Administration Of Premedication Research Articles

Ivabradine Versus Metoprolol for Heart Rate Reduction Before Coronary Computed Tomography Angiography

Several studies have demonstrated the correlation of heart rate (HR) and image quality in coronary computed tomography angiography. Beta-blocker administration is critical because of its negative inotropic effect. Ivabradine is a selective HR-lowering agent that exclusively inhibits the I(f) current in sinoatrial node cells without having any effect on cardiac contractility or atrioventricular conduction. A total of 120 patients were randomized to oral premedication with ivabradine 15 mg or metoprolol 50 mg. HR and blood pressure (BP) were measured before the administration of premedication and immediately before coronary computed tomographic angiography. The mean time between premedication administration and follow-up was 108 ± 21.5 minutes for ivabradine and 110 ± 22.2 minutes for metoprolol (p = NS). When comparing groups, there were no significant differences in reduction of HR (-11.83 ± 8.6 vs -13.20 ± 7.8 beats/min, p = NS) and diastolic BP (-5.05 ± 14.2 mm Hg vs -4.08 ± 10.8 mm Hg, p = NS), whereas the decrease of systolic BP was significantly lower in patients who received ivabradine compared to those in the metoprolol group (-3.95 ± 13.6 vs -13.65 ± 17.3 mm Hg, p <0.001). In the subgroup of patients who were receiving long-term β-blocker therapy, significantly stronger HR reduction was achieved with ivabradine (-13.19 ± 5.4 vs -10.04 ± 6.0 beats/min, p <0.05), while the decrease in systolic BP was less (-2.00 ± 13.6 vs -15.04 ± 20.8 mm Hg, p <0.05) compared to metoprolol. In conclusion, ivabradine decreases HR before coronary computed tomographic angiography sufficiently, with significantly less depression of systolic BP compared to metoprolol.

Transesophageal Echocardiography in Ross Procedure

Ross procedure is one of the surgical procedures for correction of severe congenital aortic insufficiency. Intraoperative transesophageal echocardiography is essential for optimal surgical evaluation. Furthermore, it is able to assess the blood volume profile and the need for administration of vasoactive drugs during surgery. This is a 15-year old teenager with severe congenital aortic insufficiency scheduled for corrective surgery with the Ross procedure. In the operating room, the patient was monitored with electrocardiography and pulse oximeter, and he was premedicated with midazolam. After the administration of premedication, the left radial artery and right subclavian vein were punctured. Anesthetic induction was accomplished with etomidate, cisatracurium, and fentanyl while maintenance was achieved with sevoflurane. The probe of the transesophageal echocardiography equipment was introduced immediately after tracheal intubation, showing increased left ventricle; severe aortic insufficiency due to coaptation failure of the three leaflets; and competent pulmonary valve without anatomical and physiological changes. Intercurrences were not observed during surgery, with 120 minutes of extracorporeal circulation (ECC) and 8 hours of surgery. Immediately after removal from ECC the transesophageal echocardiography showed good function of both the auto- and homograft; however, the right ventricle presented hypocontractility, which was corrected with a bolus of milrinone followed by continuous infusion. The patient was transferred to the postanesthetic recovery unit intubated and hemodynamically stable with infusion of milrinone and sodium nitroprusside. Ross procedure is one of the techniques for correction of congenital aortic insufficiency in which transesophageal echocardiography guides the surgeon precisely on the physiological and anatomical status of vascular grafts.

Comparison of the efficacy and adverse effects of sustained-release buprenorphine hydrochloride following subcutaneous administration and buprenorphine hydrochloride following oral transmucosal administration in cats undergoing ovariohysterectomy

To compare the efficacy and adverse effects of sustained-release (SR) buprenorphine following SC administration and buprenorphine following oral transmucosal (OTM) administration in cats undergoing ovariohysterectomy. Animals-21 young healthy female cats. As part of anesthetic premedication (0 hours), 10 cats received buprenorphine (0.02 mg/kg) via OTM administration with additional doses at 12, 24, 36, 48, and 60 hours and 11 cats received an equivalent total dose as a single SC injection of SR buprenorphine (0.12 mg/kg). The SR product contained buprenorphine hydrochloride in a proprietary SR matrix. All other anesthetic drugs and a single postoperative dose of meloxicam were administered similarly to all cats. Behavioral and physiologic variables were recorded, and signs of pain were assessed by use of 2 pain assessment scales and von Frey filament testing in each cat prior to premedication administration (baseline), during recovery from anesthesia (RFA), and at 12, 24, 36, 48, 60, and 72 hours. Heart rate increased and temperature (determined via microchip transponder thermometry) decreased from baseline values during RFA in both groups. Compared with baseline values, pain scores were increased during RFA and at the 12- and 24-hour time points in both groups; von Frey scores were higher during RFA. Behavioral and physiologic variables did not differ significantly between groups at any time point. In cats undergoing ovariohysterectomy, SC administration of a preoperative dose of SR buprenorphine appeared to have comparable efficacy and adverse effect profile as that of twice-daily OTM administration of buprenorphine before and after surgery.

