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Strickley T, Smith K, Ericksen AM. Dexmedetomidine - An Alternative to Midazolam in the Treatment of Ketamine-Induced Emergence Delirium: A Systematic Review. J Perianesth Nurs 2024; 39:311-318. [PMID: 37943188 DOI: 10.1016/j.jopan.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/22/2023] [Accepted: 08/07/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE Analyze the effectiveness of dexmedetomidine compared to midazolam for the treatment of ketamine-induced emergence delirium in noncardiac surgical patients. DESIGN Systematic review. METHODS Guidelines outlined in the Preferred Reporting Items For Systematic Reviews and Meta-analyses (PRISMA)22 were used for this review. PubMed, Cumulative Index To Nursing And Allied Health Literature (CINAHL), MEDLINE, The Cochrane Library, EBSCOhost, National Institute of Health clinical trials, Google Scholar, and gray literature were searched for relevant studies. Only peer-reviewed nonexperimental studies, quasi-experimental studies, and randomized control trials with or without meta-analysis were included. The evidence was assessed using the Johns Hopkins Nursing Evidence-Based Practice guidelines for quality ratings and evidence level. FINDINGS Five blinded randomized controlled trials, three quasi-experimental studies, and two retrospective nonexperimental studies comprised of 1,024 subjects were evaluated for this review. Dexmedetomidine was more effective at reducing ketamine-induced delirium in adult patients, although midazolam attenuated the psychomimetic effects of ketamine better in pediatric patients. Furthermore, postanesthesia care unit discharge times were similar between patients treated with dexmedetomidine and midazolam. The studies in this review were categorized as Level I, Level II, or Level III and rated Grade A, implying strong confidence in the actual effects of dexmedetomidine in all outcome measures of the review. CONCLUSIONS The current evidence suggests that dexmedetomidine is an effective alternative for alleviating ketamine-induced delirium in noncardiac adult surgical patients. Multiple studies in this review noted improved hemodynamics and reduced postoperative analgesic requirements after administration of dexmedetomidine in conjunction with ketamine.
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Affiliation(s)
- Trey Strickley
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Korde Smith
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Ashlee M Ericksen
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX.
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2
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Hebel JM, Lanz M, Malina T, Stodieck SRG, Le Van Quyen M. Effects of midazolam on high-frequency oscillations in amygdala and hippocampus of epilepsy patients. Epilepsia 2024; 65:e55-e60. [PMID: 38366848 DOI: 10.1111/epi.17916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/18/2024]
Abstract
High-frequency oscillations (HFOs) are associated with normal brain function, but are also increasingly recognized as potential biomarkers of epileptogenic tissue. Considering the important role of interneuron activity in physiological HFO generation, we studied their modulation by midazolam (MDZ), an agonist of γ-aminobutyric acid type A (GABAA)-benzodiazepine receptors. Here, we analyzed 80 intracranial electrode contacts in amygdala and hippocampus of 13 patients with drug-refractory focal epilepsy who had received MDZ for seizure termination during presurgical monitoring. Ripples (80-250 Hz) and fast ripples (FRs; 250-400 Hz) were compared before and after seizures with MDZ application, and according to their origin either within or outside the individual seizure onset zone (SOZ). We found that MDZ distinctly suppressed all HFOs (ripples and FRs), whereas the reduction of ripples was significantly less pronounced inside the SOZ compared to non-SOZ contacts. The rate of FRs inside the SOZ was less affected, especially in hippocampal contacts. In a few cases, even a marked increase of FRs following MDZ administration was seen. Our results demonstrate, for the first time, a significant HFO modulation in amygdala and hippocampus by MDZ, thus giving insights into the malfunction of GABA-mediated inhibition within epileptogenic areas and its role in HFO generation.
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Affiliation(s)
- Jonas M Hebel
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Lanz
- Epilepsy-Center Hamburg, Protestant Hospital Alsterdorf, Hamburg, Germany
| | - Thomas Malina
- Epilepsy-Center Hamburg, Protestant Hospital Alsterdorf, Hamburg, Germany
| | | | - Michel Le Van Quyen
- Laboratoire d'Imagerie Biomédicale, Inserm U1146/Sorbonne Université UMCR2/UMR7371 CNRS, Paris, France
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3
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Bruns N, Joist CA, Joist CM, Daniels A, Felderhoff-Müser U, Dohna-Schwake C, Tschiedel E. Correlation of Comfort Score and Narcotrend Index during Procedural Sedation with Midazolam and Propofol in Children. J Clin Med 2024; 13:1483. [PMID: 38592307 PMCID: PMC10932229 DOI: 10.3390/jcm13051483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 04/10/2024] Open
Abstract
Background/Objectives: Precise assessment of hypnotic depth in children during procedural sedation with preserved spontaneous breathing is challenging. The Narcotrendindex (NI) offers uninterrupted information by continuous electrocortical monitoring without the need to apply a stimulus with the risk of assessment-induced arousal. This study aimed to explore the correlation between NI and the Comfort Scale (CS) during procedural sedation with midazolam and propofol and to identify an NI target range for deep sedation. Methods: A prospective observational study was conducted on 176 children (6 months to 17.9 years) undergoing procedural sedation with midazolam premedication and continuous propofol infusion. Statistical analyses included Pearson correlation of NI and CS values, logistic regression, and receiver operating curves. Results: Median NI values varied with CS and age. The correlation coefficient between CS and NI was 0.50 and slightly higher in procedure-specific subgroup analyses. The optimal NI cut-off for deep sedation was between 50 and 60 depending on the analyzed subgroup and displayed high positive predictive values for sufficient sedation throughout. Conclusion: Our study found a moderate correlation between NI and CS, demonstrating reliable identification of adequately sedated patients.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Carolina A. Joist
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Constantin M. Joist
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Anna Daniels
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Eva Tschiedel
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
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4
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Bojić MG, Treven M, Pandey KP, Tiruveedhula VVNPB, Santrač A, Đukanović Đ, Vojinović N, Amidžić L, Škrbić R, Scholze P, Ernst M, Cook JM, Savić MM. Vascular effects of midazolam, flumazenil, and a novel imidazobenzodiazepine MP-III-058 on isolated rat aorta. Can J Physiol Pharmacol 2024; 102:206-217. [PMID: 37909404 DOI: 10.1139/cjpp-2023-0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Hypotensive influences of benzodiazepines and other GABAA receptor ligands, recognized in clinical practice, seem to stem from the existence of "vascular" GABAA receptors in peripheral blood vessels, besides any mechanisms in the central and peripheral nervous systems. We aimed to further elucidate the vasodilatatory effects of ligands acting through GABAA receptors. Using immunohistochemistry, the rat aortic smooth muscle layer was found to express GABAA γ2 and α1-5 subunit proteins. To confirm the role of "vascular" GABAA receptors, we investigated the vascular effects of standard benzodiazepines, midazolam, and flumazenil, as well as the novel compound MP-III-058. Using two-electrode voltage clamp electrophysiology and radioligand binding assays, MP-III-058 was found to have modest binding but substantial functional selectivity for α5β3γ2 over other αxβ3γ2 GABAA receptors. Tissue bath assays revealed comparable vasodilatory effects of MP-III-058 and midazolam, both of which at 100 µmol/L concentrations had efficacy similar to prazosin. Flumazenil exhibited weak vasoactivity per se, but significantly prevented the relaxant effects of midazolam and MP-III-058. These studies indicate the existence of functional GABAA receptors in the rat aorta, where ligands exert vasodilatory effects by positive modulation of the benzodiazepine binding site, suggesting the potential for further quest for leads with optimized pharmacokinetic properties as prospective adjuvant vasodilators.
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Affiliation(s)
- Milica Gajić Bojić
- Faculty of Medicine, Center for Biomedical Research, University of Banja Luka, Banja Luka 78000, Republic of Srpska, Bosnia and Herzegovina
| | - Marco Treven
- Neurology Department, Medical University of Vienna, Vienna, Austria
| | - Kamal P Pandey
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - V V N Phani Babu Tiruveedhula
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Anja Santrač
- Department of Pharmacology, Faculty of Pharmacy, University of Belgrade, Belgrade 11000, Serbia
| | - Đorđe Đukanović
- Faculty of Medicine, Center for Biomedical Research, University of Banja Luka, Banja Luka 78000, Republic of Srpska, Bosnia and Herzegovina
| | - Nataša Vojinović
- Faculty of Medicine, Center for Biomedical Research, University of Banja Luka, Banja Luka 78000, Republic of Srpska, Bosnia and Herzegovina
| | - Ljiljana Amidžić
- Faculty of Medicine, Center for Biomedical Research, University of Banja Luka, Banja Luka 78000, Republic of Srpska, Bosnia and Herzegovina
| | - Ranko Škrbić
- Faculty of Medicine, Center for Biomedical Research, University of Banja Luka, Banja Luka 78000, Republic of Srpska, Bosnia and Herzegovina
| | - Petra Scholze
- Department of Pathobiology of the Nervous SystemCenter for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Margot Ernst
- Department of Pathobiology of the Nervous SystemCenter for Brain Research, Medical University of Vienna, Vienna, Austria
| | - James M Cook
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Miroslav M Savić
- Department of Pharmacology, Faculty of Pharmacy, University of Belgrade, Belgrade 11000, Serbia
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Jen CK, Lu KC, Chen KW, Lu YR, Huang IT, Huang YC, Huang CJ. Oral Dexmedetomidine Achieves Superior Effects in Mitigating Emergence Agitation and Demonstrates Comparable Sedative Effects to Oral Midazolam for Pediatric Premedication: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. J Clin Med 2024; 13:1174. [PMID: 38398486 PMCID: PMC10889161 DOI: 10.3390/jcm13041174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although the results of different randomized controlled trials are conflicting. Methods: This study enrolled randomized controlled trials (RCTs) examining premedication with oral dexmedetomidine versus oral midazolam in pediatric patients undergoing general anesthesia. PubMed, the Cochrane Library, Embase, and the Web of Science database were searched from their inception until June 2023. The outcomes were the incidence of satisfactory preoperative sedation, satisfactory sedation during separation from parents, satisfactory sedation during anesthesia induction using an anesthesia mask, and the incidence of emergence agitation. Results: A total of 9 RCTs comprising 885 patients were analyzed. Our data revealed comparable effects of dexmedetomidine and midazolam with respect to satisfactory preoperative sedation and a satisfactory incidence of sedation during parental separation and mask acceptance before anesthesia induction. Notably, our data revealed that the rate of emergence agitation was significantly lower in pediatric patients receiving dexmedetomidine (n = 162) than in those receiving midazolam (n = 159) (odds ratio = 0.16; 95% confidence interval: 0.06 to 0.44; p < 0.001; I2 = 35%). Conclusions: Data from this meta-analysis revealed comparable effects for premedication with oral dexmedetomidine or oral midazolam with respect to satisfactory sedation; furthermore, premedication with oral dexmedetomidine more effectively mitigated emergence agitation in pediatric patients receiving general anesthesia compared with oral midazolam.
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Affiliation(s)
- Chun-Kai Jen
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
| | - Kuo-Ching Lu
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Department of Anesthesiology, Binkun Women’s and Children’s Hospital, Taoyuan 324, Taiwan
| | - Kuan-Wen Chen
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
| | - Yun-Ru Lu
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
| | - I-Tao Huang
- Emergency Department, Redcliffe Hospital, Redcliffe, QLD 4020, Australia;
- School of Public Health, Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
| | - Yu-Chen Huang
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan;
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
| | - Chun-Jen Huang
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
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6
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KAMIO T, ODANI Y, OHTOMO W, OGUSHI A, AKUNE Y, KURITA M, OKADA A, INOSHIMA Y. Midazolam and butorphanol combination for sedating beluga whales (Delphinapterus leucas). J Vet Med Sci 2024; 86:207-210. [PMID: 38104973 PMCID: PMC10898986 DOI: 10.1292/jvms.23-0307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023] Open
Abstract
Safe sedation doses for performing minor procedures such as bronchoscopy, endoscopy, and tooth extraction for beluga whales (Delphinapterus leucas) require elucidation. This study aimed to provide suggestions for determining appropriate midazolam and butorphanol doses to adequately sedate beluga whales to complete procedures and minimize the risk of side effects. We administered midazolam and butorphanol to six captive beluga whales (9-44 years old). Topical lidocaine anesthesia was administered during bronchoscopy. The sedation doses for the beluga whales varied from 0.020 to 0.122 mg/kg for midazolam and from 0.020 to 0.061 mg/kg for butorphanol. In beluga whales, optimal midazolam and butorphanol doses were lowest in old whales. These findings contribute to knowledge regarding appropriate sedation and prevention of overdose accidents during minor procedures in beluga whales.
