Influence of Age and Sex on the Pharmacokinetics of Midazolam and the Depth of Sedation in Pediatric Patients Undergoing Minor Surgeries. Pharmaceutics 2023; 15:pharmaceutics15020440. [PMID: 36839762 PMCID: PMC9963644 DOI: 10.3390/pharmaceutics15020440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
Whether age and sex influence the depth of sedation and the pharmacokinetics of midazolam is currently unknown. The influence of age and sex was investigated in 117 children (2 to 17 years) who required intravenous sedation for minor surgery (0.05 mg/kg). Plasma concentrations and sedation effects were simultaneously measured. The measured concentrations were analyzed using a two-compartment model with first-order elimination. Among the age ranges, significant differences were found (p < 0.05) between the volume of distribution (Vd) of the first compartment (V1) and that of the second (V2). With respect to sex, differences in V2 were found between age groups. At the administered dose, in patients younger than 6 years, a profound sedative effect (40-60 BIS) was observed for up to 120 min, while in older children, the effect lasted only half as long. The differences found in the Vd and bispectral index (BIS) in patients younger than 6 years compared to older patients may be due to immature CYP3A activity and body fat content; furthermore, the Vd varies with age due to changes in body composition and protein binding. Patients younger than 6 years require intravenous (IV) doses <0.05 mg/kg of midazolam for deep sedation. Dosage adjustments according to age group are suggested.
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Sex and Age Influence on Association of CYP450 Polymorphism with Midazolam Levels in Critically Ill Children. Diagnostics (Basel) 2022; 12:diagnostics12112797. [PMID: 36428856 PMCID: PMC9689687 DOI: 10.3390/diagnostics12112797] [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: 09/20/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022] Open
Abstract
Midazolam is a drug that is metabolized by cytochrome P450 (CYP450) enzymes, particularly CYP3A4 and CYP3A5. The present study aimed to determine the sex and age influence on association of CYP450 polymorphism with midazolam levels in critically ill children. Seventy-two DNA samples were genotyped by real-time PCR. Children ≤ five years of age who carry the rs776746 (T) allele in CYP3A5 gene were associated with lower plasma midazolam levels. The concentration median in patients was 0.0 ng/mL, while in patients with the normal (C) allele, it was 438.17 ng/mL (Q25 135.75-Q75 580.24), p = 0.005. The midazolam plasmatic concentration in female patients with the minor (T) allele was 0.0 ng/mL (Q250.00-Q75204.3), while in patients with the normal (C) allele median it was 459.0 ng/mL (Q25296.9-Q75789.7), p = 0.002. Analysis of the dominant model for the rs2740574 variant in CYP3A4 revealed a median of 0.38 L/kg (Q250.02-Q751.5) for the volume of distribution parameter in female patients with the normal T allele, while female patients with the minor C allele showed a median of 18.1 L/kg (Q257.5-Q7528.7) p = 0.02. Our results suggest an altered midazolam metabolism due to the presence the allelic rs2740574 variants of CYP3A4 and rs776746 of CYP3A5, and also the strong influence of age and sex.
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Herrod JA, Avelino JA, Schonvisky KM, Lynch JK, Hutchinson EK, Izzi JM. The use of midazolam as an appetite stimulant and anxiolytic in the common marmoset (Callithrix jacchus). J Med Primatol 2021; 50:249-258. [PMID: 34318933 DOI: 10.1111/jmp.12534] [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: 05/24/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Food avoidance secondary to disease or stress can lead to weight loss and rapid deterioration of clinical condition in the common marmoset (Callithrix jacchus). Currently, there are no data supporting the use of any pharmaceuticals as an appetite stimulant in this species; however, benzodiazepines are frequently used for this purpose in other species. METHODS Six marmosets were used in a crossover study design to evaluate the benzodiazepine midazolam as an appetite stimulant and anxiolytic. Total food intake (TFI) and latency to eat (LTE) were measured following administration of oral and injectable midazolam in non-anxious and anxious states. RESULTS Injectable midazolam increased TFI and decreased LTE in anxious marmosets, but had no effect in non-anxious animals. Oral midazolam had no effect on appetite in either state. CONCLUSIONS Injectable midazolam may be an effective treatment for anxiety-induced inappetence in marmosets. Individual response to both oral and injectable midazolam may vary.