A comparison of acepromazine-buprenorphine and medetomidine-buprenorphine for preanesthetic medication of dogs

To assess sedative and cardiopulmonary effects of premedication with a medetomidine-buprenorphine or acepromazine-buprenorphine combination in dogs anesthetized with propofol and isoflurane. Randomized controlled clinical trial. 90 dogs undergoing routine surgical and diagnostic procedures. Dogs were randomly assigned to 1 of 3 premedication groups: group 1 (acepromazine, 0.03 mg/kg [0.014 mg/lb], IM; buprenorphine, 0.02 mg/kg [0.009 mg/lb], IM), 2 (medetomidine, 5 μg/kg [2.3 μg/lb], IM; buprenorphine, 0.02 mg/kg, IM), or 3 (medetomidine, 10 μg/kg [4.5 μg/lb], IM; buprenorphine, 0.02 mg/kg, IM). Anesthesia was induced with propofol and maintained with isoflurane in oxygen. Simple descriptive scores for sedation were assigned 15 minutes (groups 2 and 3) and 30 minutes (group 1) after premedication administration. Basic cardiopulmonary data were recorded throughout the anesthetic period. Times to recovery from anesthesia were recorded. Sedation scores did not differ significantly among groups. Mean and diastolic blood pressures were significantly lower and heart rate was significantly higher in group 1 than in the other groups. Mean end-tidal partial pressure of CO(2) was significantly lower and respiratory rate was significantly higher in group 1 than in the other groups. There were no significant differences in anesthetic recovery times between groups. Results suggested that either acepromazine or medetomidine could be used in combination with buprenorphine for premedication of dogs anesthetized with propofol and isoflurane for routine surgical and diagnostic procedures. Arterial blood pressure was better maintained with the medetomidine-buprenorphine combinations, but tissue perfusion was not investigated.

Endotracheal intubation in a neonatal population remains associated with a high risk of adverse events

There has been a significant increase in premedication use for neonatal intubation in the UK over the past decade. We aimed to determine the adverse events during neonatal intubation using the most commonly used premedication regimen in the UK. We prospectively studied all intubations performed using morphine, suxamethonium and atropine during a 3-month period in three UK tertiary neonatal units. Premedication was administered for 87/93 (94%) of intubations. Median time taken to prepare premedication was 16 min (IQR 10-35). Median time to successful intubation was 5 min (IQR 2-9) following premedication. Median lowest recorded oxygen saturation after administration of premedication was 65% (IQR 39-85). A bradycardia in the range 61-99/min accompanied the procedure in 24/93 (26%) intubations, with a median duration of bradycardia of 8 s (IQR 1-10). Despite the widespread move to premedication for neonatal intubation, many deficiencies in everyday practice remain. The rate of haemodynamic complications is high in this commonly used premedication regimen. This study shows that there are important factors to control at the local level in terms of timely preparation and administration of premedication drugs, training and supervision of staff carrying out this high-risk procedure.

