Injection Of Midazolam Research Articles

Sedative effects of alfaxalone and hydromorphone with or without midazolam in cats: a pilot study.

The aim of this pilot study was to compare the quality of sedation and ease of intravenous (IV) catheter placement following sedation using two intramuscular (IM) sedation protocols in cats: hydromorphone, alfaxalone and midazolam vs hydromorphone and alfaxalone. This was a prospective, randomized and blinded study. Cats were randomly assigned to receive an IM injection of hydromorphone (0.1 mg/kg), alfaxalone (1.5 mg/kg) and midazolam (0.2 mg/kg; HAM group), or hydromorphone (0.1 mg/kg) and alfaxalone (1.5 mg/kg; HA group). Sedation scoring (0-9, where 9 indicated maximum sedation) was performed at 0, 5, 10, 15 and 20 mins from the time of injection. At 20 mins, an IV catheter placement score (0-10, where 10 indicated least resistance) was performed. Twenty-one client-owned adult cats were included in this study. Sedation and IV catheter placement scores were compared between groups using Wilcoxon rank sum tests. Peak sedation was significantly higher (P = 0.002) in the HAM group (median 9; range 7-9) than in the HA group (median 7; range 3-9), and IV catheter placement scores were significantly higher (P = 0.001) in the HAM group (median 9.5; range 7-10) compared with the HA group (median 7; range 4-9). Spearman correlations were calculated between IV catheter placement score and sedation scores. There was a significant positive correlation of average sedation over time (correlation 0.83; P <0.001) and sedation at 20 mins (correlation 0.76; P <0.001) with a higher, more favorable IV catheter placement score. These preliminary results suggest that the addition of midazolam to IM alfaxalone and hydromorphone produced more profound sedation and greater ease of IV catheter placement than IM alfaxalone and hydromorphone alone.

Correlation between pain rating index and end-tidal sevoflurane concentration during sevoflurane anesthesia.

ObjectiveTo investigate the correlation between the pain rating index (PRi), which is an index derived from processed electroencephalography signals, and the end-tidal sevoflurane concentration (ETsevo).MethodsThis study involved 50 adults with a body mass index of 18 to 25 kg/m2 who were undergoing elective surgery under general anesthesia. Thyrocricocentesis was performed with 2.5 mL of 2% tetracaine for endotracheal surface anesthesia, and intravenous injections of midazolam, etomidate, and rocuronium were then administered. The patients’ tracheas were intubated and their ventilatory rate was adjusted to maintain the partial pressure of end-tidal carbon dioxide at 30 to 35 mmHg. Anesthesia was maintained with sevoflurane. The ETsevo was adjusted to maintain anesthesia at 0.6, 0.8, 1.0, and 1.2 minimum alveolar concentration for 15 minutes each, and the PRi, mean arterial pressure (MAP), and heart rate were recorded at each concentration.ResultsA negative correlation was found between the PRi and ETsevo (−0.882) and between the MAP and ETsevo (−0.571). A low positive correlation was found between the PRi and MAP (0.484).ConclusionsThe PRi showed a high negative correlation with the ETsevo. Therefore, the PRi can be used to guide the depth regulation of sevoflurane anesthesia.Clinical trial registration number: ChiCTR-IPR-17012092

Comparison Of Lignocaine And Fentanyl For Attenuation Of Cardiovascular Stress Response To Laryngoscopy And Endotracheal Intubation