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Affiliation(s)
- Takashi KAMIO
- Port of Nagoya Public Aquarium, Aichi, Japan
- Joint Graduate School of Veterinary Sciences, Gifu
University, Gifu, Japan
- Laboratory of Food and Environmental Hygiene, Cooperative
Department of Veterinary Medicine, Gifu University, Gifu, Japan
| | | | | | | | | | | | - Ayaka OKADA
- Laboratory of Food and Environmental Hygiene, Cooperative
Department of Veterinary Medicine, Gifu University, Gifu, Japan
| | - Yasuo INOSHIMA
- Joint Graduate School of Veterinary Sciences, Gifu
University, Gifu, Japan
- Laboratory of Food and Environmental Hygiene, Cooperative
Department of Veterinary Medicine, Gifu University, Gifu, Japan
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Castro M, Butler M, Thompson AN, Gee S, Posporelis S. Effectiveness and Safety of Intravenous Medications for the Management of Acute Disturbance (Agitation and Other Escalating Behaviors): A Systematic Review of Prospective Interventional Studies. J Acad Consult Liaison Psychiatry 2024:S2667-2960(24)00012-0. [PMID: 38309683 DOI: 10.1016/j.jaclp.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
Acute disturbance is a broad term referring to escalating behaviors secondary to a change in mental state, such as agitation, aggression, and violence. Available management options include de-escalation techniques and rapid tranquilization, mostly via parenteral formulations of medication. While the intramuscular route has been extensively studied in a range of clinical settings, the same cannot be said for intravenous (IV); this is despite potential benefits, including rapid absorption and complete bioavailability. This systematic review analyzed existing evidence for effectiveness and safety of IV medication for management of acute disturbances. It followed a preregistered protocol (PROSPERO identification CRD42020216456) and is reported following the guidelines set by Preferred Reporting Items for Systematic Review and Meta-Analysis. APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible interventional studies up until May 30th, 2023. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly. Results showed mixed but positive results for the effectiveness of IV dexmedetomidine, lorazepam, droperidol, and olanzapine. Evidence was more limited for IV haloperidol, ketamine, midazolam, chlorpromazine, and valproate. There was no eligible data on the use of IV clonazepam, clonidine, diazepam, diphenhydramine, propranolol, ziprasidone, fluphenazine, carbamazepine, or promethazine. Most studies reported favorable adverse event profiles, though they are unlikely to have been sufficiently powered to pick up rare serious events. In most cases, evidence was of low or mixed quality, accentuating the need for further standardized, large-scale, multi-arm randomized controlled trials with homogeneous outcome measures. Overall, this review suggests that IV medications may offer an effective alternative parenteral route of administration in acute disturbance, particularly in general hospital settings.
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Affiliation(s)
- Megan Castro
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom
| | - Matt Butler
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom.
| | | | - Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom; Institute of Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, KCL, London, United Kingdom
| | - Sotiris Posporelis
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Heniff AC, Petritz OA, Carpenter RG, Lewbart GA, Balko JA. Anesthetic efficacy of dexmedetomidine-ketamine in eastern box turtles (Terrapene carolina carolina) is enhanced with the addition of midazolam and when administered in the forelimb versus the hindlimb. Am J Vet Res 2024; 85:ajvr.23.10.0226. [PMID: 38039626 DOI: 10.2460/ajvr.23.10.0226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/16/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To compare dexmedetomidine-ketamine (DK; 0.1 and 10 mg/kg, respectively) with midazolam (M; 1.0 mg/kg) or 0.9% sodium chloride (S; 0.2 mL/kg) administered IM in the forelimb (F) or hindlimb (H) in eastern box turtles (Terrapene carolina carolina). ANIMALS 20 clinically healthy, captive adult eastern box turtles. METHODS In a randomized, blinded, complete crossover study with 1-week washout periods, turtles were administered each of 3 treatments: F-DKS, F-DKM, or H-DKM. Palpebral reflex, muscle tone, and withdrawal responses were serially assessed and used to calculate cumulative sedation scores at each 5-minute time point. The ability to intubate was evaluated. At 60 minutes, atipamezole (1.0 mg/kg) and either flumazenil (F-DKM, H-DKM; 0.05 mg/kg) or 0.9% sodium chloride (F-DKS; 0.5 mL/kg) were administered IM. RESULTS All treatments resulted in clinically relevant anesthetic effects. F-DKM produced significantly higher sedation scores than H-DKM or F-DKS at all time points between 10 and 60 minutes (P < .05). Sedation score variability was observed with all treatments with significantly higher variability for H-DKM (P < .05). Intubation was successful in 32, 89, and 11% of turtles in F-DKS, F-DKM, and H-DKM, respectively. Median (range) recovery time was 10 (5-22), 16 (7-45), and 12 (4-28) minutes for F-DKS, F-DKM, and H-DKM, respectively. CLINICAL RELEVANCE In eastern box turtles, forelimb dexmedetomidine-ketamine resulted in clinically relevant anesthetic effects that were heightened with the addition of midazolam. Hindlimb administration of midazolam-dexmedetomidine-ketamine resulted in reduced and more variable anesthetic effects compared to forelimb administration, supporting a hepatic first-pass effect.
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Affiliation(s)
- Ashlyn C Heniff
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Olivia A Petritz
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Rachel G Carpenter
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Gregory A Lewbart
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Julie A Balko
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
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9
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van der Heijden LT, Ribbers CA, Vermunt MAC, Pluim D, Acda M, Tibben M, Rosing H, Douma JAJ, Naipal K, Bergman AM, Beijnen JH, Huitema ADR, Opdam FL. Is Higher Docetaxel Clearance in Prostate Cancer Patients Explained by Higher CYP3A? An In Vivo Phenotyping Study with Midazolam. J Clin Pharmacol 2024; 64:155-163. [PMID: 37789682 DOI: 10.1002/jcph.2362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/29/2023] [Indexed: 10/05/2023]
Abstract
Patients with prostate cancer (PCa) have a lower docetaxel exposure for both intravenous (1.8-fold) and oral administration (2.4-fold) than patients with other solid cancers, which could influence efficacy and toxicity. An altered metabolism by cytochrome P450 3A (CYP3A) due to castration status might explain the observed difference in docetaxel pharmacokinetics. In this in vivo phenotyping, pharmacokinetic study, CYP3A activity defined by midazolam clearance (CL) was compared between patients with PCa and male patients with other solid tumors. All patients with solid tumors who did not use CYP3A-modulating drugs were eligible for participation. Patients received 2 mg midazolam orally and 1 mg midazolam intravenously on 2 consecutive days. Plasma concentrations were measured with a validated liquid chromatography-tandem mass spectrometry method. Genotyping was performed for CYP3A4 and CYP3A5. Nine patients were included in each group. Oral midazolam CL was 1.26-fold higher in patients with PCa compared to patients with other solid tumors (geometric mean [coefficient of variation], 94.1 [33.5%] L/h vs 74.4 [39.1%] L/h, respectively; P = .08). Intravenous midazolam CL did not significantly differ between the 2 groups (P = .93). Moreover, the metabolic ratio of midazolam to 1'-hydroxy midazolam did not differ between the 2 groups for both oral administration (P = .67) and intravenous administration (P = .26). CYP3A4 and CYP3A5 genotypes did not influence midazolam pharmacokinetics. The observed difference in docetaxel pharmacokinetics between both patient groups therefore appears to be explained neither by a difference in midazolam CL nor by a difference in metabolic conversion rate of midazolam.
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Affiliation(s)
- Lisa T van der Heijden
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Claire A Ribbers
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Marit A C Vermunt
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dick Pluim
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Manon Acda
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthijs Tibben
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joeri A J Douma
- Department of Clinical Pharmacology, Division of Medical Oncology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, The Netherlands
- Department of Internal Medicine, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Kishan Naipal
- Department of Clinical Pharmacology, Division of Medical Oncology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, The Netherlands
| | - Andre M Bergman
- Department of Clinical Pharmacology, Division of Medical Oncology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, The Netherlands
- Department of Oncogenomics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmaco-epidemiology and Clinical Pharmacology, Faculty of Science, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Maxima Center, Utrecht, The Netherlands
| | - Frans L Opdam
- Department of Clinical Pharmacology, Division of Medical Oncology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, The Netherlands
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10
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Alzoubi H, Kabbani S, Taleb A, Bshara N, Altinawi MK, Almonakel MB, Al Kurdi S. Rectal Sedation With Ketamine and Midazolam in the Management of Uncooperative Children During Dental Treatment: A Case Series and Method Description. Cureus 2024; 16:e54825. [PMID: 38529445 PMCID: PMC10962867 DOI: 10.7759/cureus.54825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2024] [Indexed: 03/27/2024] Open
Abstract
Background In pediatric dentistry, sedation aims to eliminate anxiety to facilitate the completion of dental procedures. Sedation in children is a multidimensional field that includes the child, parents/guardians, and the health care team. The rectal route is generally painless, making it suitable for children who are afraid of needles. This route has several advantages over the oral route, including reduced patient cooperation requirements, a faster and more predictable onset, and less physical trauma than the intravenous and intramuscular routes. This case series aimed to evaluate the effectiveness and success rate of rectal sedation with ketamine and midazolam in the management of uncooperative children during dental treatment. Case presentation Ten healthy children with definitely negative behavior were enrolled in this study. Each child was given 7 mg/kg of ketamine in combination with midazolam 0.1 mg/kg by the rectal route. The mean onset sedation time was 9.5 minutes, and pulpotomy procedures were done. Behavioral response was monitored throughout treatment using the Ohio State University Behavioral Rating Scale (OSUBRS), and the depth of sedation was measured using the University of Michigan Sedation Scale (UMSS). The Houpt General Behavior Scale was used to estimate the treatment success rate based on the overall behavior rating. All 10 cases showed good anxiolysis and cooperation following rectal administration, with no side effects observed. Conclusions Rectal administration of ketamine in combination with midazolam may be considered a reliable method in the management of uncooperative children during dental treatment. No adverse effects were observed during or after the sedation procedure.
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Affiliation(s)
- Hasan Alzoubi
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
| | - Samar Kabbani
- Department of Anesthesia and Reanimation, Damascus University, Damascus, SYR
| | - Ahmad Taleb
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
| | - Nada Bshara
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
| | | | | | - Saleh Al Kurdi
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
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11
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Watanabe M, Nikaido Y, Sasaki N. Validation of the anesthetic effect of a mixture of remimazolam, medetomidine, and butorphanol in three mouse strains. Exp Anim 2024:23-0158. [PMID: 38246607 DOI: 10.1538/expanim.23-0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
Proper administration of anesthesia is indispensable for the ethical treatment of lab animals in biomedical research. Therefore, selecting an effective anesthesia protocol is pivotal for the design and success of experiments. Hence, continuous development and refinement of anesthetic agents are imperative to improve research outcomes and elevate animal welfare. "Balanced anesthesia" involves using multiple drugs to optimize efficacy while minimizing side effects. The medetomidine, midazolam, and butorphanol, called MMB, and medetomidine, alfaxalone, and butorphanol, called MAB, are popular in Japan. However, the drawbacks of midazolam, including its extended recovery time, and the narrow safety margin of MAB, have prompted research for suitable alternatives. This study replaced midazolam in the MMB combination with remimazolam (RMZ), which is noted for its ultra-short half-life. The resulting combination, called MRB, was effective inproviding a wider safety margin compared to MAB while maintaining an anesthesia depth equivalent level to that of MMB in mice. Notably, MRB consistently exhibited better recovery scores after antagonist administration in contrast to MMB. Furthermore, the re-sedation phenomenon observed with MMB was not observed with MRB. The rapid metabolism of RMZ enables reliable anesthesia induction, circumventing the complications linked to MAB. Overall, MRB excelled in providing extended surgical anesthesia and swift post-antagonist recovery. These results highlight the potential of RMZ for broader animal research applications.
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Affiliation(s)
- Masaki Watanabe
- Laboratory of Laboratory Animal Science and Medicine, School of Veterinary Medicine, Kitasato University
| | - Yuko Nikaido
- Laboratory of Laboratory Animal Science and Medicine, School of Veterinary Medicine, Kitasato University
| | - Nobuya Sasaki
- Laboratory of Laboratory Animal Science and Medicine, School of Veterinary Medicine, Kitasato University
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12
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Xiong H, Liu J, Liu G, Zhang Y, Wei Z, Fan L, Jiang F, Zhao Y, Wei W, Li S, Xue R. Effective doses of midazolam oral solution for the prevention of preoperative anxiety in paediatric patients. Int J Paediatr Dent 2024. [PMID: 38243663 DOI: 10.1111/ipd.13162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND More than 60% children exhibit anxiety before undergoing an anesthetic-surgical procedure, particularly among pre-school paediatric patients. Oral midazolam can provide procedural sedation for children prior to anesthesia. However, extemporaneous solutions of midazolam are usually prepared from injectable drug solutions, leading to inconsistent efficacy due to variable preparation methods. Xiaoerjing® is the first commercially available oral formulation of midazolam for procedural sedation in children in China. Despite the recommended dosage range of 0.25-0.5 mg/kg, its effective dose is still largely unknown. AIM To determine the 95% effective dose (ED95) of midazolam oral solution (Xiaoerjing®) for alleviating preoperative anxiety in children prior to mask induction of general anesthesia. DESIGN The study included 61 children between the ages of 1 and 6 years undergoing elective surgery under general anesthesia. The first patient received a single dose of 0.5 mg/kg midazolam oral solution, which was adjusted for subsequent patients using the biased coin design method based on their response to the previous dose. Doses were increased or decreased at the rate of 0.1 mg/kg. An effective response was defined as having a modified Ramsay sedation score ≥3a, separation anxiety score ≤2, and mask acceptance score ≤2 during inhalational anesthesia induction. RESULTS Fifty-six children were included in the final analysis. Of those, sedation was successful in 50 patients, with a median separation time of 15 (IQR: 25) min. Midazolam oral solution has an ED95 of 0.8254 mg/kg (95% CI: 0.6915-0.8700 mg/kg) for relieving preoperative anxiety in children. No adverse events occurred following drug administration. CONCLUSION Midazolam oral solution is a safe and effective medication for relieving preoperative anxiety in children. The ED95 of a single oral dose of midazolam oral solution is 0.8254 mg/kg (95% CI: 0.6915-0.8700 mg/kg).