Effectiveness of premedication agents administered prior to nitrous oxide/oxygen

In paediatric dentistry, when anxiety, fear of dental procedures or behavioural impairment precludes the conduct of dental treatments, sedation procedures are required. However, sedation at the desired level might not be achieved despite administration of various agents. The present study aimed to evaluate the effectiveness of oral premedication with different agents on children scheduled for dental treatment under nitrous oxide/oxygen (N2O/O2) sedation. The present research was approved by the Ethics Committee of Gazi University Faculty of Medicine. Sixty children aged between 5 and 8 years, ASA I or II, having no mental or motor retardation, requiring at least two-visit dental treatment, having no sedation or general anaesthesia experience, and incompliant with dental treatment (Frankl Behaviour Scale>or=3), were enrolled into the study after obtaining informed parental consent. The children were then randomly assigned to one of four groups. The treatment regimen according to the study groups was as follows: oral administration of 1 mg kg(-1) hydroxyzine hydrochloride suspension (Atarax) 1 h preoperatively (group I, n=15), oral administration of 0.7 mg kg(-1) midazolam (Dormicum) 15 min preoperatively (group II, n=15), oral administration of 3 mg kg(-1) ketamine (Ketalar) with 0.25 mg kg(-1) midazolam (Dormicum) 15 min preoperatively (group III, n=15), and no oral premedication administration [group IV (controls), n=15]. Peripheral oxygen saturation (SpO2) and heart rate were monitored with a pulse oximeter during treatment. The sedation level was monitored with the bispectral index. Following premedication, 40% N2O and 60% O2 was administered to all groups by means of a nasal mask. Sedation depth was evaluated using the Ramsay Sedation Scale and data were recorded at 5 min intervals. Sedation success and other sedation-related events were recorded. The evaluation of the findings of this study revealed that treatment procedures were completed without any serious complications. Achievement of sedation in terms of satisfactory/mid-level satisfactory/unsatisfactory was as follows: 13.3/53.3/33.3% in group I; 54/20/26% in group II; 33.3/33.3/33.3% in group III, and 6.7/60/33.3% in group IV, respectively. Ramsay Sedation Scale results revealed that the most effective medication was 0.7 mg kg(-1) midazolam. It is concluded that 0.7 mg kg(-1) midazolam is more effective than 0.25 mg kg(-1) midazolam with 3 mg kg(-1) ketamine and 1 mg kg(-1) hydroxyzine hydrochloride in terms of oral premedication prior to N2O/O2 sedation in children scheduled for dental treatments.

パクリタキセル注投与時におけるｄ‐クロルフェニラミンマレイン酸塩注射液によるアレルギー反応の予防効果

As a preventive measure against allergic/hypersensitivity reactions due to paclitaxel (PTX),the administration of premedication composed of three components,dexamethasone sodium phosphate injection,diphenhydramine hydrochloride tablet,and ranitidine hydrochloride injection solution (or injectable famotidine),is stipulated in the package insert.In the present study,we used d -chlorpheniramine maleate injection instead of diphenhydramine hydrochloride tablet and examined its effectiveness against PTX-related allergic reactions in 101 patients.When d -chlorpheniramine maleate injection was given as premedication,the frequency of allergic reactions was 13.9% (14/101),and for those of greater than Grade 3,which are considered to be severe,it was 2.0% (2/101).In addition,the frequencies of allergic reactions in patients with and without an allergic past were 37.5% (6/16)and 9.4% (8/85),respectively,a significant difference (p=0.0087).Although none of the patients with an allergic past had severe allergic reactions (greater than Grade 3),there were severe reactions in 2 (2.4%) patients with no allergic past.Seven of the 101 patients (6.9 %) experienced PTX-related allergic reactions in the first treatment,whereas 1 patient (1.0%) had an allergic reaction in the second treatment.In the 3rd and later treatments,PTX-related allergic reactions occurred in 6 patients (0.6%),though PTX had been administered 992 times to 91 patients.In conclusion,when d -chlorpheniramine maleate injection was used as premedication,it was equivalent to the conventional premedication as regards preventing allergic/hypersensitivity reactions.However,in patients with no allergic past and those under long-term treatment who had been treated 3 or more times,we consider that d -chlorpheniramine maleate injection was particularly effective in preventing PTX-related allergic reactions.

Midazolam in the reduction of surgical stress: A randomized clinical trial

The objective of this study was to assess the role of midazolam in reducing surgical stress as measured using subjective and objective variables. The study was a double-blind randomized controlled trial. Thirty-eight male patients undergoing surgical removal of third molars under general anesthesia were recruited for this study, each patient was given premedication (midazolam or placebo) and subjective variables (HAD scale) were obtained and objective variables (salivary cortisol samples and vital signs) were collected pre-, peri-, and postoperatively. The salivary samples were analyzed by direct immunofluorimetric assay using the "DELFIA" system. There were no significant differences in anxiety between the treatment group and the control group before the administration of the premedication. Following the administration of premedication, the majority of the control group showed high cortisol levels on the day of surgery, compared with relatively low cortisol levels in the majority of the treatment group. A few patients in the control group gave a placebo effect (sedative effect) and a number of the treatment group were unresponsive to the drug. There was a slight drop in the blood pressure and respiration rate with a slight increase in the heart rate in the treatment group; however these results were not statistically significant. The HAD scores were not statistically different between the 2 groups. Midazolam has proved to be very successful in reducing anxiety and stress pre-, peri-, and postoperatively with no significant effect on the vital signs of a healthy patient. Salivary cortisol technique is an easy, noninvasive method to assess anxiety and stress level in patients undergoing surgery.

Parental anxiety levels during pediatric induction with and without administration of premedication for general anesthesia.