BACKGROUND AND AIM Intravenous Fentanyl Citrate and Lignocaine hydrochloride is being used as premedication for general anaesthesia with an intent to attenuate cardiovascular reflexes of laryngoscopy and endotracheal intubation. Present study was aimed to compare efficacy of both drugs as premedication to attenuate cardiovascular reflexes of laryngoscopy. METHODOLOGY Present study was carried out on randomly selected 50 patients of ASA Grade 1 and 2, aged 20 to 50 years with mallam pati airway assessment grade 1 scheduled for elective surgery requiring general anaesthesia with endotracheal intubation. All routine non-invasive monitors were applied and iv line secured. Glycopyrrolate 0.004 mg/kg and injection midazolam 0.02 mg/kg was given intravenously and IV infusion of ringer lactate was started. Patients were divided in two groups. Group-1: -Lignocaine hydrochloride group. Here patients received injection lignocaine hydrochloride 1.5 mg / kg IV bolus 3 minutes prior to induction. Group-2: -Fentanyl citrate group. Here patients received injection fentanyl citrate 2 µg / kg IV bolus 3 minutes prior to induction. After preoxygenation general anaesthesia with Thiopentone Sodium 5mg/kg and Succinyl choline 2mg/kg was given and endotracheal intubation was done. Heart rate, SBP, DBP, MAP and ECG were recorded in all patients pre operatively, after premedication, before study drug, after induction, after laryngoscopy and intubation and for every 1 minute up to 6 minutes after intubation during which no stimulus was given to patients. Laryngoscopy done and endotracheal intubation was done. An observation was made related to adverse effects of drugs and laryngoscopy related problems and were attended to appropriately. RESULTS In our study, injection fentanyl citrate 2 µg/kg attenuated the haemodynamic response better than Lignocaine 1.5 mg/kg. Heart rate, systolic blood pressure, diastolic blood presuure and mean arterial pressure did not rise significantly after intubation with Fentanyl compared to Lignocaine and reached basal value within study time. CONCLUSION Fentanyl citrate is safe and effective in attenuation of hemodynamic response to laryngoscopy without significant side effects as compared to lignocaine hydrochloride.

Catatonia associated with seizures due to parietal cavernoma.

Catatonia associated with seizures due to parietal cavernoma.

Ultrasound Guided Popliteal Nerve Block For Various Ankle &amp; Foot Surgeries

Background: Ankle&amp; foot surgeries are very common surgeries in various age groups like young &amp; geriatric as well as in patients with comorbidities. Popliteal nerve block is one of multimodal Anaesthesia &amp; analgesia for same. we have used ultrasound guided block to prevent complications &amp;precise volume at a site for improving Characteristics of block. Aims of study: To study the technique of giving popliteal nerve blocks with ultrasonographic guidance and evaluate it in terms of: No of attempts, Time required for sensory and motor blockade, Quality of Intra operative analgesia, Duration for post-operative analgesia, Supplementation required in form of sedo analgesia/general anaesthesia &amp; Complications encountered. Methods: We performed ultrasonography guided popliteal nerve block in 60 adult patients of ASA grade I/II/III undergoing foot and ankle surgeries. The volume of drug used was 20ml consisting of Lignocaine (1.5%) 10ml and Bupivacaine (0.5%) 10ml; Results: The mean time taken to conduct the block was 4.3±1.4 mins. The mean time taken for sensory onset was 3.8±1.1 mins. The mean time taken for motor onset was 7.0± 1.4 mins. The mean time taken for completing the surgery was 39.2±5.0 mins. The mean time taken for complete motor regression was 143.8±13.5 mins. The mean time taken for complete sensory regression was 184.8± 16.8 mins. The patients first complained of pain at the mean time of 239±22.4 mins. The patients have stable haemodynamic parameters: pulse rate, SBP, DBP throughout the operation. Failure of block was seen in 4 patients where supplementation in the form of Injection Midazolam 1mg IV and Injection Fentanyl 50microgm IV was given in 2 patients and general anaesthesia was given in 2 patients. No other neurological complications were noticed in our study. Conclusion: ultrasound guided Popliteal nerve block is safe&amp; effective block for various ankle &amp;foot surgeries.

Application of Midazolam Injection in Patients with Intraoperative Nerve Block Anesthesia and Sedation Assisted by Imaging Guidance