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Affiliation(s)
- Hongfei Xiong
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
- Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi'an Jiaotong University, Xi'an, China
| | - Jing Liu
- The Second Affiliated Hospital of Xi'an Medical College, Xi'an, China
| | - Guangbo Liu
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Yunyun Zhang
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Ziwen Wei
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Linna Fan
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Fangfang Jiang
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Yingchao Zhao
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Wei Wei
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Siyuan Li
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Rongliang Xue
- Anesthesia & Comfort Health Center, Xi'an International Medical Center Hospital, Xi'an, China
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13
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Bolt R, Hyslop MC, Herbert E, Papaioannou DE, Totton N, Wilson MJ, Clarkson J, Evans C, Ireland N, Kettle J, Marshman Z, Norrington AC, Paton RH, Vernazza C, Deery C. The MAGIC trial: a pragmatic, multicentre, parallel, noninferiority, randomised trial of melatonin versus midazolam in the premedication of anxious children attending for elective surgery under general anaesthesia. Br J Anaesth 2024; 132:76-85. [PMID: 37953202 PMCID: PMC10797512 DOI: 10.1016/j.bja.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Child anxiety before general anaesthesia and surgery is common. Midazolam is a commonly used premedication to address this. Melatonin is an alternative anxiolytic, however trials evaluating its efficacy in children have delivered conflicting results. METHODS This multicentre, double-blind randomised trial was performed in 20 UK NHS Trusts. A sample size of 624 was required to declare noninferiority of melatonin. Anxious children, awaiting day case elective surgery under general anaesthesia, were randomly assigned 1:1 to midazolam or melatonin premedication (0.5 mg kg-1, maximum 20 mg) 30 min before transfer to the operating room. The primary outcome was the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary outcomes included safety. Results are presented as n (%) and adjusted mean differences with 95% confidence intervals. RESULTS The trial was stopped prematurely (n=110; 55 per group) because of recruitment futility. Participants had a median age of 7 (6-10) yr, and 57 (52%) were female. Intention-to-treat and per-protocol modified Yale Preoperative Anxiety Scale-Short Form analyses showed adjusted mean differences of 13.1 (3.7-22.4) and 12.9 (3.1-22.6), respectively, in favour of midazolam. The upper 95% confidence interval limits exceeded the predefined margin of 4.3 in both cases, whereas the lower 95% confidence interval excluded zero, indicating that melatonin was inferior to midazolam, with a difference considered to be clinically relevant. No serious adverse events were seen in either arm. CONCLUSION Melatonin was less effective than midazolam at reducing preoperative anxiety in children, although the early termination of the trial increases the likelihood of bias. CLINICAL TRIAL REGISTRATION ISRCTN registry: ISRCTN18296119.
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Affiliation(s)
- Robert Bolt
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Marie C Hyslop
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Esther Herbert
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Diana E Papaioannou
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Nikki Totton
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Matthew J Wilson
- Sheffield School of Health & Related Research, University of Sheffield, Sheffield, UK
| | - Janet Clarkson
- Dundee Dental Hospital and School, University of Dundee, Dundee, UK
| | - Christopher Evans
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Ireland
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jennifer Kettle
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Zoe Marshman
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | | | | | | | - Christopher Deery
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK.
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14
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Yamasaki K, Tokuno M, Tsukigawa K, Nagatsuka Y, Nishi K, Otagiri M, Sato Y. Possible Involvement of Protein Binding Inhibition in Changes in Dexmedetomidine Concentration in Extracorporeal Circuits during Midazolam Use. Biol Pharm Bull 2024; 47:389-393. [PMID: 38325827 DOI: 10.1248/bpb.b23-00659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
It was recently reported that the dexmedetomidine concentration within the extracorporeal circuit decreases with co-administration of midazolam. In this study, we investigated whether displacement of dexmedetomidine by midazolam from the binding site of major plasma proteins, human serum albumin (HSA) and α1-acid glycoprotein (AAG), would increase levels of free dexmedetomidine that could be adsorbed to the circuit. Equilibrium dialysis experiments indicated that dexmedetomidine binds to a single site on both HSA and AAG with four times greater affinity than midazolam. Midazolam-mediated inhibition of the binding of dexmedetomidine to HSA and AAG was also examined. The binding of dexmedetomidine to these proteins decreased in the presence of midazolam. Competitive binding experiments suggested that the inhibition of binding by midazolam was due to competitive displacement at site II of HSA and due to non-competitive displacement at the site of AAG. Thus, our present data indicate that free dexmedetomidine displaced by midazolam from site II of HSA or from AAG is adsorbed onto extracorporeal circuits, resulting in a change in the dexmedetomidine concentration within the circuit.
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Affiliation(s)
- Keishi Yamasaki
- Faculty of Pharmaceutical Sciences, Sojo University
- DDS Research Institute, Faculty of Pharmaceutical Sciences, Sojo University
| | | | - Kenji Tsukigawa
- Faculty of Pharmaceutical Sciences, Sojo University
- DDS Research Institute, Faculty of Pharmaceutical Sciences, Sojo University
| | - Yuka Nagatsuka
- Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University
| | - Koji Nishi
- Faculty of Pharmaceutical Sciences, Sojo University
- DDS Research Institute, Faculty of Pharmaceutical Sciences, Sojo University
| | - Masaki Otagiri
- Faculty of Pharmaceutical Sciences, Sojo University
- DDS Research Institute, Faculty of Pharmaceutical Sciences, Sojo University
| | - Yuhki Sato
- Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University
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15
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Yano T, Watanabe S, Kurokawa Y, Sakamoto Y, Hidaka N, Tanaka M. Pharmacological Investigation of Hypoalbuminemia on the Prolonged and Potentiated Action of Midazolam in Rats. Biol Pharm Bull 2024; 47:785-790. [PMID: 38583949 DOI: 10.1248/bpb.b23-00906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Midazolam (MDZ) is clinically used for its sedative and anticonvulsant properties. However, its prolonged or potentiated effects are sometimes concerning. The main binding protein of MDZ is albumin, and reduced serum albumin levels could lead to MDZ accumulation, thereby potentiating or prolonging its effects. Previous investigations have not thoroughly examined these phenomena from a behavioral pharmacology standpoint. Consequently, this study aimed to evaluate both the prolonged and potentiated effects of MDZ, as well as the effects of serum albumin levels on the action of MDZ in low-albumin rats. Male Wistar rats were classified into control (20% protein diet), low-protein (5% protein), and non-protein groups (0% protein diet) and were fed the protein-controlled diets for 30 d to obtain low-albumin rats. The locomotor activity and muscle relaxant effects of MDZ were evaluated using the rotarod, grip strength, and open-field tests conducted 10, 60, and 120 min after MDZ administration. Serum albumin levels decreased significantly in the low-protein and non-protein diet groups compared with those in the control group. Compared with the control rats, low-albumin rats demonstrated a significantly shorter time to fall, decreased muscle strength, and a significant decrease in the distance traveled after MDZ administration in the rotarod, grip strength, and open-field tests, respectively. Decreased serum albumin levels potentiated and prolonged the effects of MDZ. Hence, serum albumin level is a critical parameter associated with MDZ administration, which should be monitored, and any side effects related to decreased albumin levels should be investigated.
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Affiliation(s)
- Takaaki Yano
- Division of Pharmacy, Ehime University Hospital
- Department of Clinical Pharmacy, College of Pharmaceutical Sciences, Matsuyama University
| | - Shinichi Watanabe
- Department of Clinical Pharmacy, College of Pharmaceutical Sciences, Matsuyama University
| | - Yukiro Kurokawa
- Division of Pharmacy, Ehime University Hospital
- Department of Clinical Pharmacy, College of Pharmaceutical Sciences, Matsuyama University
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16
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Paolini A, Vignoli M, Bernabò N, Bianchi A, Tamburro R, Pincelli MC, Del Signore F, De Bonis A, Rosto M, Collivignarelli F, Distefano C, Cerasoli I. A Comparison of the Intrarectal and Intramuscular Effects of a Dexmedetomidine, Ketamine and Midazolam Mixture on Tear Production in Cats: A Randomized Controlled Trial. Animals (Basel) 2023; 14:145. [PMID: 38200876 PMCID: PMC10778512 DOI: 10.3390/ani14010145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Cats are often easily stressed and uncooperative. The use of sedative agents in the feline species is widely used to perform even minor clinical and diagnostic procedures. The aim of this study is to assess the impact on tear film production of the intrarectal route (IR) administration of a mixture of dexmedetomidine, ketamine and midazolam in comparison with the intramuscular (IM) one. A group of twenty cats were involved in a randomized and blinded clinical trial. A clinical and ophthalmological examination was conducted on the cats. The IR group received dexmedetomidine 0.003 mg kg-1, ketamine 4 mg kg-1 and midazolam 0.4 mg kg-1; the IM group received dexmedetomidine 0.003 mg kg-1, ketamine 2 mg kg-1 and midazolam 0.2 mg kg-1. A Shirmer tear test I (STT- I) was conducted 1 h before sedation and 2', 10', 20', 30', 40', and 80' post drug administration. The reaction to STT-I administration was also evaluated. The IM group has a lower mean tear production than the IR group for all time points evaluated. Cats in the IM group showed less reaction to STT-I administration. This study may suggest that the effect of sedative agents administered by the IR route has a lower incidence on tear production than the IM one. The use of eye lubricant is recommended in any case.
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Affiliation(s)
- Andrea Paolini
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Massimo Vignoli
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Nicola Bernabò
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Amanda Bianchi
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Roberto Tamburro
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Maria Cristina Pincelli
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Francesca Del Signore
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Andrea De Bonis
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Martina Rosto
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Francesco Collivignarelli
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
| | - Clelia Distefano
- Faculty of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy; (M.V.); (N.B.); (A.B.); (M.C.P.); (F.D.S.); (A.D.B.); (M.R.); (F.C.); (C.D.)
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17
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Lim JA, Jo S, Choi EK. Comparison of the antiemetic efficacy of a combination of midazolam with ramosetron and midazolam with palonosetron for postoperative nausea and vomiting prophylaxis in laparoscopic cholecystectomy. Medicine (Baltimore) 2023; 102:e36824. [PMID: 38206711 PMCID: PMC10754572 DOI: 10.1097/md.0000000000036824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/08/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND A multimodal therapeutic strategy for preventing postoperative nausea and vomiting (PONV) benefits moderate- and high-risk surgical patients. We compared the efficacy of a combination of midazolam and ramosetron and a combination of midazolam and palonosetron for PONV prophylaxis in patients scheduled for laparoscopic cholecystectomy. METHODS We enrolled 68 patients aged 20 to 65 years undergoing laparoscopic cholecystectomy. Patients were randomly allocated to the midazolam 0.05 mg/kg with ramosetron 0.3 mg (MR) or midazolam 0.05 mg/kg with palonosetron 0.075 mg (MP) groups. The incidence of PONV, severity of nausea, use of rescue antiemetics, and pain severity were evaluated at 2, 24, and 48 hours after surgery. RESULTS The incidence (38.2% vs 5.9%) and severity of postoperative nausea were significantly lower in the MP group at 2 hours after surgery (P < .05). There were no significant differences in the incidence of vomiting, use of rescue antiemetics, or pain severity between the 2 groups. CONCLUSION The combination of midazolam with palonosetron significantly decreased the incidence and severity of postoperative nausea compared with midazolam combined with ramosetron, especially in the early postoperative phase (0-2 hours) in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Jung A Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Sungbin Jo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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18
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Li SJ, Shen KF, He L, Zhang YP, Ming L, Wu ZF. Clinical Analysis of Intranasal Dexmedetomidine Combined With Midazolam in Pediatric Cranial Magnetic Resonance Examinations. J Perianesth Nurs 2023; 38:925-929. [PMID: 37278686 DOI: 10.1016/j.jopan.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE To observe the efficacy and safety of intranasal dexmedetomidine combined with midazolam in cranial magnetic resonance imaging of children. DESIGN A prospective, observational, single-arm, one-center study. METHODS A total of 474 children were scheduled for cranial 3.0 T MRI at the first time. All patients were initially given 3 mcg/kg dexmedetomidine combined with 0.15 mg/kg midazolam. The one-time success rate, vital signs before and after treatment, onset time, recovery time, and incidence of adverse reactions were recorded. FINDINGS The one-time success rate was 78.1%. There were significant differences in respiration, heart rate, and blood oxygen saturation before and after treatment (P < .001). The onset time was 10 (8-15) minutes. The average recovery time was 2.58 ± 1.10 hours. Only 1.27% (6 cases) of adverse reactions were observed, including bradycardia (3 cases, 0.6%), tachycardia (1 case, 0.2%), and startle (2 cases, 0.4%). No special treatment was needed. The success of the examination was significantly correlated with age (OR 1.320, 95% CI 1.019-1.710, P = .035) and onset time (OR 0.959, 95% CI 0.921-0.998, P = .038). CONCLUSION Dexmedetomidine 3 mcg/kg combined with midazolam 0.15 mg/kg intranasally has a good sedative effect in pediatric cranial magnetic resonance examinations, little impact on breathing and circulation, and few adverse reactions. Age and onset time are related factors affecting the one-time success rate.
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Affiliation(s)
- Si-Jie Li
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Kai-Feng Shen
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li He
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yu-Ping Zhang
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Ming
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Zhi-Feng Wu
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China.