This study measured parental anxiety before, during, and after elective dental procedures under general anesthesia using the Spielberger State-Trait Anxiety questionnaire. State anxiety started relatively high before the procedures, peaked immediately after induction using general anesthesia, and dropped during recovery to below the initial score. Parents, whose children were premedicated and fathers in general, had significantly higher anxiety immediately after induction. This study supports interventions to lower anxiety of the parents as well as that of children.

Antibioprophylaxie en chirurgie cardiaque : enquête de pratique

Objective: To assess the prescription patterns in French and foreign centres for antibiotic prophylaxis in cardiac surgery. Material and methods: Phone and written surveys concerned 64 French and 70 foreign centres. It focused on the first injection, the duration of treatment and the recommended agents. Results: 87% of the French centres and 67% of the foreign centres answered the questionnaire. The first injection took place at anaesthesia induction in all French centres but during administration of premedication in 11% of foreign centres ( p<0.05). The duration of prophylaxis was restricted to the intraoperative period only in 20% and 15% of centres, respectively (ns), as specified by the recommendations. No French centres carried on the antibiotics more than 48h versus 11% of foreign centres ( p<0.05). Cephalosporines of the second generation were prescribed in 84 and 49% of centres, respectively ( p<0.05). The combination of two antibiotics was less frequent in France than in foreign countries (5 versus 17%, p<0.01). In absence of betalactamin allergy glycopeptides were not utilized in France versus 8% in foreign countries ( p<0.05). In case of allergy vancomycin was used in 66% of French and 42% of foreign centres. Conclusion: The French recommendations may have influenced favourably the antibiotic choice but the prophylaxis duration was too long in most of the non French European centres.

Infusion rates and levels of premedication in tumescent liposuction.

Tumescent liposuction has proven to be an extremely safe and effective method of liposuction. However, the infusion of tumescent anesthesia can take 1 hour or more to complete. To document the types, dosages, and routes of administration of premedication utilized by four experienced tumescent liposuction surgeons. To determine if infusion rates for tumescent anesthesia are affected by types of premedication. Four experienced liposuction surgeons were asked to review their most recent 100 tumescent liposuction patients with respect to types and dosages of premedication and routes of administration. Data were also provided on corresponding infusion pump settings and infusion rates. Volumes of tumescent anesthesia and corresponding volumes of fat aspirated were also collected on the same 400 patients. Infusion of tumescent anesthesia could be performed more rapidly in patients who were given greater amounts of premedication. Volumes of tumescent anesthesia infused were generally two or more times the volume of fat aspirated. Patients could be infused with less premedication if slow infiltration was employed. Infusion rates for tumescent anesthesia can be increased of greater amounts of premedication are given. However, this must be balanced against the safety of the premedication.

Pain relief for children

Abstract The rationale has been stated of basing depressant drug dosage in children upon the supposed parallel curves for cell irritability and metabolic activity rather than solely upon age and weight. Satisfactory accomplishment of pain relief and of pre-anesthetic sedation with morphine and scopolamine has been described. Attention has been directed to the desirability of combining these two drugs in the proportion of twenty-five to one unless physical signs indicate a variation from this combination. Complete familiarity with a given combination of depressant drugs, and individualization of their dosage has afforded more satisfactory pain relief and pre-anesthetic sedation than attempts to change from one combination of drugs to another. It is our belief that ninety minutes is the optimum interval between a pre-anesthetic hypodermic of morphine and scopolamine and the induction of inhalation anesthesia. The time interval between administration of premedication and induction of inhalation is as important as the dose of agent. Disturbance of oxygen ingress to, and carbon dioxide egress from, the tissues of the body is a more likely fault of anesthesia than is an ill-advised choice of agent. Careful supervision of respiration throughout the period of anesthetic drug action is essential.

Comparison of Rectal to Intranasal Administration of Midazolam for Premedication of Children

Sixty children aged 3 to 9, undergoing minor surgical procedures, were studied to compare 0.5 mg/kg intranasal with 0.5 mg/kg rectal midazolam as a premedication. The children were evaluated for their ability to tolerate the medication, preanesthetic sedation, and alertness after anesthesia. Both premedication routes were equally effective in sedating the children. In both groups, a significant loss of effectiveness was noted if induction of the anesthesia began more than 30 minutes after administration of the medication (p < 0.0003). Rectal midazolam was much better tolerated by the children than the intranasal route (30 versus 3, p < 0.0001). We advocate the rectal over the intranasal route for premedication with midazolam in children, and anesthetic induction should occur no more than 30 minutes after administration of premedication.

