Iv Midazolam Research Articles

PBPK perspective on alternative CYP3A4 inducers for rifampin.

PBPK perspective on alternative CYP3A4 inducers for rifampin.

Comparative study of intubating conditions and hemodynamic changes during awake fiber-optic intubation using midazolam with fentanyl versus dexmedetomidine in cases of difficult airway.

Background:The aim of the study is to compare intubating conditions and hemodynamic changes during awake fiber-optic intubation (AFOI) using midazolam and fentanyl versus dexmedetomidine in cases of difficult airway.Materials and Methods:A randomized prospective study was conducted in the department of oral and maxillofacial surgery, with a total of 60 patients, 18–55 years of age, ASA class I–II, of either sex with anticipated difficult airway planned for elective surgery. They were divided into two groups; group I patients received 1 μg/kg of dexmedetomidine and then an infusion of 0.5 to 0.7 μg/kg/hr of dexmedetomidine, whereas group II patients received 1 μg/kg of intra-venous (iv) fentanyl and 0.05 mg/kg of iv midazolam with additional doses of 0.02 mg/kg to achieve a Ramsay Sedation Scale score of ≥2. The ease of placement of the fiber-optic scope and the endotracheal tube and the patient's reaction to placement of the fiber-optic scope were assessed on a scale of 1–4 and were recorded as endoscopist satisfaction score and patient discomfort score, respectively.Results:The endoscopy time ranged from 2.66 ± 1.00 (group I) to 3.90 ± 0.96 (group II) minutes and was found to be statistically significant (p < 0.05). Also, the patient discomfort score was recorded during endoscopy (1–4) and ranged from 1.3 ± 0.53 (group I) and 2.33 ± 0.66 (group II) and was found to be statistically significant (p value < 0.05). Patients undergoing the procedure who received dexmedetomidine were thus more comfortable than those who received fentanyl and midazolam combination.Conclusion:Dexmedetomidine provided better intubating conditions, patient tolerance, higher endoscopist satisfaction, and reduced hemodynamic responses compared to fentanyl and midazolam combinations. Also, the major advantage of dexmeditomidine for preservation of airway with a lesser degree of respiratory depression allows for safer use of AFOI in cases of difficult airway.

Evaluation of IV to Enteral Benzodiazepine Conversion Calculations in a Pediatric Intensive Care Setting

To evaluate if institutionally established calculations for transitioning continuous IV midazolam to enteral benzodiazepines maintain Withdrawal Assessment Tool-Version 1 scores equal to or less than preconversion values. Retrospective cohort study evaluating the effectiveness and safety of benzodiazepine conversion calculations embedded within an institution-specific clinical pathway for sedation and weaning of mechanically ventilated pediatric patients. A 55-bed, mixed-medical, noncardiac surgical PICU in a tertiary care children's hospital. All patients age 6 months to 18 years who received continuous midazolam for 5 days or longer while mechanically ventilated for 5-21 days and were then converted to either enteral diazepam or lorazepam following extubation (or return to baseline ventilator settings in tracheostomy-dependent patients) between January 1, 2015, and June 30, 2016. Benzodiazepine conversion calculations were applied according to institutional clinical pathway guidance. Withdrawal Assessment Tool-Version 1 scores were compared pre and post benzodiazepine conversion. Patient demographics, benzodiazepine dose escalations, as needed benzodiazepine requirements, and severe adverse events within 48 hours of conversion were assessed. Seventy-one patient encounters were analyzed (median age, 2.5 yr; interquartile range, 1.2-5.3). The median Withdrawal Assessment Tool-Version 1 scores pre conversion and post conversion were not significantly different (1 [interquartile range, 0.75-2] and 1 [interquartile range, 0.25-2], respectively, p = 0.1). As needed benzodiazepine doses were administered in 38% of encounters post conversion, but escalation of a scheduled enteral benzodiazepine regimen was only required in 2.8% of encounters. Post conversion, one patient (1.4%) had increased seizure activity, and four patients (5.6%) required fluid boluses secondary to tachycardia or dehydration, but not hypotension. These findings suggest that standardized benzodiazepine conversions successfully achieved consistent Withdrawal Assessment Tool-Version 1 scores compared with preconversion values. Severe adverse events associated with oversedation and/or withdrawal were minimal and confounded by underlying disease states.