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Patel B, Shah MM, Suresh A, Patel PN, Patel P, Gandhi SK. Evaluation of Febrile Seizures: A Therapeutic Review of Current Modalities. Cureus 2023; 15:e50947. [PMID: 38249234 PMCID: PMC10800093 DOI: 10.7759/cureus.50947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
As benign as its nature is, a febrile seizure (FS) can be one of the most frightening experiences for parents to witness. It is a seizure that occurs in infants and children aged six months to five years, accompanied by a fever (with a temperature of at least 100.4°F or 38.0°C by any method), without any infection in the central nervous system. FS is typically benign and tends to resolve on its own. Overall, the risk of recurrence after an FS is high, so there is still a sizable knowledge discrepancy that needs to be addressed for better understanding and management of the disease. Thus, the objective of this review is to evaluate current therapeutic modalities available for FS and summarize recent recommendations on the management of this condition. On June 25, 2023, a review was undertaken using the Medical Subject Headings Tool (MeSH), and the following keywords yielded 867 results: seizures, febrile/drug therapy [Mesh] and seizures, and febrile/therapy [Mesh]. A total of 21 relevant articles were chosen for the research. Seizures were classified as simple and complex FS (CFS) based on clinical features. CFS usually results in recurrence. Certain investigations like computed tomography (CT) scans, magnetic resonance imaging (MRIs), and electroencephalography (EEG) are helpful, along with laboratory investigations, to rule out other causes of FS. After reviewing the current literature, we have tried to conclude whether the current pharmacotherapy is effective in treating FS.
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Affiliation(s)
- Brinda Patel
- Department of Internal Medicine, Gujarat Medical Education and Research Society, Ahmedabad, IND
| | - Mokshit M Shah
- Department of Internal Medicine, Gujarat Medical Education and Research Society, Patan, IND
| | - Amrita Suresh
- Department of Pediatrics, Kasturba Medical College, Mangalore, IND
| | - Parag N Patel
- Department of Internal Medicine, Gujarat Medical Education and Research Society, Patan, IND
| | - Priyansh Patel
- Department of Internal Medicine, Medical College Baroda, Vadodara, IND
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Yoshimura M, Hidaka Y, Morimoto Y. Association Between the Use of Midazolam During Cardiac Anesthesia and the Incidence of Postoperative Delirium: A Retrospective Cohort Study Using a Nationwide Database. J Cardiothorac Vasc Anesth 2023; 37:2546-2551. [PMID: 37730454 DOI: 10.1053/j.jvca.2023.08.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To evaluate the association between the intraoperative administration of midazolam and the incidence of postoperative delirium in patients undergoing cardiac surgery. DESIGN Retrospective observational cohort study. SETTING The Japanese Diagnosis Procedure Combination database. PARTICIPANTS Patients aged 65 years and older who underwent cardiovascular surgery (excluding transcatheter surgeries, multiple surgeries per admission, and preoperative delirium) between April 1, 2015, and October 31, 2019. MEASUREMENTS AND MAIN RESULTS Patients who received midazolam (midazolam group) were compared with those who did not receive midazolam (no midazolam group). The primary outcome was the incidence of postoperative delirium. The secondary outcomes were the incidence of postoperative nausea and vomiting, mortality, and duration of intensive care unit stay and hospitalization. Propensity scores were estimated using logistic regression based on the covariates. The outcomes were compared using stabilized inverse probability of treatment-weighting analyses. Among the 16,185 patients analyzed, 10,633 (65.7%) received midazolam. No significant differences were observed in the incidences of postoperative delirium (odds ratio [OR] 0.95; 95% CI 0.87-1.03; p = 0.21) and hospital mortality (OR 0.92; 95% CI 0.76-1.11; p = 0.39) between the groups; however, the midazolam group had slightly longer durations of intensive care unit stay (3.5 [3.5-3.6] v 3.3 [3.3-3.4] days, p < 0.001) and hospitalization (31.5 [31.1-31.9] v 29.4 [28.8-29.9] days, p < 0.001), and slightly lower incidences of postoperative nausea and vomiting (OR 0.92; 95% CI 0.85-0.99; p = 0.03). The sensitivity analyses supported these results. CONCLUSIONS Intraoperative administration of midazolam may not induce postoperative delirium in patients undergoing cardiac surgery.
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Affiliation(s)
- Manabu Yoshimura
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan.
| | - Yoshiyuki Hidaka
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Yasuhiro Morimoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
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Cochran-Caggiano NC, Mann D, Aiello PJ. An Unusual Case of Delayed Midazolam Anaphylaxis and a Review of the Current Literature. J Pediatr Pharmacol Ther 2023; 28:658-661. [PMID: 38025146 PMCID: PMC10681077 DOI: 10.5863/1551-6776-28.7.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/20/2023] [Indexed: 12/01/2023]
Abstract
Midazolam is a commonly used, well-tolerated, anxiolytic, sedative, anesthesia induction agent, and an adjunct for procedural sedation that is used widely in the emergency department. The ability to administer midazolam via multiple routes, including intranasal, makes it a particularly common choice for use in children. Intranasal administration is safe, easy, and well tolerated and has been shown to be an effective method of obtaining anxiolysis and/or sedation. Adverse drug reactions, including allergic reactions, can occur with any medication. However, anaphylaxis is an uncommon phenomenon from midazolam. Despite being one of the most common medications used in the emergency department and operating room, there are only a handful of unequivocal cases of anaphylaxis secondary to midazolam. The rarity of this presentation may lead to delays in care and potential adverse outcomes as a result. We present one such case of a 10-year-old patient who experienced anaphylaxis after administration of intranasal midazolam to facilitate a computed tomography scan.
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Affiliation(s)
| | - Deborah Mann
- Upstate University Hospital, Department of Emergency Medicine, Syracuse, NY (NCC, DM)
| | - Peter J Aiello
- Division of Pediatric Emergency Medicine (PA), Department of Emergency Medicine, Upstate University Hospital, Syracuse, NY
- Department of Pharmacy (PA), Upstate University Hospital, Syracuse, NY
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22
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Zhang G, Xin L, Yin Q. Intranasal dexmedetomidine vs. oral midazolam for premedication in children: a systematic review and meta-analysis. Front Pediatr 2023; 11:1264081. [PMID: 38027288 PMCID: PMC10661234 DOI: 10.3389/fped.2023.1264081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To compare the effects of intranasal dexmedetomidine (Dex) and oral midazolam in the preoperative medication of children by using a method of meta-analysis. Methods Cochrane Library, Pubmed, Embase, and Web of Science were searched from inception to July 2023. Randomized controlled trials (RCTs) of intranasal Dex vs. oral midazolam in pediatric premedication were collected. Stata 15.0 statistical software was used to analyze the collected data. Relative risk (RR) and 95% confidence interval (CI) were used as effect sizes. Results A total of 11 studies with 824 children were included, containing 415 patients in the Dex group and 409 patients in the midazolam group. Compared with the oral midazolam group, the intranasal Dex group had a better preoperative sedation effect at parent-child separation (RR = 1.37, 95% CI: 1.14-1.64) and anesthesia induction (RR = 2.08, 95% CI: 1.03-4.22). In addition, there was no significant difference in the incidence of analgesia remedy (RR = 0.60, 95% CI: 0.36-1.00) the acceptance of anesthesia masks (RR = 0.97, 95% CI: 0.83-1.12), and incidence of adverse events between (RR = 0.25, 95% CI: 0.06-1.13, P = 0.072) between the intranasal Dex and oral midazolam groups. Conclusion Compared with oral midazolam, intranasal Dex has better sedative effects of parent-child separation and anesthesia induction in pediatric premedication, but there was no difference in the incidence of anesthesia remedy, anesthesia mask acceptance, and incidence of adverse events. Therefore, compared with oral midazolam, intranasal Dex is a better choice for premedication in children.
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Affiliation(s)
- Guangxuan Zhang
- Department of Anesthesiology, Hainan Branch, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Sanya, Hainan, China
| | - Li Xin
- Department of Pharmacy, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingtang Yin
- Department of Anesthesiology, Haimen District People’s Hospital, Nantong, China
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Sethi A, Rezk A, Couban R, Chowdhury T. Role of midazolam on cancer progression/survival - An updated systematic review. Indian J Anaesth 2023; 67:951-961. [PMID: 38213688 PMCID: PMC10779977 DOI: 10.4103/ija.ija_731_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 01/13/2024] Open
Abstract
Background and Aims Cancer is a leading cause of mortality worldwide. Despite advancements in cancer management, cancer progression remains a challenge, requiring the development of novel therapies. Midazolam is a commonly used adjunct to anaesthesia care for various surgeries, including cancer. Recently, there has been a growing interest in exploring the potential role of midazolam as an anticancer agent; however, the exact mechanism of this linkage is yet to be investigated thoroughly. Methods Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, this systematic review presented aggregated evidence (till November 2022) of the effects of midazolam on cancer progression and survival. All primary research article types where midazolam was administered in vivo or in vitro on subjects with cancers were included. No restrictions were applied on routes of administration or the type of cancer under investigation. Narrative synthesis depicted qualitative findings, whereas frequencies and percentages presented numerical data. Results Of 1720 citations, 19 studies were included in this review. All articles were preclinical studies conducted either in vitro (58%, 11/19) or both in vivo and in vitro (42%, 8/19). The most studied cancer was lung carcinoma (21%, 4/19). There are two main findings in this review. First, midazolam delays cancer progression (89%, 17/19). Second, midazolam reduces cancer cell survival (63%, 12/19). The two major mechanisms of these properties can be explained via inducing apoptosis (63%, 12/19) and inhibiting cancer cell proliferation (53%, 10/19). In addition, midazolam demonstrated antimetastatic properties via inhibition of cancer invasion (21%, 4/19), migration (26%, 5/19), or epithelial-mesenchymal transition (5%, 1/19). These anticancer properties of midazolam were demonstrated through different pathways when midazolam was used alone or in combination with traditional cancer chemotherapeutic agents. Conclusion This systematic review highlights that midazolam has the potential to impede cancer progression and decrease cancer cell survival. Extrapolation of these results into human cancer necessitates further investigation.
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Affiliation(s)
- Ansh Sethi
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Amal Rezk
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Rachel Couban
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tumul Chowdhury
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
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Bromfalk Å, Hultin M, Myrberg T, Engström Å, Walldén J. Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine. Paediatr Anaesth 2023; 33:962-972. [PMID: 37528645 DOI: 10.1111/pan.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2-6 years. METHODS In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured. RESULTS After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups. CONCLUSIONS No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2 -agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.
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Affiliation(s)
- Åsa Bromfalk
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderbyn), Umeå University, Umeå, Sweden
| | - Åsa Engström
- Division of Nursing and Medical Technology, Department of Health, Education and Technology, Lulea University of Technology, Luleå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sundsvall), Umeå University, Umeå, Sweden
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25
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Jason AS, Sundaram GA, J P, Kumar SP, Krishnan M. Comparison of the Efficacy of Midazolam and Dexmedetomidine As Sedative Agents in Third Molar Surgery. Cureus 2023; 15:e49477. [PMID: 38156170 PMCID: PMC10753092 DOI: 10.7759/cureus.49477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction Minor dental and oral surgical procedures have been made comfortable with the rise in the use of daycare sedatives. Of these sedatives, midazolam is deemed a common sedative used for minor oral surgical procedures. Newer and safer sedatives such as dexmedetomidine have certain properties that may prove more efficient in oral surgical procedures. Third molar surgery is one of the most common minor oral surgical procedures performed in dentistry. Thus, this study aims to compare the efficacy of midazolam and dexmedetomidine as sedative agents in third molar surgery. Materials and methods Sixty young adult patients free from other comorbidities were included in the study with ages ranging between 18 and 50 years. The samples were matched for the difficulty of impacted teeth and randomly distributed among the groups. Groups were administered the respective sedative drugs midazolam and dexmedetomidine and their effects were observed through the Observer's Assessment of Alertness/Sedation scale. The intraoperative vitals and sedation effects were checked every 15 minutes. Statistical analysis was done using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). Independent samples t-test and analysis of variance were the statistical tests employed to analyze the obtained data with p<0.05 considered as statistically significant. Results The depth of sedation has been both subjectively and objectively assessed and had no significant difference among the groups. The intra-operative heart rate assessment proved a more efficient reduction of pulse rate in the dexmedetomidine group as compared with the midazolam group. However, it was not statistically significant (p=0.121). The mean diastolic blood pressure showed a statistically significant difference between the groups with dexmedetomidine having lower blood diastolic pressure compared to midazolam (p=0.004). Quick arousal was witnessed in the dexmedetomidine group. Conclusion It can be concluded from the study that both dexmedetomidine and midazolam were equally effective as sedative agents for third molar surgery. However, the nature of cardio-protection, anti-sialagogue, and analgesic properties of dexmedetomidine can prove helpful, especially in minor oral surgical procedures like third molar surgery and it is recommended.
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Affiliation(s)
- Alden S Jason
- Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Gidean A Sundaram
- Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Preethi J
- Anesthesiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Santhosh P Kumar
- Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Murugesan Krishnan
- Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lee S, Park J, Kim NH, Hong H, Sohn KH, Kang HY, Kim MK, You AH. Remimazolam Anaphylaxis during Induction of General Anesthesia Confirmed by Provocation Test-A Case Report and Literature Review. Medicina (Kaunas) 2023; 59:1915. [PMID: 38003965 PMCID: PMC10673581 DOI: 10.3390/medicina59111915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/26/2023] [Accepted: 10/28/2023] [Indexed: 11/26/2023]
Abstract
Background: Remimazolam besylate, a newly developed drug, is linked to various anaphylaxis cases. We present a case of remimazolam anaphylaxis confirmed using a provocation test. Case: A 51-year-old female patient was scheduled for humeral pinning. General anesthesia was induced using remimazolam, rocuronium, and remifentanil. After tracheal intubation, the patient experienced decreased blood pressure, increased heart rate, and a systemic rash. Epinephrine was administered repeatedly, and the patient's vital signs stabilized. Acute phase tryptase levels were within normal limits. After four weeks, intradermal test results were negative. When remimazolam was administered intravenously for the provocation test, facial swelling, flushing, and coughing occurred, which improved with epinephrine. The culprit drug was identified as remimazolam using a provocation test. Conclusions: When anaphylaxis occurs during anesthesia induction, remimazolam should not be ruled out as the causative drug. If the skin test result for remimazolam is negative, a provocation test should be considered. The provocation test should be initiated cautiously at a low dose under careful patient monitoring.