In the present study, we explored the clinical effect of midazolam as an adjuvant analgesic and tranquilizer after brachial plexus block anesthesia with the aid of imaging guidance. We selected 106 patients who had undergone elective unilateral upper extremity surgery from January 2017 to December 2019 and randomly divided them into groups A and B, with 53 cases in each group. All the patients had undergone brachial plexus block anesthesia. Group A received imidazole-assisted sedation, and group B received fentanyl plus midazolam-assisted sedation. Under ultrasound-guided intermuscular sulcus brachial plexus block, we observed and recorded the ultrasound anatomical images before injection, including the distance from the lower edge of the upper, middle, and lower trunk of the forearm brachial plexus to the skin. We also recorded the anesthesia and operation times, effects of the anesthetic block, and incidence of adverse reactions. The distance from the lower edge of each nerve trunk to the skin averaged 1.002 cm for the upper stem, 1.598 cm for the middle stem, and 2.26 cm for the lower stem. The average anesthesia procedure time was 3 minutes, 56 seconds and was within 3-5 minutes for 92% of the procedures. The anesthesia effect was excellent, good, and poor in 81%, 11%, and 6%, respectively, and ineffective for 2% and effective for 92%. The ultrasound-guided inferior intermuscular sulcus approach for brachial plexus block is suitable for unilateral upper extremity radial hand surgery. For surgery involving the upper extremity ulnar hand side, a larger dose (concentration) of local anesthetic should be used within a safe range and/or an additional ulnar nerve block might be necessary. Midazolam adjuvant medication can have a good sedative and amnestic effect in brachial plexus block anesthesia, helping to reduce pain and inhibit the increase in stress levels.

Transcutaneous electrical acupoint stimulation relieves post-operative nausea and vomiting possibly by reducing serum motilin secretion in patients undergoing laparoscopic surgery

To observe the effect of transcutaneous electrical acupoint stimulation (TEAS) of different acupoint combinations on postoperative nausea and vomiting (PONV) and serum motilin (MTL) content in patients undergoing laparoscopic surgery, so as to provide evidence for clinical selection of suitable acupoint compatibility. A total of 140 patients undergoing elective laparoscopic surgery were randomly divided into general anesthesia (GA) control, TG2 ［Neiguan (PC6) + Hegu (LI4)］, TG3 ［PC6 + LI4 + Zusanli (ST36)］, and TG4 ［PC6 + LI4 + ST36 + Sanyinjiao (SP6)］ groups, with 35 cases in each group. Patients of the TG2, TG3 and TG4 groups received TEAS (2 Hz/100 Hz, 3-8 mA) of the above mentioned acupoint (bilateral) groups for 30 min before the induction of anesthesia until the end of the operation. Patients of the GA control group received intravenous injection of Midazolam, Sufentanil, Propofol, Rocuronium Bromide, etc. The blood sample (4 mL) from the right median cubital vein was collected at the time of patient's entry, 12 and 24 h after surgery, respectively, for measuring MTL concentration by enzyme-linked immunosorbent assay. The incidence of early and late PONV and changes of PONV degree within 24 h after surgery were recorded. The serum MTL concentrations were significantly decreased at 12 h after surgery in all the 4 groups (P<0.05), and decreased at 24 h after surgery in GA and TG2 groups vs their own pre-surgery (P < 0.05), and considerably higher at both 12 and 24 h after surgery in the TG2, TG3 and TG4 groups than in the GA control group (P<0.05), and also evidently higher in the TG3 and TG4 groups than in the TG2 group (P<0.05). The incidence of PONV was significantly lower in the TG2, TG3 and TG4 groups than in the GA control group in the early and late periods (except TG2 group) of surgery (P<0.05). The number of patients with PONV grade Ⅰ was significantly larger in the TG2, TG3 and TG4 groups than in the GA control group at 24 h after surgery (P<0.05), suggesting a mild PONV in more patients undergoing TEAS. TEAS has a preventive effect on PONV in patients undergoing laparoscopic surgery, which may be related to its effect in reducing serum MTL concentration. The preventive effect of TEAS of PC6 + LI4 + ST36 and PC6 +LI4 + ST36 + SP6 is similar and better than TG2 (two acupoints) group.

Oxygenation before Endoscopic Sedation Reduces the Hypoxic Event during Endoscopy in Elderly Patients: A Randomized Controlled Trial.