Effect of hyperlipidemia on pulmonary uptake in patients inhaling sevoflurane for anesthesia

Objective To evaluate the effect of hyperlipidemia on pulmonary uptake in the patients inhaling sevoflurane for anesthesia. Methods A total of 103 patients of both sexes, aged 20-50 yr, with body mass index of 18-25 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing elective operation under general anesthesia, were enrolled in the study.Anesthesia was induced with iv midazolam 0.1 mg/kg, vecuronium 0.1 mg/kg, fentanyl 0.1 mg/kg and etomidate 0.3 mg/kg.Patients were mechanically ventilated after endotracheal intubation.Patients inhaled 2% sevoflurane for 30 min at an oxygen flow rate of 2 L/min.The inspired concentrations(Fi)and expired concentrations(Fe, Fe≈alveolar concentration[Fa]) of sevoflurane were recorded at 1, 3, 5, 7, 10, 15, 20 and 30 min of inhalation(T0-7). Patients were divided into either control group(group C)or hyperlipidemia group(group H)according to the results of blood lipid levels after the end of observation.The ratio of Fa/Fi and time spent in reaching the titration value(Fa/Fi= 0.8)were calculated in each group. Results There were 67 cases in group C and 36 cases in group H. Compared with group C, the Fa/Fi ratio was significantly decreased at 5, 7 and 10 min of inhalation, and the time spent in reaching the titration value was prolonged in group H(P < 0.05). Conclusion The pulmonary uptake of sevoflurane is increased, which may be associated with increased blood/gas partition coefficient. Key words: Hyperlipemia; Anesthetic, inhalation; Pulmonary uptake; Pharmacokinetics

Efficacy of clemastine fumarate in antagonizing atracurium-induced release of histamine in patients undergoing surgery under general anesthesia

Objective To evaluate the efficacy of clemastine fumarate in antagonizing atracurium-induced release of histamine in the patients undergoing surgery under general anesthesia. Methods Eighty American Society of Anesthesiologists physical statusⅠ or Ⅱ patients, aged 21-59 yr, with body mass index of 17-26 kg/m2, scheduled for elective modified radical mastectomy, were divided into 2 groups (n=40 each) using a random number table: control group (group C) and clemastine fumarat group (group CF). Clemastine fumarate 2 mg was injected intramuscularly at 20 min before induction of anesthesia.Anesthesia was induced with iv midazolam 0.1 mg/kg, etomidate 0.3 mg/kg, fentanyl 4-6μg/kg and atracurium 0.8 mg/kg.The patients were mechanically ventilated after insertion of the larygeal mask airway.Anesthesia was maintained with inhalation of 2% sevoflurane.Before administration of clemastine fumarate, at 20 min after administration, immediately before administration of atracurium, and at 2, 5, 10 and 20 min after administration of atracurium, arterial blood samples were taken for determination of plasma histamine concentrations, and the peak airway pressure and degree of cutaneous color were recorded.The development of histaminemia and adverse cardiovascular events was assessed.Steward recovery scores and Ramsay sedation scores were recorded at 10 min after removal of the laryngeal mask airway. Results The incidence of histaminemia was 60% and 8% in C and CF groups, respectively.Compared with group C, the plasma histamine concentrations, incidence of histaminemia, degree of cutaneous color, and incidence of hypotension and tachycardia were significantly decreased (P 0.05). Conclusion For atracurium-induced release of histamine in the patients undergoing surgery under general anesthesia, clemastine fumarate 2 mg injected intramuscularly before operation can not only antagonize histamine at H1 level, but also reduce histamine release, and exerts no influence on recovery from anesthesia and produces good antihistamine efficacy. Key words: Histamine H1 antagonists; Atracurium; Histamine release; Anesthesia, general

Reliability of serum catecholamine concentrations in reflecting depth of dexmedetomidine-based gene-ral anesthesia

Objective To evaluate the reliability of serum catecholamine concentrations in reflecting the depth of dexmedetomidine-based general anesthesia. Methods Forty patients, aged 30-45 yr, of American Society of Anesthesiologists physical statusⅠ-Ⅱ, undergoing elective laparoscopic hysterectomy under general anesthesia, were divided into 2 groups(n=20 each)using a random number table: dexmedetomidine-based general anesthesia group(groupⅠ)and general anesthesia group(group Ⅱ). Dexmedetomidine was intravenously infused as a loading bolus of 1 μg/kg over 10 min before induction of anesthesia, followed by an infusion of 0.5 μg·kg-1·h-1 until 30 min before the end of operation in groupⅠ.The equal volume of normal saline was given instead of dexmedetomidine in group Ⅱ.Anesthesia was induced with iv midazolam 0.05 mg/kg, propofol 1 mg/kg, cisatracurium 0.15 mg/kg and sufentanil 0.4 μg/kg.Anesthesia was maintained with iv infusion of remifentanil 0.1-0.3 μg·kg-1·min-1, 1%-2% sevoflurane inhalation and intermittent iv boluses of cisatracurium.Before administration of dexmedetomidine, at the end of administration of the loading dose, at the end of intubation, at the end of skin incision, after establishment of pneumoperitoneum and at the end of operation(T0-5), venous blood samples were taken from the peripheral vein for determination of concentrations of epinephrine(E)and norepinephrine(NE)in serum(by enzyme-linked immunosorbent assay). Results Compared with group Ⅱ, the serum NE and E concentrations were significantly decreased at T1-4 in groupⅠ(P<0.05). Compared with the baseline at T0, the serum NE and E concentrations were significantly decreased at T1 in groupⅠ, and increased at T2-4 in group Ⅱ(P<0.05). Conclusion The serum catecholamine concentration produces poor reliability in reflecting the depth of dexmedetomidine-based general anesthesia, and thus it is not a suitable monitoring index. Key words: Dexmedetomidine; Catecholamine; Anesthesia, general