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Affiliation(s)
- Sangho Lee
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
| | - Joyoung Park
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
| | - Na Hei Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
| | - Halin Hong
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
| | - Kyoung Hee Sohn
- Division of Pulmonary and Allergy, Department of Internal Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea
| | - Hee Yong Kang
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
| | - Mi Kyeong Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
| | - Ann Hee You
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.P.); (N.H.K.); (H.H.); (H.Y.K.); (M.K.K.)
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Liu S, Zheng Q, Bai F. Differences of Atomic-Level Interactions between Midazolam and Two CYP Isoforms 3A4 and 3A5. Molecules 2023; 28:6900. [PMID: 37836743 PMCID: PMC10574787 DOI: 10.3390/molecules28196900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
CYP 3A4 and CYP 3A5 are two important members of the human cytochrome P450 family. Although their overall structures are similar, the local structures of the active site are different, which directly leads to obvious individual differences in drug metabolic efficacy and toxicity. In this work, midazolam (MDZ) was selected as the probe substrate, and its interaction with two proteins, CYP 3A4 and CYP 3A5, was studied by molecular dynamics simulation (MD) along with the calculation of the binding free energy. The results show that two protein-substrate complexes have some similarities in enzyme-substrate binding; that is, in both complexes, Ser119 forms a high occupancy hydrogen bond with MDZ, which plays a key role in the stability of the interaction between MDZ and the enzymes. However, the complex formed by CYP 3A4 and MDZ is more stable, which may be attributed to the sandwich structure formed by the fluorophenyl group of the substrate with Leu216 and Leu482. Our study interprets the binding differences between two isoform-substrate complexes and reveals a structure-function relationship from the atomic perspective, which is expected to provide a theoretical basis for accurately measuring the effectiveness and toxicity of drugs for individuals in the era of precision medicine.
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Affiliation(s)
- Shuhui Liu
- Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun 130023, China;
- School and Hospital of Stomatology, Jilin University, Changchun 130023, China
| | - Qingchuan Zheng
- Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun 130023, China;
| | - Fuquan Bai
- Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun 130023, China;
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Lv LL, Zhang MM. Up-to-date literature review and issues of sedation during digestive endoscopy. Wideochir Inne Tech Maloinwazyjne 2023; 18:418-435. [PMID: 37868289 PMCID: PMC10585454 DOI: 10.5114/wiitm.2023.127854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/03/2023] [Indexed: 10/24/2023] Open
Abstract
Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.
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Affiliation(s)
- Lu-Lu Lv
- Department of Gastroenterology, Shengzhou People’s Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, Zhejiang Province, China
| | - Meng-Meng Zhang
- Hangzhou Shangcheng District People’s Hospital, Hangzhou, Zhejiang Province, China
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Yang L, Zhuang G, Zhang D, Liu W. Harlequin color change in a premature infant: A case report. Clin Case Rep 2023; 11:e7840. [PMID: 37636880 PMCID: PMC10448236 DOI: 10.1002/ccr3.7840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
Key Clinical Message This case of HCC report contributes to the knowledge of HCC in China. In this case, the longer duration of the color change observed in this case compared to previous reports, which will be useful for all medical practitioners. Abstract Harlequin color change (HCC) is a benign skin color change that lasts for a short time with no obvious physical abnormalities. Its pathogenesis is still unclear. It occurs in newborns, especially premature infants. However, few cases of HCC have been reported in China. Herein, we report a case of HCC. The infant was born at 34 + 4 weeks of gestation and was admitted to the hospital due to metabolic acidosis and neonatal pneumonia after birth. On the third day after birth, there were two red bands with obvious edges along the body centreline, and the erythema characteristics were consistent with those of HCC. The immature hypothalamus of newborns may cause the occurrence of HCC. At the same time, some drugs (midazolam), hypoxemia, and blood sampling may also be associated with HCC during neonatal hospitalization. All doctors should be thoroughly knowledgeable about the clinical characteristics of HCC and avoid using unnecessary drugs during treatment.
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Affiliation(s)
- Linzhi Yang
- Department of NeonatologyThe Maternal and Children Health Care Hospital (Huzhong Hospital) of HuaduGuangzhouChina
| | - Guiying Zhuang
- Department of NeonatologyThe Maternal and Children Health Care Hospital (Huzhong Hospital) of HuaduGuangzhouChina
| | - Dahu Zhang
- Department of NeonatologyThe Maternal and Children Health Care Hospital (Huzhong Hospital) of HuaduGuangzhouChina
| | - Weiqi Liu
- Department of Clinical LaboratoryThe Maternal and Children Health Care Hospital (Huzhong Hospital) of HuaduGuangzhouChina
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Stróżyk A, Paraskevas T, Romantsik O, Calevo MG, Banzi R, Ley D, Bruschettini M. Pharmacological pain and sedation interventions for the prevention of intraventricular hemorrhage in preterm infants on assisted ventilation - an overview of systematic reviews. Cochrane Database Syst Rev 2023; 8:CD012706. [PMID: 37565681 PMCID: PMC10421735 DOI: 10.1002/14651858.cd012706.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH) may contribute to neonatal morbidity and mortality and result in long-term neurodevelopmental sequelae. Appropriate pain and sedation management in ventilated preterm infants may decrease the risk of GMH-IVH; however, it might be associated with harms. OBJECTIVES To summarize the evidence from systematic reviews regarding the effects and safety of pharmacological interventions related to pain and sedation management in order to prevent GMH-IVH in ventilated preterm infants. METHODS We searched the Cochrane Library August 2022 for reviews on pharmacological interventions for pain and sedation management to prevent GMH-IVH in ventilated preterm infants (< 37 weeks' gestation). We included Cochrane Reviews assessing the following interventions administered within the first week of life: benzodiazepines, paracetamol, opioids, ibuprofen, anesthetics, barbiturates, and antiadrenergics. Primary outcomes were any GMH-IVH (aGMH-IVH), severe IVH (sIVH), all-cause neonatal death (ACND), and major neurodevelopmental disability (MND). We assessed the methodological quality of included reviews using the AMSTAR-2 tool. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included seven Cochrane Reviews and one Cochrane Review protocol. The reviews on clonidine and paracetamol did not include randomized controlled trials (RCTs) matching our inclusion criteria. We included 40 RCTs (3791 infants) from reviews on paracetamol for patent ductus arteriosus (3), midazolam (3), phenobarbital (9), opioids (20), and ibuprofen (5). The quality of the included reviews was high. The certainty of the evidence was moderate to very low, because of serious imprecision and study limitations. Germinal matrix hemorrhage-intraventricular hemorrhage (any grade) Compared to placebo or no intervention, the evidence is very uncertain about the effects of paracetamol on aGMH-IVH (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.38 to 2.07; 2 RCTs, 82 infants; very low-certainty evidence); midazolam may result in little to no difference in the incidence of aGMH-IVH (RR 1.68, 95% CI 0.87 to 3.24; 3 RCTs, 122 infants; low-certainty evidence); the evidence is very uncertain about the effect of phenobarbital on aGMH-IVH (RR 0.99, 95% CI 0.83 to 1.19; 9 RCTs, 732 infants; very low-certainty evidence); opioids may result in little to no difference in aGMH-IVH (RR 0.85, 95% CI 0.65 to 1.12; 7 RCTs, 469 infants; low-certainty evidence); ibuprofen likely results in little to no difference in aGMH-IVH (RR 0.99, 95% CI 0.81 to 1.21; 4 RCTs, 759 infants; moderate-certainty evidence). Compared to ibuprofen, the evidence is very uncertain about the effects of paracetamol on aGMH-IVH (RR 1.17, 95% CI 0.31 to 4.34; 1 RCT, 30 infants; very low-certainty evidence). Compared to midazolam, morphine may result in a reduction in aGMH-IVH (RR 0.28, 95% CI 0.09 to 0.87; 1 RCT, 46 infants; low-certainty evidence). Compared to diamorphine, the evidence is very uncertain about the effect of morphine on aGMH-IVH (RR 0.65, 95% CI 0.40 to 1.07; 1 RCT, 88 infants; very low-certainty evidence). Severe intraventricular hemorrhage (grade 3 to 4) Compared to placebo or no intervention, the evidence is very uncertain about the effect of paracetamol on sIVH (RR 1.80, 95% CI 0.43 to 7.49; 2 RCTs, 82 infants; very low-certainty evidence) and of phenobarbital (grade 3 to 4) (RR 0.91, 95% CI 0.66 to 1.25; 9 RCTs, 732 infants; very low-certainty evidence); opioids may result in little to no difference in sIVH (grade 3 to 4) (RR 0.98, 95% CI 0.71 to 1.34; 6 RCTs, 1299 infants; low-certainty evidence); ibuprofen may result in little to no difference in sIVH (grade 3 to 4) (RR 0.82, 95% CI 0.54 to 1.26; 4 RCTs, 747 infants; low-certainty evidence). No studies on midazolam reported this outcome. Compared to ibuprofen, the evidence is very uncertain about the effects of paracetamol on sIVH (RR 2.65, 95% CI 0.12 to 60.21; 1 RCT, 30 infants; very low-certainty evidence). Compared to midazolam, the evidence is very uncertain about the effect of morphine on sIVH (grade 3 to 4) (RR 0.08, 95% CI 0.00 to 1.43; 1 RCT, 46 infants; very low-certainty evidence). Compared to fentanyl, the evidence is very uncertain about the effect of morphine on sIVH (grade 3 to 4) (RR 0.59, 95% CI 0.18 to 1.95; 1 RCT, 163 infants; very low-certainty evidence). All-cause neonatal death Compared to placebo or no intervention, the evidence is very uncertain about the effect of phenobarbital on ACND (RR 0.94, 95% CI 0.51 to 1.72; 3 RCTs, 203 infants; very low-certainty evidence); opioids likely result in little to no difference in ACND (RR 1.12, 95% CI 0.80 to 1.55; 5 RCTs, 1189 infants; moderate-certainty evidence); the evidence is very uncertain about the effect of ibuprofen on ACND (RR 1.00, 95% CI 0.38 to 2.64; 2 RCTs, 112 infants; very low-certainty evidence). Compared to midazolam, the evidence is very uncertain about the effect of morphine on ACND (RR 0.31, 95% CI 0.01 to 7.16; 1 RCT, 46 infants; very low-certainty evidence). Compared to diamorphine, the evidence is very uncertain about the effect of morphine on ACND (RR 1.17, 95% CI 0.43 to 3.19; 1 RCT, 88 infants; very low-certainty evidence). Major neurodevelopmental disability Compared to placebo, the evidence is very uncertain about the effect of opioids on MND at 18 to 24 months (RR 2.00, 95% CI 0.39 to 10.29; 1 RCT, 78 infants; very low-certainty evidence) and at five to six years (RR 1.6, 95% CI 0.56 to 4.56; 1 RCT, 95 infants; very low-certainty evidence). No studies on other drugs reported this outcome. AUTHORS' CONCLUSIONS None of the reported studies had an impact on aGMH-IVH, sIVH, ACND, or MND. The certainty of the evidence ranged from moderate to very low. Large RCTs of rigorous methodology are needed to achieve an optimal information size to assess the effects of pharmacological interventions for pain and sedation management for the prevention of GMH-IVH and mortality in preterm infants. Studies might compare interventions against either placebo or other drugs. Reporting of the outcome data should include the assessment of GMH-IVH and long-term neurodevelopment.
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Affiliation(s)
- Agata Stróżyk
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Olga Romantsik
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Directorate, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Rita Banzi
- Center for Health Regulatory Policies, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - David Ley
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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Chen Y, Lu Y, Xiang X, Fu L, Liu Y, Li C, Sun J. Efficacy and safety analysis of midazolam combined with dezocine sedation and analgesia colonoscopy in patients with inflammatory bowel disease: a prospective single-center open study. Front Pharmacol 2023; 14:1150045. [PMID: 37492093 PMCID: PMC10364117 DOI: 10.3389/fphar.2023.1150045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/03/2023] [Indexed: 07/27/2023] Open
Abstract
Objective: Colonoscopy plays an important role in the diagnosis, prognosis prediction, assessment of disease activity and severity, and treatment of inflammatory bowel disease (IBD)-related complications. However, some patients refuse to undergo colonoscopy due to perceived pain and other discomfort, their diagnosis and treatment are affected. Therefore, we conducted a prospective study to explore the efficacy and safety of midazolam combined with dezocine for sedation in IBD patients undergoing colonoscopy. Methods: 224 patients were divided into sedative-colonoscopy-group (SCG, n = 93), anesthesia-colonoscopy-group (ACG, n = 90) and ordinary-colonoscopy-group (OCG, n = 41). The vital signs (blood pressure, pulse, respiration and blood oxygen saturation), pain degree during colonoscopy, satisfaction and complication rates of the three groups were compared. Results: Before colonoscopy, there was no significant difference among the vital signs of the three groups. The vital signs of the ACG were significantly lower than those of the SEG and the OCG (p < 0.05), and the difference was not significant between the SCG and OCG during colonoscopy. The colonoscopy pain score in the SCG was lower than that in the OCG (0.79 ± 1.09 vs. 2.98 ± 1.27, p < 0.001). The satisfaction score of the SCG (9.26 ± 1.16) was not significantly different from that of the ACG (9.42 ± 1.41) but was higher than that of the OCG (6.63 ± 1.13) (p < 0.001). The total complication rate of the ACG was 45.56% (41/90), which was significantly higher than that of the SCG [20.43% (19/93)] and the OCG [19.51% (8/41)]. Colon perforation, abnormal blood pressure fluctuation and hypoxemia were significantly more common in the ACG than in the SCG and the OCG (p < 0.05). However, there was no significant difference in the incidence of complications between the SCG and OCG. Conclusion: Compared with ordinary-colonoscopy, colonoscopy performed under midazolam and dezocine sedation is more comfortable for patients, thereby increasing satisfaction and compliance. Colonoscopy that is performed under midazolam and dezocine is similar to colonoscopy that is anesthesia with propofol in terms of comfort, satisfaction and compliance and similar to ordinary-colonoscopy in terms of safety. Considering the shortage of anesthesiologists, the application of midazolam combined with dezocine for digestive endoscopy is worthy of clinical promotion.