Background: Sedation endoscopy increases patient and examiner satisfaction but involves complications. The most serious complication is hypoxia, the risk factors for which are old age, obesity, and American Society of Anesthesiologists physical status of 3 or greater. However, clear evidence of oxygenation during sedation endoscopy for elderly people is lacking in US, European, and Korean guidelines. Method: This study was conducted for 1 year starting in August 2018 to evaluate whether pre-oxygenation use 1 min before sedation endoscopy could reduce the incidence of hypoxia in patients older than 65 years of age. A total of 70 patients were divided into the non-oxygenated group (n = 35; control group) and oxygen-treated group (n = 35; experimental group) during endoscopy. Result: The incidence of hypoxia was 28 (80%) in the control group versus 0 (0%) in the pre-oxygenated group. Factors related to hypoxia in the non-oxygenated group were a relatively high dose of midazolam and concomitant injection with narcotic analgesics such as pethidine. Conclusion: The incidence of hypoxia during sedation endoscopy is high in patients over 65 years, but oxygenation during endoscopic sedation in elderly people can significantly reduce the incidence of intraprocedural hypoxic events.

Avoiding the incompatibility of peripheral parenteral nutrition solution and midazolam injection for intravenous sedation.

We have observed white turbidity when a midazolam injection is administered from a lateral tube during the administration of a peripheral parenteral nutrition (PPN) solution. The aim of the current study was to determine how to avoid compound changes when co-administering a midazolam injection and a PPN solution. Midazolam solutions were prepared by diluting a midazolam injection with a 5% glucose intravenous infusion. We examined the formulation of the midazolam injection and a PPN solution at the concentrations used in a clinical setting for changes in appearance, pH, and midazolam content in test tubes and during administration conditions. With a 1/4.8 dilution of midazolam in undiluted solution, clouding occurred. A strong correlation was revealed between the midazolam content as measured through high-performance liquid chromatography and the mixture's midazolam concentration (R2=0.9918). The capture rate of midazolam infused with PPN solution was 91.0% at a 1/6 dilution, whereas it decreased to <90% at a 1/4.8 dilution. Our results suggest that the administration of a midazolam injection solution diluted by ≥6-fold with glucose solution or saline from a side tube during the administration of a PPN solution did not cause changes in composition.

Flow-Identified Site of Collapse During Drug-Induced Sleep Endoscopy: Feasibility and Preliminary Results

Flow-Identified Site of Collapse During Drug-Induced Sleep Endoscopy: Feasibility and Preliminary Results

Delta brush variant: A novel ictal EEG pattern in anti-NMDAR encephalitis.

Seizure is one of the main symptoms of anti‐NMDAR encephalitis, but data of ictal electroencephalogram (EEG) patterns remain limited. In this study, we aimed to introduce a unique ictal pattern. This delta brush variant (DBV) was characterized as generalized delta rhythm with fast spike activity riding on it. We retrospectively evaluated the ictal pattern from six patients with anti‐NMDAR encephalitis, and patients were grouped based on the presence of DBV. DBV was found in two patients who were in the florid phase of the disease: (a) A 17‐year‐old girl experienced rhythmical jerking of bilateral limbs. Corresponding EEG patterns showed generalized DBV. Seizure terminated after intravenous injection of midazolam, but oral‐facial dyskinesia reappeared; and (b) a 24‐year‐old man suffered stiffening of the right limbs and oral‐facial dyskinesia. The EEG pattern showed frontal DBV with left prominence. Seizure was controlled, but oral‐facial dyskinesia remained after intravenous injection of midazolam. Compared with patients without DBV, patients in this group were more likely to have prolonged excessive delta brush (100% vs 25%) and hyperpyrexia (39.7℃ vs 38.2℃). Duration in ICU (36 days vs 18 days) and hospital (52 days vs 36 days) was relatively longer in DBV group, and no significant difference was found in terms of the mRS score (1 vs 0.5) and seizure relapse rate (0% vs 25%) during 3‐month follow‐up. DBV is a peculiar pattern in anti‐NMDAR encephalitis. An EEG‐based monitoring should be considered to avoid misleading this ictal EEG pattern to the electromyographic artifact.