Lack of anxiolytic effect of diazepam in pre-anaesthetic medication

In 30 female patients undergoing elective cholecystectomy, we have compared the anxiolytic effect of diazepam 10 mg with placebo, using measurements of cardiovascular (arterial pressure and heart rate), biochemical (plasma concentrations of noradrenaline, adrenaline, cortisol and dopamine beta-hydroxylase), subjective (visual analogue scale) and behavioural (Hamilton anxiety test) variables. Pretreatment evaluation was carried out the day before surgery and post-treatment examination was performed 1.5-2 h after oral administration of premedication, immediately before transfer of patients to the operating room. We found that diazepam 10 mg had no significant effect on any of the measured variables.

Local anesthesia blocks the antiemetic action of P6 acupuncture

The incidence of postoperative illness was monitored for 6 hours in 74 women premedicated with nalbuphine, 10 mg, and undergoing short gynecologic operations of similar duration under methohexitalnitrous oxide-oxygen anesthesia. Each patient received P6 acupuncture for 5 minutes at the time of administration of premedication. In random order the site of the acupuncture had been previously infiltrated with normal saline solution in half of the patients and 1% lidocaine in the remaining patients. Postoperative emetic sequelae occurred significantly more often in those who received lidocaine compared with the group that received saline solution. This demonstrates the ability of a local anesthetic administered at the point of stimulation to block the antiemetic action of P6 acupuncture in a manner similar to that shown by others for analgesia.

Overview of Monitoring in Endoscopy

Gastrointestinal endoscopy has evolved rapidly over the past 30 years and has become one of the larger specialities in medicine. An increasing number of diagnostic and therapeutic procedures are being performed with the aid of the flexible endoscope. With this expansion in the use of endoscopy came the routine administration of premedication. The endoscopist thus became a part-time anaesthetist. The lack of proper studies to evaluate the untoward effects of diazepam and, later, midazolam, at their introduction led to an unfortunate increase in reports of fatalities after the introduction of midazolam. Later studies showed the safety of these agents when properly administered, but the affair served to focus attention on monitoring in gastrointestinal endoscopy. The benefits of using extracorporeal monitoring equipment during endoscopy has not been proved in clinical trials, and because of this those bodies that issue guidelines on medical practice, such as the American Society for Gastrointestinal Endoscopy, have not mandated the use of these devices. The guidelines issued have emphasized the importance of training and recertification in advanced cardiac life support. Many endoscopists are reluctant to recognize their role as anaesthetist, and to adopt new practices recommended in the guidelines. However, these changes represent the evolution of medicine and reflect the desire to ensure a uniform high quality of care and as such should not be resisted.

The effect of a standardized premedication on oxygen saturation in the cardiac patient before transfer to the operating room

The effect of premedication with morphine and scopolamine on arterial hemoglobin oxygen saturation (SaO 2) was measured continuously in 26 undisturbed patients in their hospital rooms before coronary artery bypass surgery. Two hours preoperatively each patient received morphine, 0.1 mg/kg, and scopolamine, 0.2 or 0.4 mg. SaO 2 was continuously recorded using pulse oximetry from one-half hour before premedication until 1 1 2 hours after premedication. The lowest SaO 2 measured both the evening before surgery and one-half hour before premedication was 95% ± 0.5% (mean ± SEM). After administration of premedication, the lowest SaO 2 for the patient population decreased to 93% ± 0.4% ( P < 0.001 compared with that before premedication), and occurred 52 ± 2 minutes after premedication was given. Two patients (8%) had an SaO 2 < 90% (lowest SaO 2 for both was 88%). It is concluded that the dose of morphine/ scopolamine premeditation used was associated with a low risk of clinically important hypoxemia in the patient population studied.

Pain relief for children

The rationale has been stated of basing depressant drug dosage in children upon the supposed parallel curves for cell irritability and metabolic activity rather than solely upon age and weight. Satisfactory accomplishment of pain relief and of pre-anesthetic sedation with morphine and scopolamine has been described. Attention has been directed to the desirability of combining these two drugs in the proportion of twenty-five to one unless physical signs indicate a variation from this combination. Complete familiarity with a given combination of depressant drugs, and individualization of their dosage has afforded more satisfactory pain relief and pre-anesthetic sedation than attempts to change from one combination of drugs to another. It is our belief that ninety minutes is the optimum interval between a pre-anesthetic hypodermic of morphine and scopolamine and the induction of inhalation anesthesia. The time interval between administration of premedication and induction of inhalation is as important as the dose of agent. Disturbance of oxygen ingress to, and carbon dioxide egress from, the tissues of the body is a more likely fault of anesthesia than is an ill-advised choice of agent. Careful supervision of respiration throughout the period of anesthetic drug action is essential.