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Affiliation(s)
- Yongpeng Chen
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Lu
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xueyuan Xiang
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liping Fu
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanan Liu
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chujun Li
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiachen Sun
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Farlie KH, Austin TM, Gonzalez SN, Edwards CM, Gravenstein N, Dooley FC. The Effect of Computer Tablets on the Need for Medical Anxiolysis in Children in an Ambulatory Surgical Center. Cureus 2023; 15:e42553. [PMID: 37637603 PMCID: PMC10460165 DOI: 10.7759/cureus.42553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Background Preoperative anxiety is common in children undergoing surgery. When anxiety is identified or suspected, there are several strategies typically used to manage it. Perhaps the most common is anxiolytic premedication or parental presence at induction. Medications such as midazolam have been associated with adverse effects, such as a slower wakeup, and require timing of administration, while parental presence can be disturbing to the parent and divert the attention of the operating room team. A more recent option is distraction via electronic tablets. The purpose of this study was to retrospectively investigate and quantify any change in the use of midazolam, the most common anxiolytic approach at our institution, and any change in the length of time in the post-anesthesia care unit (PACU) following the introduction of tablet computers to a pediatric ambulatory surgical center. Methods We conducted an IRB-approved retrospective chart review of 13,790 pediatric patients ages one to 18 undergoing outpatient elective surgeries at the University of Florida (UF) Children's Surgical Center over a five-year period. A univariate analysis was conducted using the Fisher's Exact test and interrupted time series analysis to determine differences between midazolam administration and PACU times, with interruption occurring at tablet implementation. A multivariable analysis and sensitivity analyses were performed to confirm the findings of the univariate analysis. Results On univariate analysis, tablet availability was associated with both a decreased preoperative oral midazolam administration (odds ratio (OR) 0.158, 95% confidence interval (CI): 0.140 to 0.179, P-value <0.001) and a decreased PACU length of stay (-17.4 min, 95% CI: -19.6 to -15.3 min, P-value <0.001). The association with decreased preoperative midazolam administration held after multivariable analysis (adjusted OR 0.207, 95% CI: 0.154 to 0.278, P-value <0.001), but PACU length of stay was not statistically significant (-9.1 min, 95% CI: -20.6 to 2.4, P-value = 0.12). These results were confirmed on sensitivity analysis, with tablet availability continuing to be associated with decreased preoperative oral midazolam administration but not with reduced PACU length of stay. Conclusion Our results demonstrate that computer tablets were associated with a significant decrease in the frequency of midazolam administration and consequently may reduce preoperative pediatric anxiety. We did not find an associated change in PACU length of stay following the introduction of tablets. Tablets present a unique distraction alternative to chemical anxiolysis for institutions seeking to reduce medication use in pediatric patients.
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Affiliation(s)
- Kerry H Farlie
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Thomas M Austin
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Sandra N Gonzalez
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | | | | | - Fred C Dooley
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
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Janiani P, Gurunathan D, Manohar R. Assessment of Pain During Pediatric Dental Treatment Using Different Sedative Agents: A Crossover Trial. Cureus 2023; 15:e41676. [PMID: 37575859 PMCID: PMC10413166 DOI: 10.7759/cureus.41676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Background Behavioral management techniques are employed for children who are fearful and uncooperative. Pharmacologic sedation and anesthesia are frequently utilized to manage pain and anxiety in pediatric dental patients. Aim To evaluate the intraoperative and postoperative pain levels during dental treatment of children sedated with 1.5 μg/kg intranasal dexmedetomidine, 0.3 mg/kg intranasal midazolam, and nitrous oxide. Materials and methods In this crossover study, 24 children between the ages of five and seven years were randomly assigned to receive intranasal atomized dexmedetomidine, intranasal atomized midazolam, and inhaled nitrous oxide during three different visits. At each visit, a single pulp therapy procedure was conducted after administering the respective sedative agent, and the pain levels were documented. There was a one-week interval between each visit to allow for a washout period. The data were analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp, Armonk, NY, United States) using the Wilcoxon signed-rank test and Kruskal-Wallis H test (p < 0.05). Results All three sedative agents were equally effective in controlling postoperative and intraoperative pain. Although there was no statistically significant difference among the groups, clinically, midazolam showed lower intraoperative pain levels (mean 1.78 ± 1.42). Conclusion In pediatric dental patients, intranasal midazolam at a dosage of 0.3 mg/kg and intranasal dexmedetomidine at a dosage of 1.5 μg/kg demonstrate comparable effectiveness to nitrous oxide sedation in pain management. These options serve as effective alternatives for anxious children who may not tolerate nitrous oxide sedation.
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Affiliation(s)
- Palak Janiani
- Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Deepa Gurunathan
- Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Ramsesh Manohar
- Department of Anaesthesiology, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
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Wang L, Yang H, Le X. Comparison of dexmedetomidine with midazolam for third molar surgery: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2023; 102:e33155. [PMID: 37352026 PMCID: PMC10289754 DOI: 10.1097/md.0000000000033155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 06/25/2023] Open
Abstract
INTRODUCTION The analgesic sedation of dexmedetomidine compared with midazolam for third molar surgery remains controversial. We conduct a systematic review and meta-analysis to explore the influence of dexmedetomidine versus midazolam for third molar surgery. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through December 2022 for randomized controlled trials assessing the effect of dexmedetomidine versus midazolam for third molar surgery. This meta-analysis was performed using the random-effect model. RESULTS Four randomized controlled trials were included in the meta-analysis. Overall, compared with midazolam for third molar surgery, dexmedetomidine administration leads to comparable oxygen saturation (standard mean difference [SMD] = 0.25; 95% confidence interval [CI] = -0.24 to 0.74; P = .31), heart rate (SMD = -0.37; 95% CI = -1.18 to 0.44; P = .37), SBP (SMD = -0.24; 95% CI = -0.57 to 0.09; P = .16), DBP (SMD = -0.26; 95% CI = -0.60 to 0.07; P = .12), as well as nausea and vomiting (OR = 0.58; 95% CI = 0.05-6.61; P = .66). CONCLUSIONS Dexmedetomidine may obtain the comparable sedation efficacy with midazolam for third molar surgery.
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Affiliation(s)
- Ling Wang
- Department of Stomatology, The First People’s Hospital of Chongqing Liangjiang New Areas, Chongqing, China
| | - Hongmei Yang
- Department of Stomatology, The First People’s Hospital of Chongqing Liangjiang New Areas, Chongqing, China
| | - Xi Le
- Department of Stomatology, The First People’s Hospital of Chongqing Liangjiang New Areas, Chongqing, China
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Michihara A, Hanada M, Nagatsuka Handa Y, Mizoguchi T, Ohchi Y, Sato Y. Change of dexmedetomidine and midazolam concentrations by simultaneous injection in an in vitro extracorporeal circuit. Perfusion 2023:2676591231184715. [PMID: 37325845 DOI: 10.1177/02676591231184715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE Patient sedation and analgesia are vital for safety and comfort during extracorporeal membrane oxygenation (ECMO). However, adsorption by the circuit may alter drug pharmaco-kinetics and remains poorly characterized. This study is the first to examine the concentrations of DEX and MDZ in the presence of drug-drug interactions using an in vitro extracorporeal circuit system that incorporates a polymer-coated polyvinyl chloride tube, but not a membrane oxygenator. METHODS AND RESULTS Nine in vitro extracorporeal circuits were prepared using polymer-coated PVC tubing. Once the circuits were primed and running, either a single drug or two drugs were injected as boluses into the circuit with three circuits per drug. Drug samples were drawn following injection at 2, 5, 15, 30, 60, and 120 min and at 4, 12, and 24 h. They were then analyzed using high-performance liquid chromatography with mass spectrometry. When compared with an injection of DEX alone, the combination of DEX and MDZ is highly changed, with DEX and MDZ affecting the availability of free drugs in the circuit. CONCLUSIONS The change of DEX and MDZ concentrations was confirmed by a combination of both drugs as compared with either single-infusion DEX or MDZ in an in vitro extracorporeal circuit. Drug-drug interactions developed between DEX and MDZ through albumin in an extracorporeal circuit; as a result, the unbounded drugs might change in the circuit.
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Affiliation(s)
- Ayana Michihara
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Miyu Hanada
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Yuka Nagatsuka Handa
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Takayuki Mizoguchi
- Department of Clinical Engineering, Oita University Hospital, Yufu-shi, Japan
| | - Yoshifumi Ohchi
- Department of Intensive Care Unit, Oita University Hospital, Yufu-shi, Japan
| | - Yuhki Sato
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
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Boudin C, Eysseric-Guérin H, Paysant F, Revet M, Stanke-Labesque F, Scolan V, Willeman T. Suicide with oral midazolam: post-mortem toxicological investigations using Ostro® plate and UPLC-MS/MS. J Anal Toxicol 2023:7193760. [PMID: 37300548 DOI: 10.1093/jat/bkad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/12/2023] Open
Abstract
A middle-aged woman was found dead with multiple empty blisters of midazolam (DORMICUM®), equivalent to 450mg, near her body. The autopsy revealed that the cause of death was secondary to an asphyxia syndrome. Standard toxicological procedures identified midazolam only in blood, urine and gastric content. A quantitative analytical method for midazolam (MDZ) and 1-hydroxy-midazolam (1-OH-MDZ) was validated using protein precipitation, a phospholipid removal Ostro® plates and liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). MDZ and 1-OH-MDZ were quantified in peripheral blood at 910 ng/mL and 534 ng/mL, respectively, and superior to 2000 ng/mL in urine. Reported to the body weight, the dose, which was lethal, was estimated to 6.7 mg/kg. The usual dose used in intensive care unit is 0.03-0.3 mg/kg. MDZ intoxication outside of hospital are rare given the restricted availably of this drug in France. Nevertheless, MDZ under oral form remains available in several countries. Toxic MDZ blood concentrations are described after intravenous administration for anesthesia and are not suited for oral intoxication. Based on the autopsy findings, police investigation and toxicology results, the cause of death was determined to be a self-inflicted oral MDZ acute intoxication, which is the first to be documented to the best of our knowledge. This fatal intoxication provides analytical data that could support subsequent toxicological result interpretation in similar forensic cases.
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Affiliation(s)
- Coralie Boudin
- Forensic Laboratory, University Grenoble Alpes, Grenoble, France
| | - Hélène Eysseric-Guérin
- Forensic Laboratory, University Grenoble Alpes, Grenoble, France
- Laboratory of Pharmacology, Pharmacogenetics and Toxicology, Grenoble University Hospital, Grenoble, France
| | - François Paysant
- Clinical Forensic Medicine Department, Grenoble University Hospital, Grenoble, France
| | - Melissa Revet
- Clinical Forensic Medicine Department, Grenoble University Hospital, Grenoble, France
| | - Françoise Stanke-Labesque
- Laboratory of Pharmacology, Pharmacogenetics and Toxicology, Grenoble University Hospital, Grenoble, France
- Grenoble Alpes University, HP2 Inserm U1300 Laboratory, Grenoble, France
| | - Virginie Scolan
- Clinical Forensic Medicine Department, Grenoble University Hospital, Grenoble, France
| | - Théo Willeman
- Laboratory of Pharmacology, Pharmacogenetics and Toxicology, Grenoble University Hospital, Grenoble, France
- Clinical Forensic Medicine Department, Grenoble University Hospital, Grenoble, France
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Park JI, Kang C, Jeong W, Soo Park J, You Y, Joon Ahn H, Cho Y, Young Jeon S, Hong Min J, Nam In Y. Time-course relationship between cerebrospinal fluid and serum concentrations of midazolam and albumin in patients with cardiac arrest undergoing targeted temperature management. Resuscitation 2023:109867. [PMID: 37302686 DOI: 10.1016/j.resuscitation.2023.109867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
AIM To understand the serum and cerebrospinal fluid (CSF) distribution of midazolam is important for proper timing of neurological prognostication of targeted temperature management(TTM) patients. Midazolam binds extensively to albumin in serum although non protein bound form exist in CSF. We investigated the time-course of CSF, serum concentrations of midazolam and albumin in patients with cardiac arrest who underwent TTM. METHODS This prospective, single-center, observational study was conducted between May 2020 and April 2022. Midazolam and albumin concentrations in CSF and serum were quantified 0, 24, 48, and 72 h after the return of spontaneous circulation for comparison between the good (Cerebral Performance Category (CPC) 1 and 2) and poor (CPC 3, 4, and 5) neurologic outcome groups. The CSF/serum (C/S) ratios of midazolam and albumin concentrations were determined, along with their correlation coefficients. RESULTS Of the 19 enrolled patients, 13 experienced poor outcomes. At 0 h, serum midazolam concentrations were the lowest, whereas serum albumin levels were the highest; in the CSF, the concentrations of both peaked at 24 h. There were no significant inter-group differences in midazolam concentrations in CSF or serum. The C/S ratios of midazolam and albumin significantly differed between the groups. Moderate to strong positive correlations were observed between the midazolam and albumin C/S ratios. CONCLUSION In CSF, midazolam and albumin concentrations peaked 24 h post-cardiac arrest. Midazolam and albumin C/S ratios were significantly higher in the poor outcome group and positively correlated with each other, suggesting blood-brain barrier disruption 24 h post-cardiac arrest.