A study to evaluate the efficacy of intrathecal dexmeditomedine in patients undergoing laparoscopic surgeries under conventional general anaesthesia

The advent of laparoscopic surgery has benefited the patient and surgeon; however creation of pneumoperitoneum for same has bearings during the perioperative period. These effects of pneumoperitoneum are associated with significant hemodynamic changes, increasing the morbidity of the patient. Dexmedetomidine, a new α2 agonist provides stable hemodynamic condition, good quality of intra operative analgesia and prolonged post-operative analgesia with minimal side effects.: A total of 74 patients of either sex, planned for laparoscopic cholecystectomy were included. The patients were randomly divided into two groups of 37 each. GROUP D received Injection Dexmeditomedine 5µg (0.05ml) is diluted in 0.5ml of cerebrospinal fluid and injected intrathecally. A 5minutes interval is given for recording of post injection hemodynamic parameters prior to general anaesthesia. Patients will be premedicated with Injection glycopyrrolate 0.04 mg/kg, Injection midazolam 0.02 mg/kg and Injection Fentanyl 2µg/kg intravenously. After adequate preoxygenation, conventional general anaesthesia will be given to the patients. GROUP ‘E’: Conventional general anaesthesia alone. Heart rate (HR), systolic blood pressure, diastolic blood pressure and mean arterial pressure (MAP), ETco2 were recorded preoperative, after study drug, after induction, after pneumoperitoneum at 5 min intervals, post pneumoperitoneumIn group D, there was no statistically significant increase in HR and blood pressure after pneumoperitoneum at any time intervals and there was significant increase in time for first rescue analgesic, intraoperative fentanyl requirement, whereas in Group E, there was a statistical significant increase in MAP after pneumoperitoneum at 5, 10 and 15 min and HR during the whole pneumoperitoneum period.Dexmedetomidine 5 µg given intrathecally improves the hemodynamic stability, decreased intraoperative requirement of fentanyl and the duration of postoperative analgesia and also provides an analgesic sparing effect in patients undergoing laparoscopic abdominal surgery.

Anti-metastatic effect of midazolam on melanoma B16F10 cells in the lungs of diabetic mice

Midazolam is an anesthetic agent commonly used for anesthesia and sedation in surgery. However, there is no information on the role of midazolam in hyperglycemia-induced cancer metastasis to date. In this study, we investigated the effects of midazolam on inhibiting metastases in the lungs of diabetic mice and on human pulmonary microvascular endothelial cells (HPMVECs). Subcutaneous injection of midazolam inhibited hyperglycemia-induced cancer metastasis in the lungs of diabetic mice. Midazolam also prevented the generation of ROS, activation of TGase, and subsequent vascular leakage in the lungs of diabetic mice. Furthermore, in vitro studies with HPMVECs confirmed that midazolam inhibited VEGF-induced intracellular events including ROS generation, TGase activation, and disruption of vascular endothelial-cadherins, thus preventing the permeability of endothelial cells. Notably, midazolam had no direct effect on the migration or proliferation of melanoma cells, instead acting upon endothelial cells. The midazolam-mediated inhibition of VEGF-induced intracellular events was reversed by treatment with the GABAA receptor antagonist flumazenil. These findings suggest that midazolam prevents hyperglycemia-induced cancer metastasis by inhibiting VEGF-induced intracellular events and subsequent vascular leakage via the GABAA receptors in the lungs of diabetic mice.

Use of medetomidine, midazolam, ketamine and sevoflurane as an anesthetic protocol for domestic chickens

Changes in physiological and biochemical parameters after administration of medetomidine (MED), midazolam (MID), ketamine (KET) and a 2% of the inhalation anesthetic sevoflurane (SEVO), were investigated in domestic chickens. The anesthetic protocol began with a simultaneous intrapectoral injection (IP) of MED (50 μg/kg) and MID (0.5 mg/kg), followed by IP administration of 25 mg/kg of KET 10 min later. Anesthesia was then maintained for 30 min by 2% SEVO (with a 500 ml/min oxygen flow), using an Ayres T piece device. Heart and respiratory rates, cloacal temperature, reflex response and electrocardiogram (ECG) parameters were recorded at time cero (T0) before anesthesia (BA, baseline values), at time of MED+MID administration (T1), at time of ketamine injection (T2), 30 min after the start of SEVO inhalation (T3) and at recovery. Blood was also drawn at T0 and T3 to assess albumin, creatinine, glucose and liver enzyme concentrations. Cloacal temperature, heart and respiratory rates differed from baseline values at all time intervals during anesthesia (p&lt;0.05). Heart rate decreased following the MED + MID injection (at T1, T2 and T3), and partially recovered by the reanimation period. Reflex response also differed between time 0 and all anesthesia time points (p&lt;0.05). Mean amplitude of the P wave of the ECG was increased during MED + MID (T1) and KET (T2) anesthesia. The mean ST interval showed a large increase at T1, which was maintained throughout anesthesia (p &lt;0.05). Albumin, glucose and the ALT enzyme decreased between T0 and T3. In conclusion, the use of MED+MID+KET and SEVO as an anesthetic combination altered cardiorespiratory and biochemical parameters of chickens, but no life-threatening effects were observed as a result of these changes. Hence, this drug combination can be adequately used as an anesthesia protocol in chickens.