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Affiliation(s)
- Jessica Ann Herrod
- Research Animal Resources, Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janelle Arcey Avelino
- Research Animal Resources, Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,College of Veterinary Medicine, North Caroline State University, Raleigh, NC, USA
| | - Kayla Marie Schonvisky
- Research Animal Resources, Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica Kay Lynch
- Laboratory of Auditory Neurophysiology, Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric Kenneth Hutchinson
- Research Animal Resources, Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica Marie Izzi
- Research Animal Resources, Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tesoro S, Marchesini V, Fratini G, Engelhardt T, De Robertis E. Drugs for anesthesia and analgesia in the preterm infant. Minerva Anestesiol 2020; 86:742-755. [DOI: 10.23736/s0375-9393.20.14073-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Prommer E. Midazolam: an essential palliative care drug. Palliat Care Soc Pract 2020; 14:2632352419895527. [PMID: 32215374 PMCID: PMC7065504 DOI: 10.1177/2632352419895527] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022] Open
Abstract
Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. Acting on the benzodiazepine receptor, it promotes the action of gamma-aminobutyric acid. Gamma-aminobutyric acid action promotes sedative, anxiolytic, and anticonvulsant properties. Midazolam has a faster onset and shorter duration of action than other benzodiazepines such as diazepam and lorazepam lending itself to greater flexibility in dosing than other benzodiazepines. The kidneys excrete midazolam and its active metabolite. Metabolism occurs in the liver by the P450 system. This article examines the pharmacology, pharmacodynamics, and clinical uses of midazolam in palliative care.
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Affiliation(s)
- Eric Prommer
- UCLA/VA Hospice and Palliative Medicine Program, UCLA School of Medicine, 11301 Wilshire Blvd., Bldg. 500, Room 2064A, Los Angeles, CA 90073, USA
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Kos MK, Miksić M, Jovanović M, Roškar R, Grosek Š, Grabnar I. Maturation of midazolam clearance in critically ill children with severe bronchiolitis: A population pharmacokinetic analysis. Eur J Pharm Sci 2019; 141:105095. [PMID: 31626965 DOI: 10.1016/j.ejps.2019.105095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/24/2019] [Accepted: 09/29/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the present study was to develop a population pharmacokinetic model of midazolam, and to evaluate the influence of maturation process and other variability factors in critically ill children with severe acute bronchiolitis, who received a long-term intravenous infusion of midazolam. METHODS In the study were included 49 critically ill children of both genders (from 0 to 130 weeks of age) with severe acute bronchiolitis hospitalised in intensive care units. Nonlinear mixed effects modelling approach was applied for data analyses and simulations. RESULTS The final model is a two-compartment model that includes the effects of body weight using allometric scaling with fixed exponents and maturation of clearance. For a typical subject, scaled to the adult body weight of 70 kg, population pharmacokinetic values were estimated at 8.52 L/h for clearance (when maturation function was 1), 25.5 L/h for intercompartmental clearance, and 5.71 L and 39.8 L for the volume of the central and peripheral compartment, respectively. Based on the final model, maturation reaches 50% of the adult clearance in 45.9 weeks of postmenstrual age. The influence of gender, ABCB1 genotype and biochemical parameters on midazolam clearance was not detected. Results of simulations indicate the need for reduced dosing in certain groups of patients in order to maintain plasma concentrations of midazolam within recommended values. CONCLUSIONS The developed population pharmacokinetic model can contribute to the dosing optimisation of midazolam, especially in critically ill children as it includes the influence of size and maturation of clearance, which are important parameters for achieving the desired plasma concentrations of midazolam.