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Affiliation(s)
- Jong-Il Park
- Department of Biochemistry, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yongchul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - So Young Jeon
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7- ro, Sejong, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7- ro, Sejong, Republic of Korea
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Zhang X, Han Z, Li Z, Wang T. Midazolam impedes lung carcinoma cell proliferation and migration via EGFR/MEK/ERK signaling pathway. Open Med (Wars) 2023; 18:20230730. [PMID: 37305523 PMCID: PMC10251164 DOI: 10.1515/med-2023-0730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/14/2023] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Non-small-cell lung cancer (NSCLC) is a dominating type of lung cancer with high morbidity and mortality. Midazolam has been reported to promote cell apoptosis in NSCLC, but the molecular mechanism of midazolam remains to be further explored. In the current work, cell viability, proliferation, migration, and apoptosis rates of NSCLC cells treated with midazolam were measured using cell counting kit-8 assay, 5-ethynyl-2'-deoxyuridine (EdU) and colony formation assays, transwell, and flow cytometry assay, respectively, to evaluate the malignant behaviors. Western blot was applied to access EGFR/MEK/ERK pathway-related protein levels. The results demonstrated midazolam significantly declined the viability of NSCLC cells. Furthermore, midazolam restrained cell proliferation and migration and contributed to cell apoptosis in NSCLC. Midazolam exerted suppressive function to EGFR pathway during NSCLC development. Moreover, the activation of EGFR/MEK/ERK pathway abrogated the effects of midazolam on NSCLC cell proliferation, apoptosis, and migration. Taken together, midazolam exhibited anti-tumor effects hallmarked by EGFR pathway inhibition, providing a novel insight into the treatment of NSCLC.
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Affiliation(s)
- Xiangchao Zhang
- Department of Anesthesiology, Shengyang Chest Hospital, Shenyang City, Liaoning 110044, China
| | - Zhe Han
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang City, Liaoning 110015, China
| | - Zhengjun Li
- Department of Thoracic Surgery, Shengyang Chest Hospital, Shenyang City, Liaoning 110044, China
| | - Tao Wang
- Department of Anesthesiology, Shengyang Chest Hospital, No. 11 Beihai Street, Dadong District, Shenyang City, Liaoning 110044, China
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Barends C, den Daas I, Driesens M, Visser A, Absalom A, Colin P. Development of a pharmacokinetic and pharmacodynamic model for intranasal administration of midazolam in older adults: a single-site two-period crossover study. Br J Anaesth 2023:S0007-0912(23)00228-3. [PMID: 37268446 DOI: 10.1016/j.bja.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/09/2023] [Accepted: 04/17/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Intranasal midazolam can produce procedural sedation in frail older patients with dementia who are unable to tolerate necessary medical or dental procedures during domiciliary medical care. Little is known about the pharmacokinetics and pharmacodynamics of intranasal midazolam in older (>65 yr old) people. The aim of this study was to understand the pharmacokinetic/pharmacodynamic properties of intranasal midazolam in older people with the primary goal of developing a pharmacokinetic/pharmacodynamic model to facilitate safer domiciliary sedation care. METHODS We recruited 12 volunteers: ASA physical status 1-2, aged 65-80 yr, and received midazolam 5 mg intravenously and 5 mg intranasally on two study days separated by a 6 day washout period. Concentrations of venous midazolam and 1'-OH-midazolam, Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score, bispectral index (BIS), arterial pressure, ECG, and respiratory parameters were measured for 10 h. RESULTS Time to peak effect of intranasal midazolam for BIS, MAP, and SpO2 were 31.9 (6.2), 41.0 (7.6), and 23.1 (3.0) min, respectively. Intranasal bioavailability was lower compared with intravenous administration (Fabs 95%; 95% confidence interval: 89-100%). A three-compartment model best described midazolam pharmacokinetics following intranasal administration. A separate effect compartment linked to the dose compartment best described an observed time-varying drug-effect difference between intranasal and intravenous midazolam, suggesting direct nose-to-brain transport. CONCLUSIONS Intranasal bioavailability was high and sedation onset was rapid, with maximum sedative effects after 32 min. We developed a pharmacokinetic/pharmacodynamic model for intranasal midazolam for older persons and an online tool to simulate changes in MOAA/S, BIS, MAP, and SpO2 after single and additional intranasal boluses. CLINICAL TRIAL REGISTRATION EudraCT (2019-004806-90).
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Affiliation(s)
- Clemens Barends
- Department of Anaesthesiology, University Medical Center Groningen, Groningen, The Netherlands.
| | | | - Mendy Driesens
- Department of Anaesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Anita Visser
- Department of Gerodontology, Center for Dentistry and Oral Hygiene, University Medical Center Groningen, Groningen, The Netherlands; Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, Groningen, The Netherlands; Department of Gerodontology, College of Dental Sciences, Radboud University, Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Anthony Absalom
- Department of Anaesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Pieter Colin
- Department of Anaesthesiology, University Medical Center Groningen, Groningen, The Netherlands
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Paparoupa M, Fischer M, Pinnschmidt HO, Grensemann J, Roedl K, Kluge S, Jarczak D. Impact of COVID-19 on Sedation Requirements during Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:jcm12103515. [PMID: 37240620 DOI: 10.3390/jcm12103515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
COVID-19-associated ARDS (C-ARDS) is mentioned to express higher analgosedation needs, in comparison to ARDS of other etiologies. The objective of this monocentric retrospective cohort study was to compare the analgosedation needs between C-ARDS and non-COVID-19 ARDS (non-C-ARDS) on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Data were collected from the electronic medical records of all adult patients treated with C-ARDS in our Department of Intensive Care Medicine between March 2020 and April 2022. The control group included patients treated with non-C-ARDS between the years 2009 and 2020. A sedation sum score was created in order to describe the overall analgosedation needs. A total of 115 (31.5%) patients with C-ARDS and 250 (68.5%) with non-C-ARDS requiring VV-ECMO therapy were included in the study. The sedation sum score was significantly higher in the C-ARDS group (p < 0.001). COVID-19 was significantly associated with analgosedation in the univariable analysis. By contrast, the multivariable model did not show a significant association between COVID-19 and the sum score. The year of VV-ECMO support, BMI, SAPS II and prone positioning were significantly associated with sedation needs. The potential impact of COVID-19 remains unclear, and further studies are warranted in order to evaluate specific disease characteristics linked with analgesia and sedation.
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Affiliation(s)
- Maria Paparoupa
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Okur S, Yanmaz LE, Golgeli A, Senocak MG, Ersoz U, Orhun OT, Gumurcinler B. Sedative and cardiopulmonary effects of intranasal butorphanol with midazolam or dexmedetomidine in New Zealand white rabbits. Vet Rec 2023:e2999. [PMID: 37183183 DOI: 10.1002/vetr.2999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND This study aimed to compare the sedative and cardiopulmonary effects of intranasal (IN) administration of dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations in New Zealand white rabbits. METHODS Eight New Zealand white rabbits were sedated by IN administration of a combination of 0.1 mg/kg dexmedetomidine and 0.4 mg/kg butorphanol (DB treatment) and 2 mg/kg midazolam and 0.4 mg/kg butorphanol (MB treatment). The electrocardiogram, pulse rate (PR), respiratory frequency (fR ), arterial haemoglobin oxygen saturation (SpO2 ), fraction of expired carbon dioxide (EtCO2 ), rectal temperature (RT), noninvasive mean arterial pressure (MAP), noninvasive systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) were recorded. The onset of sedation, duration of sedation and sedation score (SS) were also noted. RESULTS There were no significant differences in the EtCO2 , RT, MAP, SAP and DAP measurements between treatments. The PR significantly decreased in DB compared with MB over time (p = 0.001). Compared with baseline, SpO2 decreased over time in both treatments. The SS was significantly elevated over time in DB compared with MB (p = 0.002). LIMITATIONS No pharmacokinetic information was available for either treatment, so the findings should be interpreted cautiously. CONCLUSIONS IN DB provides more effective sedation than MB, but cardiopulmonary impairment was observed in both treatments.
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Affiliation(s)
- Sitkican Okur
- Department of Surgery, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Latif Emrah Yanmaz
- Department of Surgery, Faculty of Veterinary Medicine, Burdur Mehmet Akif Ersoy University, Burdur, Turkey
| | - Ayse Golgeli
- Department of Surgery, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Mumin Gokhan Senocak
- Department of Surgery, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Ugur Ersoz
- Department of Surgery, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Omer Tarik Orhun
- Department of Surgery, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Burak Gumurcinler
- Department of Surgery, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
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Niquet J, Nguyen D, de Araujo Furtado M, Lumley L. Treatment of cholinergic-induced status epilepticus with polytherapy targeting GABA and glutamate receptors. Epilepsia Open 2023; 8 Suppl 1:S117-S140. [PMID: 36807554 PMCID: PMC10173853 DOI: 10.1002/epi4.12713] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/15/2023] [Indexed: 02/23/2023] Open
Abstract
Despite new antiseizure medications, the development of cholinergic-induced refractory status epilepticus (RSE) continues to be a therapeutic challenge as pharmacoresistance to benzodiazepines and other antiseizure medications quickly develops. Studies conducted by Epilepsia. 2005;46:142 demonstrated that the initiation and maintenance of cholinergic-induced RSE are associated with trafficking and inactivation of gamma-aminobutyric acid A receptors (GABAA R) thought to contribute to the development of benzodiazepine pharmacoresistance. In addition, Dr. Wasterlain's laboratory reported that increased N-methyl-d-aspartate receptors (NMDAR) and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPAR) contribute to enhanced glutamatergic excitation (Neurobiol Dis. 2013;54:225; Epilepsia. 2013;54:78). Thus, Dr. Wasterlain postulated that targeting both maladaptive responses of reduced inhibition and increased excitation that is associated with cholinergic-induced RSE should improve therapeutic outcome. We currently review studies in several animal models of cholinergic-induced RSE that demonstrate that benzodiazepine monotherapy has reduced efficacy when treatment is delayed and that polytherapy with drugs that include a benzodiazepine (eg midazolam and diazepam) to counter loss of inhibition, concurrent with an NMDA antagonist (eg ketamine) to reduce excitation provide improved efficacy. Improved efficacy with polytherapy against cholinergic-induced seizure is demonstrated by reduction in (1) seizure severity, (2) epileptogenesis, and (3) neurodegeneration compared with monotherapy. Animal models reviewed include pilocarpine-induced seizure in rats, organophosphorus nerve agent (OPNA)-induced seizure in rats, and OPNA-induced seizure in two mouse models: (1) carboxylesterase knockout (Es1-/- ) mice which, similarly to humans, lack plasma carboxylesterase and (2) human acetylcholinesterase knock-in carboxylesterase knockout (KIKO) mice. We also review studies showing that supplementing midazolam and ketamine with a third antiseizure medication (valproate or phenobarbital) that targets a nonbenzodiazepine site rapidly terminates RSE and provides further protection against cholinergic-induced SE. Finally, we review studies on the benefits of simultaneous compared with sequential drug treatments and the clinical implications that lead us to predict improved efficacy of early combination drug therapies. The data generated from seminal rodent studies of efficacious treatment of cholinergic-induced RSE conducted under Dr. Wasterlain's guidance suggest that future clinical trials should treat the inadequate inhibition and temper the excess excitation that characterize RSE and that early combination therapies may provide improved outcome over benzodiazepine monotherapy.
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Affiliation(s)
- Jerome Niquet
- Department of NeurologyDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- Epilepsy Research LaboratoryVeterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Donna Nguyen
- Neuroscience DepartmentU.S. Army Medical Research Institute of Chemical Defense (USAMRICD)Aberdeen Proving GroundMarylandUSA
| | | | - Lucille Lumley
- Neuroscience DepartmentU.S. Army Medical Research Institute of Chemical Defense (USAMRICD)Aberdeen Proving GroundMarylandUSA
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DeLeon AM, Lu S, Gaston I, Samworth AG, Lopez C, Farrer J. Midazolam for the Successful Treatment of Refractory Spinal-Anesthesia-Associated Hypothermia After Cesarean Delivery. Cureus 2023; 15:e39492. [PMID: 37250603 PMCID: PMC10212551 DOI: 10.7759/cureus.39492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 05/31/2023] Open
Abstract
Cesarean deliveries receiving spinal anesthesia with intrathecal morphine are associated with post-operative hypothermia. Lorazepam has been proposed as a reversal agent for treating intrathecal morphine-associated post-cesarean hypothermia. Midazolam is a benzodiazepine familiar to most anesthesia providers and is frequently administered in the perioperative period. We present a post-cesarean delivery spinal anesthesia-associated hypothermia patient successfully treated with intravenous midazolam.