Hypnotic sedation and musical background during cimentoplasty on prone position: A comparative study

Purpose To report prospectively the effect of erikson hypnoanalgesia and musical background on procedural medication and well-being in patients undergoing cimentoplasty on prone position. Material and methods All the patients (n = 118, mean age 68.9 ± 13.3 years) had an IV injection of paracetamol (1 g) and midazolam (0.5 mg) and a local anesthesia before the cimentoplasty. Hypnoanalgesia (H) was proposed in consultation and performed if the technician was available. Three groups were compared: group hypnoanalgesia (H), music (M) or control (C). Numbers of lumbar or thoracic levels was 1 to 4. The necessity to add medication during the treatment was evaluated. The procedural well-being (0-incomfortable- to 10-comfortable) was asked 2 hours after the cimentoplasty. Duration of the procedure, hearth rate and arterial pressure during cimentoplasty were notified. Results Thirty-three patients were included in the group (H), 38 in (M) and 47 in (C). The mean number of levels was 1.61, 1.53 and 1.66 for groups (H), (M) and (C) respectively. 18.2% of patients in (H), 29% in (M) and 40.4% of patients in (C) had an adjunctive medication during the treatment (P = 0.101) for a well-being state of 7.5 ± 2.3, 7.1 ± 2 and 6.9 ± 2 respectively (P = 0.381). Time durations were 49.8, 44.1 and 46.4 min for group (H), (M) and (C) respectively. No significative difference of cardiac frequency, arterial pressure was observed during the cimentoplasty between the three groups. Conclusion The best reduction of painfulness was reached under hypnoanalgesia, allowing less injection of adjunctive medication during the treatment for an equivalent comfort. Musical background is also an interesting way to improve the comfort of patients undergoing cimentoplasty in prone position.

Effects of intrathecal midazolam-bupivacaine combination on postoperative analgesia

Background and aim Subarachnoid injection of local anesthetic with midazolam potentiates spinal blockade. Midazolam is known to produce antinociception and to potentiate the effect of local anesthetic when given in the neuraxial block without significant side effects. This study was designed to assess the effects of adding midazolam to intrathecal bupivacaine in patients undergoing subumbilical surgery. Patients and methods Sixty adult patients were randomly divided into two groups: Group I was administered 3 ml of 0.5% hyperbaric bupivacaine+0.4 ml of normal saline and Group II was administered 3 ml of 0.5% hyperbaric bupivacaine+2 mg (0.4 ml) of preservative-free midazolam. Time of onset of sensory analgesia, level of sensory blockade, time for maximum cephalic spread, and motor blockade as well as vital parameters and intraoperative complications were assessed and recorded. Postoperative pain scores were assessed using the visual analog scale immediately postoperatively. Results The level of sensory blockade is higher in group II while the time of maximum cephalic spread was longer in group I. Concerning the postoperative visual analog scale, there were lower scores in group II than in group I. There was significant difference between groups I and II regarding total diclofenac sodium consumption in the postoperative 24 h with total consumption of 146.83±53.25 and 112.33±25.18 mg, respectively. The P value was found to be 0.002. Conclusion Subarachnoid injection of preservative-free midazolam as an adjuvant to intrathecal bupivacaine potentiates its effect in terms of prolonged motor and sensory blockade without any significant hemodynamic compromise or sedation and with a significant decrease of postoperative analgesic requirements.