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Affiliation(s)
- Mojca Kerec Kos
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia.
| | - Mirjana Miksić
- Division of Paediatrics, University Medical Centre Maribor, Ljubljanska ulica 5, Maribor 2000, Slovenia; Division of Gynaecology and Perinatology, Department of Perinatology, University Medical Centre Maribor, Ljubljanska ulica 5, Maribor 2000, Slovenia
| | - Marija Jovanović
- Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, Belgrade 11221, Serbia
| | - Robert Roškar
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia
| | - Štefan Grosek
- Division of Surgery, Department of Paediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Bohoriceva ulica 20, Ljubljana 1525, Slovenia; Department of Perinatology, Divison of Gynecology and Obstetrics, University Medical Centre Ljubljana, Šlajmerjeva 3, Ljubljana 1000, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
| | - Iztok Grabnar
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia
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Park SH, Park S, Lee S, Choi JI, Bae HB, You Y, Jeong S. Effect of transportation method on preoperative anxiety in children: a randomized controlled trial. Korean J Anesthesiol 2019; 73:51-57. [PMID: 31304694 PMCID: PMC7000284 DOI: 10.4097/kja.19191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study was performed to evaluate the effect of a wagon as a transport vehicle instead of the standard stretcher car to reduce children's anxiety of separation from parents. The secondary goal was to evaluate whether this anxiolytic effect was related to age. METHODS We divided 80 children (age 2-7 years) into two groups. The stretcher group was transferred to the operating room on a conventional stretcher car, whereas the wagon group was transferred using a wagon. The level of anxiety was evaluated three times using the Modified Yale Preoperative Anxiety Scale (mYPAS): in the waiting area (T0), in the hallway to the operating room (T1), and before induction of anesthesia (T2). RESULTS The mYPAS score was significantly lower in the wagon group (36.7 [31.7, 51.7]) than in the stretcher group (51.7 [36.7, 83.3]) at T1 (P = 0.007). However, there was no difference in the mYPAS score between the two groups at T2 (46.7 [32.5, 54.2] vs. 51.7 [36.7, 75.0], respectively, P = 0.057). The baseline anxiety tended to be lower with increasing age (r = -0.248, P = 0.031). During transportation to the operating room, the increase in the mYPAS score (T1-T0) was greater as the age of children decreased in the stretcher group (r = -0.340, P = 0.034). However, no correlation was observed in the wagon group (r = -0.053, P = 0.756). CONCLUSION The wagon method decreased preoperative anxiety, suggesting that it may be a good alternative for reducing preoperative anxiety in children.
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Affiliation(s)
- Sun-Hong Park
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Sanghee Park
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Seongheon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Jeong Il Choi
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Hong-Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Youngwook You
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Seongtae Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
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12
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Brussee JM, Vet NJ, Krekels EHJ, Valkenburg AJ, Jacqz-Aigrain E, van Gerven JMA, Swart EL, van den Anker JN, Tibboel D, de Hoog M, de Wildt SN, Knibbe CAJ. Predicting CYP3A-mediated midazolam metabolism in critically ill neonates, infants, children and adults with inflammation and organ failure. Br J Clin Pharmacol 2017; 84:358-368. [PMID: 29072785 PMCID: PMC5777436 DOI: 10.1111/bcp.13459] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/04/2017] [Accepted: 10/19/2017] [Indexed: 12/14/2022] Open
Abstract
AIMS Inflammation and organ failure have been reported to have an impact on cytochrome P450 (CYP) 3A-mediated clearance of midazolam in critically ill children. Our aim was to evaluate a previously developed population pharmacokinetic model both in critically ill children and other populations, in order to allow the model to be used to guide dosing in clinical practice. METHODS The model was evaluated externally in 136 individuals, including (pre)term neonates, infants, children and adults (body weight 0.77-90 kg, C-reactive protein level 0.1-341 mg l-1 and 0-4 failing organs) using graphical and numerical diagnostics. RESULTS The pharmacokinetic model predicted midazolam clearance and plasma concentrations without bias in postoperative or critically ill paediatric patients and term neonates [median prediction error (MPE) <30%]. Using the model for extrapolation resulted in well-predicted clearance values in critically ill and healthy adults (MPE <30%), while clearance in preterm neonates was over predicted (MPE >180%). CONCLUSION The recently published pharmacokinetic model for midazolam, quantifying the influence of maturation, inflammation and organ failure in children, yields unbiased clearance predictions and can therefore be used for dosing instructions in term neonates, children and adults with varying levels of critical illness, including healthy adults, but not for extrapolation to preterm neonates.