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Affiliation(s)
| | - Samantha Lu
- Obstetric Anesthesia, Northwestern Memorial Hospital, Chicago, USA
| | - Ian Gaston
- Obstetric Anesthesia, Northwestern Memorial Hospital, Chicago, USA
| | - Alexander G Samworth
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Carmen Lopez
- Obstetric Anesthesia, Northwestern Memorial Hospital, Chicago, USA
| | - Jason Farrer
- Anesthesiology, Northwestern Memorial Hospital, Chicago, USA
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Joshi SP, Thomas M, Yoganathan S, Danda S, Chandran M, Jasper A. Clinico-Etiological Spectrum and Functional Outcomes of Children with Pre-Status Dystonicus and Status Dystonicus (SD): A Descriptive Study. Ann Indian Acad Neurol 2023; 26:268-274. [PMID: 37538432 PMCID: PMC10394458 DOI: 10.4103/aian.aian_660_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 08/05/2023] Open
Abstract
Background Status dystonicus (SD) is a life-threatening movement disorder emergency characterized by increasingly frequent and severe episodes of generalized dystonia, requiring urgent hospital admission. The diverse clinico-etiological spectrum, high risk of recurrence, and residual disabilities complicate functional outcomes. Aim We aim to describe the clinico-etiological spectrum, radiology, therapeutic options, and follow-up of patients with pre-status dystonicus (pre-SD) and SD. Methodology A cross-sectional retrospective study was carried out in a tertiary care referral center. The clinical, laboratory, and radiology data of all patients aged less than 18 years with pre-SD and SD from January 2010 to December 2020 were collected. The Dystonia Severity Assessment Plan (DSAP) scale for grading severity and the modified Rankin Scale (mRS) for assessing outcome were used at the last follow-up visit. Results Twenty-eight patients (male:female: 2.1:1) experiencing 33 episodes of acute dystonia exacerbation were identified. The median age at the onset of dystonia and SD presentation was 8.71 (range: 0.25-15.75) and 9.12 (range: 1-16.75) years, respectively. Four patients experienced more than one episode of SD. The etiological spectrum of SD includes metabolic (Wilson's disease-13, L-aromatic amino acid decarboxylase deficiency-one, and Gaucher's disease-one), genetic (neurodegeneration with brain iron accumulation-three and KMT2B and THAP 1 gene-related-one each), structural-three, post-encephalitic sequelae (PES)-four, and immune-mediated (anti-NMDA receptor encephalitis-one). Five patients had pre-SD (DSAP grade 3), and 23 patients had established SD (DSAP grade 4-17 and DSAP grade 5-six). The Rapid escalation of chelation therapy precipitated SD in 11 patients with Wilson's disease. Febrile illness or pneumonia precipitated SD in nine patients. Twenty-three episodes of SD required midazolam infusion in addition to anti-dystonic medications. The median duration of hospital stay was 10 days (range: 3-29). Twenty-three patients had resolution of SD but residual dystonia persisted, while two patients had no residual dystonia at follow-up. Three patients succumbed owing to refractory SD and its complications. Conclusion Early identification of triggers, etiology, and appropriate management are essential to calm the dystonic storm.
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Affiliation(s)
- Shridhar P. Joshi
- Paediatric Neurology Unit, Departments of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Maya Thomas
- Paediatric Neurology Unit, Departments of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sangeetha Yoganathan
- Paediatric Neurology Unit, Departments of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sumita Danda
- Medical Genetics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mahalakshmi Chandran
- Neurochemistry Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anitha Jasper
- Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
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O'Hara K, Dewar S, Bougher G, Dean P, Misra SN, Desai J. Overcoming barriers to the management of seizure clusters: ease of use and time to administration of rescue medications. Expert Rev Neurother 2023; 23:425-432. [PMID: 37126472 DOI: 10.1080/14737175.2023.2206568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Patients with epilepsy can experience seizure clusters (acute repetitive seizures), defined as intermittent, stereotypic episodes of frequent seizure activity that are distinct from typical seizure patterns. There are three FDA-approved rescue medications, diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray, that can be administered to abort a seizure cluster in a nonmedical, community setting. Despite their effectiveness and safety, rescue medications are underutilized, and patient/caregiver experiences and perceptions of ease of use may constitute a substantial barrier to greater utilization. AREAS COVERED The literature on rescue medications for seizure clusters is reviewed, including the effectiveness and safety, with an emphasis on ease and timing of treatment and associated outcomes. Barriers to greater utilization of rescue medication and the role of seizure action plans are discussed. EXPERT OPINION Intranasal rescue medications are easier to use and can be administered more rapidly than other routes (rectal, intravenous). Importantly, rapid administration of intranasal rescue medications has been associated with shorter durations of seizure activity as compared with rectal/intravenous routes. Intranasal rescue medications are also easy to use and socially acceptable. These factors potentially remove or reduce barriers to use and optimize the management of seizure clusters.
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Affiliation(s)
- Kathryn O'Hara
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sandra Dewar
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Genei Bougher
- Northwest Florida Clinical Research Group, LLC, Gulf Breeze, FL, USA
- Child Neurology Center of Northwest Florida, Gulf Breeze, FL, USA
| | - Patricia Dean
- Comprehensive Epilepsy Center, Nicklaus Children's Hospital, Miami, FL, USA
| | - Sunita N Misra
- Clinical Development & Medical Affairs, Neurelis, Inc, San Diego, CA, USA
| | - Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Fukuno S, Nagai K, Kurotobi A, Sahori Y, Nakagawa R, Nomura R, Ito T, Konishi H. Danazol increases the oral bioavailability of midazolam by inactivation of hepatic and intestinal CYP3A in rats. Xenobiotica 2023; 53:421-428. [PMID: 37640546 DOI: 10.1080/00498254.2023.2253314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 08/31/2023]
Abstract
Danazol (DNZ) is a synthetic androgen derivative used for the treatment of intractable hematological disorders. In this study, we investigated the effects of DNZ on CYP3A activity in hepatic and small intestinal microsomes and the pharmacokinetics of midazolam (MDZ), a typical substrate for CYP3A, in rats.MDZ 4-hydroxylation activities in hepatic and small intestinal microsomes significantly decreased 24 h after DNZ (100 mg/kg, i.p.) treatment. Time-dependent inactivation of MDZ 4-hydroxylation activities was noted when microsomes were pre-incubated with DNZ in the presence of a NADPH-generating system.The Western blot analysis indicated that the decrease observed in enzyme activity was not due to changes in the protein expression of CYP3A.In contrast to the intravenous administration, serum MDZ concentrations in DNZ-treated rats were markedly higher than those in control rats when administered orally. DNZ treatment increased MDZ oral bioavailability by approximately 2.5-folds.We herein demonstrated that DNZ increased the bioavailability of orally administered MDZ through irreversible inactivation of hepatic and intestinal CYP3A in rats.
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Affiliation(s)
- Shuhei Fukuno
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Katsuhito Nagai
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Akemi Kurotobi
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Yuki Sahori
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Ryo Nakagawa
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Rena Nomura
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Takuya Ito
- Laboratory of Natural Medicines, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
| | - Hiroki Konishi
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, Tondabayashi, Japan
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Li R, Wang Q, Liu Z, Xie L, Diao Z, Peng Y, Wang G, Sun J. Dose-dependent pharmacokinetics of midazolam in rats: influence of hepatic first-pass metabolism. Xenobiotica 2023:1-9. [PMID: 37042732 DOI: 10.1080/00498254.2023.2200524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
1. To characterize the dose-dependent pharmacokinetics of midazolam and evaluate the intestinal and hepatic first-pass effects on midazolam in Sprague-Dawley rats, the concentrations and area under the concentration-time curve (AUC) of midazolam in the portal and systemic plasma were simultaneously determined with a double cannulation method.2. It was found that about 75% of the dose was left in the portal blood with different oral administration doses, while the bioavailability in the liver was 37.86% at 20 mg/kg, significantly higher than 9.16% at 2 mg/kg.3. The disproportional increase in AUC of midazolam and significant decrease in exposure of metabolites were observed in systemic plasma after hepatic portal vein administration. And in the in vitro study, the formation rate of the metabolites of midazolam significantly decreased when midazolam was at 300 μM compared with 100 μM.4. These results indicated that not only the saturation of first-pass metabolism but also the inhibition of hepatic metabolism is responsible for the nonlinear PK of midazolam. Thus, a rational dose should be chosen when midazolam is used as a probe in the drug-drug interaction study, particularly for orally administered drugs that undergo hepatic first-pass metabolism.
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Affiliation(s)
- Run Li
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Qingqing Wang
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Zihou Liu
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Like Xie
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Zhipeng Diao
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Ying Peng
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Guangji Wang
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Jianguo Sun
- Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
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Figueiredo TH, Aroniadou-Anderjaska V, Apland JP, Rossetti K, Braga MFM. Delayed tezampanel and caramiphen treatment but not midazolam protects against long-term neuropathology after soman exposure. Exp Biol Med (Maywood) 2023; 248:612-623. [PMID: 37300407 PMCID: PMC10350803 DOI: 10.1177/15353702231171911] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 06/12/2023] Open
Abstract
Prolonged status epilepticus (SE) can cause brain damage; therefore, treatment must be administered promptly after seizure onset to limit SE duration and prevent neuropathology. Timely treatment of SE is not always feasible; this would be particularly true in a mass exposure to an SE-inducing agent such as a nerve agent. Therefore, the availability of anticonvulsant treatments that have neuroprotective efficacy even if administered with a delay after SE onset is an imperative. Here, we compared the long-term neuropathology resulting from acutely exposing 21-day-old male and female rats to the nerve agent soman, and treating them with midazolam (3 mg/kg) or co-administration of tezampanel (10 mg/kg) and caramiphen (50 mg/kg), at 1 h postexposure (~50 min after SE onset). Midazolam-treated rats had significant neuronal degeneration in limbic structures, mainly at one month postexposure, followed by neuronal loss in the basolateral amygdala and the CA1 hippocampal area. Neuronal loss resulted in significant amygdala and hippocampal atrophy, deteriorating from one to six months postexposure. Rats treated with tezampanel-caramiphen had no evidence of neuropathology, except for neuronal loss in the basolateral amygdala at the six-month timepoint. Anxiety was increased only in the midazolam-treated rats, at one, three, and six months postexposure. Spontaneous recurrent seizures appeared only in midazolam-treated rats, at three and six months postexposure in males and only at six months in females. These findings suggest that delayed treatment of nerve agent-induced SE with midazolam may result in long-lasting or permanent brain damage, while antiglutamatergic anticonvulsant treatment consisting of tezampanel and caramiphen may provide full neuroprotection.
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Affiliation(s)
- Taiza H Figueiredo
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Vassiliki Aroniadou-Anderjaska
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Psychiatry, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - James P Apland
- Neuroscience Program, U.S. Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD 21010, USA
| | - Katia Rossetti
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Maria FM Braga
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Psychiatry, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Jain S, Patel S, Arora KK, Sharma A. A Comparative Study on Effectiveness of Parental Presence versus Sedative Premedication for Reducing Anxiety in Children Undergoing General Anesthesia. Int J Appl Basic Med Res 2023; 13:101-105. [PMID: 37614833 PMCID: PMC10443447 DOI: 10.4103/ijabmr.ijabmr_636_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/26/2023] [Accepted: 06/16/2023] [Indexed: 08/25/2023] Open
Abstract
Background Preoperative anxiety is an important, yet often unattended problem in children. Minimizing anxiety and distress at the time of anesthetic induction may reduce adverse psychological and physiological outcomes. Sedative premedication and parental presence during anesthesia induction are among the most commonly employed strategies for reducing child anxiety. Aims and Objective The study aimed to compare the effectiveness of a pharmacological intervention (premedication with midazolam) versus behavioral intervention (parental presence) in reducing preoperative anxiety in children undergoing general anesthesia. Methodology Sixty patients of age group of 4-12 years, of ASA Grade 1 and 2 and either sex posted for elective surgery under general anesthesia were divided into two groups of 30 each Group M (midazolam group) and Group P (parental presence). Group M received intravenous midazolam 0.03-0.05 mg/kg preoperatively and anxiety was measured in preoperative room, during separation from parents and during introduction of anesthesia mask, whereas in Group P, parents accompanied the child inside the operation theater and anxiety was measured at preoperative room and during introduction of mask. Parental anxiety was measured in both groups at preoperative room and waiting room. Modified Yale Preoperative Anxiety Scale (mYPAS) and State Trait Anxiety Inventory (STAI) tool was used to measure anxiety in children and parents, respectively. Results The mean mYPAS score while the introduction of anesthesia mask in Group M was 31.30 ± 12.04 and in Group P was 63.19 ± 25.31, and the difference was found to be statistically significant (P = 0.001). In preoperative room, there was no significant difference in anxiety in the two study groups. The mean STAI score in Group P was 45.63 ± 1.45 and in Group M was 41.10 ± 1.69, and the difference was found to be statistically significant (P = 0.001). In preoperative room, parental anxiety was found to be comparable among the two groups. The mean duration of induction of anesthesia in Group M was 5.53 ± 1.01 min, and in Group P, it was 8.77 ± 2.03 min. The difference was found to be statistically significant (P = 0.001). Conclusion Both interventions were effective in reducing anxiety in children, but midazolam was more effective compared to parental presence. Parents in Group M were less anxious in the waiting room than Group P. Children in Group M were more compliant during the induction of anesthesia, hence a lesser duration of induction than Group P.
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Affiliation(s)
- Shalini Jain
- Department of Anaesthesiology, MGM Medical College and MY Hospital, Indore, Madhya Pradesh, India
| | - Suruchi Patel
- Department of Anaesthesiology, MGM Medical College and MY Hospital, Indore, Madhya Pradesh, India
| | - Kishore Kumar Arora
- Department of Anaesthesiology, MGM Medical College and MY Hospital, Indore, Madhya Pradesh, India
| | - Aseem Sharma
- Department of Anaesthesiology, MGM Medical College and MY Hospital, Indore, Madhya Pradesh, India
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