Randomized comparison between dexmedetomidine\u2013remifentanil and midazolam\u2013fentanyl for deep sedation during catheter ablation of atrial fibrillation

Background and objectivesThe efficacy of dexmedetomidine for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) has not been well established. We evaluated the efficacy and safety of sedation using dexmedetomidine with remifentanil compared to conventional sedative agents during RFCA for AF.Subjects and methodsA total of 240 patients undergoing RFCA for AF were randomized to either the dexmedetomidine (DEX) group (continuous infusion of dexmedetomidine and remifentanil) or the midazolam (MID) group (intermittent injections of midazolam and fentanyl) according to sedative agents. Non-invasive positive pressure ventilation was applied to all patients during the procedure. The primary outcome was patient movement during the procedure resulting in a 3D mapping system discordance, and the secondary outcome was adverse events including respiratory or hemodynamic compromise.ResultsDuring AF ablation, the incidence of the primary outcome was significantly reduced for the DEX group (18.2% vs. 39.5% in the DEX and the MID groups, respectively, p < 0.001). The frequency of a desaturation event (oxygen saturation < 90%) did not significantly differ between the two groups (6.6% vs. 1.7%, p = 0.056). However, the incidences of hypotension not owing to cardiac tamponade (systolic blood pressure < 80 mmHg, 19.8% vs. 8.4%, p = 0.011) and bradycardia (HR < 50 beats/min: 39.7% vs. 21.8%, p = 0.003) were higher in the DEX group. All efficacy and safety results were consistent within the predefined subgroups.ConclusionThe combined use of dexmedetomidine and remifentanil provides higher stability sedation during AF ablation, but can lead to more frequent hemodynamic compromise compared to midazolam and fentanyl.

The Effect of the Modified Jaw-Thrust Maneuver on the Depth of Sedation During Drug-Induced Sleep Endoscopy.

The modified jaw-thrust maneuver (MJTM) during drug-induced sleep endoscopy (DISE) is known to predict the treatment effect of mandibular advancement devices. However, its effect on the depth of sedation and potential to provoke arousal by awakening patients during the maneuver has not been studied so far. This study investigated the effect of the MJTM on the depth of sedation during DISE. Forty patients on whom the MJTM was performed during DISE were included. The effect of the maneuver was evaluated at the levels of the velum, lateral wall of the oropharynx, base of the tongue, and epiglottis. Obstruction was defined as the collapse of the upper airway exceeding 75%, and improvement with the MJTM was defined as the widening of the upper airway by more than 50% during the maneuver. A bolus injection of midazolam was used to induce sedation and control the depth of sedation (bispectral index value of 60 to 80). Obstructions were present in the velum of all patients, lateral wall of the oropharynx of 13 patients, base of the tongue of 28 patients, and epiglottis of 6 patients. After the MJTM, improvement of the obstruction was observed in 57.5%, 61.5%, 82%, and 66.7% of patients with velum, lateral wall of the oropharynx, base of the tongue, and epiglottis obstructions, respectively. An increase in the bispectral index value of more than 20 was observed in 8 patients. Four patients awakened during the procedure. The MJTM significantly relieved obstruction during DISE, especially at the base of the tongue. However, this might have been caused by an increase in the degree of awakening during the maneuver. Therefore, MJTM's effect on the depth of sedation may help in improving the degree of airway obstruction.