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Affiliation(s)
- Janneke M Brussee
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Nienke J Vet
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Abraham J Valkenburg
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
| | | | - Eleonora L Swart
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, The Netherlands
| | - Johannes N van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Dick Tibboel
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthijs de Hoog
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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13
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Baarslag MA, Allegaert K, Knibbe CAJ, van Dijk M, Tibboel D. Pharmacological sedation management in the paediatric intensive care unit. J Pharm Pharmacol 2016; 69:498-513. [DOI: 10.1111/jphp.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
This review addresses sedation management on paediatric intensive care units and possible gaps in the knowledge of optimal sedation strategies. We present an overview of the commonly used sedatives and their pharmacokinetic and pharmacodynamic considerations in children, as well as the ongoing studies in this field. Also, sedation guidelines and current sedation strategies and assessment methods are addressed.
Key findings
This review shows that evidence and pharmacokinetic data are scarce, but fortunately, there is an active research scene with promising new PK and PD data of sedatives in children using new study designs with application of advanced laboratory methods and modelling. The lack of evidence is increasingly being recognized by authorities and legislative offices such as the US Food and Drug Administration (FDA) and European Medicines Agency (EMA).
Conclusion
The population in question is very heterogeneous and this overview can aid clinicians and researchers in moving from practice-based sedation management towards more evidence- or model-based practice. Still, paediatric sedation management can be improved in other ways than pharmacology only, so future research should aim on sedation assessment and implementation strategies of protocolized sedation as well.
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Affiliation(s)
- Manuel A Baarslag
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of development and regeneration, KU Leuven, Belgium
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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14
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Rioux N, Waters NJ. Physiologically Based Pharmacokinetic Modeling in Pediatric Oncology Drug Development. Drug Metab Dispos 2016; 44:934-43. [DOI: 10.1124/dmd.115.068031] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/01/2016] [Indexed: 12/23/2022] Open
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15
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Altamimi MI, Choonara I, Sammons H. Inter-individual variation in morphine clearance in children. Eur J Clin Pharmacol 2015; 71:649-655. [PMID: 25845657 PMCID: PMC4430598 DOI: 10.1007/s00228-015-1843-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/24/2015] [Indexed: 11/29/2022]
Abstract
Objectives The aim of the study was to determine the extent of inter-individual variation in clearance of intravenous morphine in children and to establish which factors are responsible for this variation. Methods A systematic literature review was performed to identify papers describing the clearance of morphine in children. The following databases were searched: Medline, Embase, International Pharmaceutical Abstracts, CINAHL, and Cochrane library. From the papers, the range in plasma clearance and the coefficient of variation (CV) in plasma clearance were determined. Results Twenty-eight studies were identified. After quality assessment, 20 studies were included. Only 10 studies gave clearance values for individual patients. The majority of the studies were in critically ill patients. Inter-individual variability of morphine clearance was observed in all age groups, but greatest in critically ill neonates (both preterm and term) and infants. In critically ill patients, the CV was 16–9 7 % in preterm neonates, 24–87 % in term neonates, 35 and 134 % in infants, 39 and 55 % in children, and 74 % in adolescents. The CV was 37 and 44 % respectively in non-critically ill neonates and infants. The mean clearance was higher in children (32 and 52 ml min-1 kg-1) than in neonates (2 to 16 ml min-1 kg-1). Conclusions Large inter-individual variation was seen in morphine clearance values in critically ill neonates and infants. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1843-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohammed I Altamimi
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, DE22 3DT, UK.
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, DE22 3DT, UK
| | - Helen Sammons
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, DE22 3DT, UK
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