EARLY PHASE POSTMORTEM REDISTRIBUTION OF LIDOCAINE AND MIDAZOLAM IN ADULT ALBINO RATS

Background: Postmortem redistribution (PMR) is the changes that occur in drugconcentrations after death. Lidocaine is the most popular local anesthetic used worldwideand midazolam is a widely used pre-anesthetic anxiolytic and sedative. Aim of theWork: This work was performed to study potential early phase postmortemredistribution of lidocaine and midazolam, as well as, the influence of storagetemperature on it in adult albino rats. This was done by measuring their concentrations inblood (cardiac blood and external iliac vein blood) and tissues (heart, lungs and liver).Calculation of cardiac blood to peripheral blood ratio (C/P) and Liver to peripheral bloodratio (L/P) was performed. Materials and Methods: This study was carried out on 36adult male albino rats which divided into two main groups (18 rats each). Group I(Lidocaine): Rats received a single SC injection of 2% lidocaine HCL (67 mg/kg), andsacrificed 30 minutes later. This group was subdivided into three equal groups; AMcontrol (L-AM), 15 minutes PM at 4oC (L-PM4) and 15 minutes PM at 21oC (L-PM21).Group II (Midazolam): Rats received single IV injection of midazolam (75 mg/kg), andsacrificed 30 minutes later. This group was subdivided into three equal groups; AMcontrol (M-AM), 15 minutes PM at 4oC (M-PM4), 15 minutes PM at 21oC (M-PM21).Results: There were significant changes in lidocaine and midazolam concentrations inboth tissues and blood samples as compared to those of corresponding AM controlgroups. Markers of PMR revealed early phase PMR of lidocaine by L/P ratios > 20 at 21oC. Storage temperature at 4oC arrested lidocaine PMR as recorded by both C/P ratios <1 and L/P ratios < 5. Midazolam was prone to postmortem degradation that interferedwith PMR assessment. Midazolam revealed minimal early phase postmortemredistribution as demonstrated by C/P ratios just above 1 at 4 oC. L/P ratio was a morereliable marker for PMR than C/P ratio. Conclusion: Lidocaine was highly liable toundergo early phase PMR as demonstrated by L/P ratios above 20 at 21 oC. However,storage at 4oC retarded lidocaine PMR. Midazolam was subjected to postmortemdegradation and had minimal early phase PMR as demonstrated by C/P ratios just above1 at 4 oC. Recommendation: it is recommended to increase forensic toxicologists'awareness about PMR of lidocaine and midazolam, and their influence on theinterpretation of PM toxicological analysis.

Interventional Treatments for Postherpetic Neuralgia: A Systematic Review

Background: Postherpetic neuralgia, a persistent pain condition often characterized by allodynia and hyperalgesia, is a deleterious consequence experienced by patients after an acute herpes zoster vesicular eruption has healed. The pain associated with postherpetic neuralgia can severely affect a patient’s quality of life, quality of sleep, and ability to participate in activities of daily living. Currently, first-line treatments for this condition include the administration of medication therapies such as tricyclic antidepressants, pregabalin, gabapentin, and lidocaine patches, followed by the application of tramadol and capsaicin creams and patches as second- or third-line therapies. As not all patients respond to such conservative options, however, interventional therapies are valuable for those who continue to experience pain. Objective: This review focuses on interventional therapies that have been subjected to randomized controlled trials for the treatment of postherpetic neuralgia, including transcutaneous electrical nerve stimulation; local botulinum toxin A, cobalamin, and triamcinolone injection; intrathecal methylprednisolone and midazolam injection; stellate ganglion block; dorsal root ganglion destruction; and pulsed radiofrequency therapy. Study Design: Systematic review Setting: Hospital department in Taiwan Methods: Search of PubMed database for all randomized controlled trials regarding postherpetic neuralgia that were published before the end of May 2017. Results: The current evidence is insufficient for determining the single best interventional treatment. Considering invasiveness, price, and safety, the subcutaneous injection of botulinum toxin A or triamcinolone, transcutaneous electrical nerve stimulation, peripheral nerve stimulation, and stellate ganglion block are recommended first, followed by paravertebral block and pulsed radiofrequency. If severe pain persists, spinal cord stimulation could be considered. Given the destructiveness of dorsal root ganglion and adverse events of intrathecal methylprednisolone injection, these interventions should be carried out with great care and only following comprehensive discussion. Limitations: Although few adverse effects were reported, these procedures are invasive, and a careful assessment of the risk-benefit ratio should be conducted prior to administration. Conclusion: With the exception of intrathecal methylprednisolone injection for postherpetic neuralgia, the evidence for most interventional procedures used to treat postherpetic neuralgia is Level 2, according to “The Oxford Levels of Evidence 2”. Therefore, these modalities have received only grade B recommendations. Despite the lack of a high level of evidence, spinal cord stimulation and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia. Key words: Interventional treatment, postherpetic neuralgia, botulinum toxin, steroid, stellate ganglion block, peripheral nerve stimulation, paravertebral block, radiofrequency, spinal cord stimulation