Effect of ORM1 genetic polymorphism on time-course of muscle relaxation induced by rocuronium

Objective To evaluate the effect of ORM1 genetic polymorphism on the time-course of muscle relaxation induced by rocuronium. Methods Seventy American Society of Anesthesiologists physical status Ⅰor Ⅱ patients, aged 25-55 yr, scheduled for elective gynecological laparoscopic surgery, with body mass index of 20-25 kg/m2, were enrolled in this study.Anesthesia was induced with iv midazolam and fentanyl and target-controlled infusion of propofol.After the patients lost consciousness, neuromuscular block was assessed with TOF Watch-SX using single stimulation of the ulnar nerve.When the maximal twitch depression was achieved, tracheal intubation was facilitated with rocuronium 0.6 mg/kg.The patients were mechanically ventilated.End-tidal carbon dioxide partial pressure was maintained at 35-45 mmHg.The onset time, nonresponse time, clinical duration, 75% recovery time and recovery index of rocuronium were recorded.Peripheral venous blood samples were collected before surgery for determination of concentrations of plasma alpha1 acid glycoprotein, C-reactive protein(by enzyme-linked immunosorbent assay)and albumin(by biochemical method). ORM1 genotypes were detected by polymerase chain reaction-restriction fragment length polymorphism.The patients were divided into 3 groups according to the ORM1 genotypes: wild homozygote(ORM1*F1/*F1) group (AA group), mutation heterozygote(ORM1*F1/*S) group (AG group)and mutation homozygote(ORM1*S/*S) group (GG group). Results There were 40 cases in group AA, 25 cases in group AG, and 5 cases in group GG.There were no significant differences in plasma alpha1 acid glycoprotein, albumin and C-reactive protein concentrations between the three groups(P>0.05). Compared with group AA, the clinical duration, 75% recovery time and recovery index of rocuronium were significantly prolonged(P 0.05). Conclusion ORM1 genetic polymorphism is one of the genetic factors which affect the time-course of muscle relaxation induced by rocuronium. Key words: Orosomucoid; Polymorphism, single nucleotide; Androstanols; Neuromuscular blockade; Dose-response relationship, drug

Comparison of cerebral oxygenation inpatients undergoing gynecological laparoscopic surgery under sevoflurane- versus propofol-based anesthesia

Objective To compare the cerebral oxygenation in the patients undergoing gynecological laparoscopic surgery under sevoflurane- versus propofol-based anesthesia. Methods Fifty adult patients, aged 18-56 yr, weighing 55-72 kg, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, with hemoglobin≥110 g/L, undergoing elective gynecological laparoscopic surgery under general anesthesia, were equally and randomly divided into sevoflurane group(group S)and propofol group(group P)using a random number table.Anesthesia was induced with iv midazolam 0.04 mg/kg, sufentanil 1.5-2.0 μg/kg, rocuronium 0.9 mg/kg, and propofol 1.5-2.0 mg/kg.Anesthesia was maintained with inhalation of sevoflurane(2.0%-2.6%)in group S, or with target-controlled infusion of propofol(plasma concentration 2.5-4.0 μg/ml)in group P. The concentrations of sevoflurane and propofol were adjusted to maintain bispectral index value at 40-50.In both groups, remifentanil was given by target-controlled infusion(target plasma concentration 2 ng/ml), and vecuronium 0.06-0.08 mg/kg was injected intermittently to maintain muscle relaxation.The regional cerebral oxygen saturation(rSO2)was recorded after induction and at 10 min before pneumoperitoneum(T1), at 10 min of pneumoperitoneum in the Trendelenburg position(T2), and at 10 min after the end of pneumoperitoneum(T3). The occurrence of cerebral oxygen desaturation was recorded during surgery. Results The rSO2 was significantly higher at T2, 3 in group S than in group P(P 0.05), and the rSO2 was significantly decreased at T2, 3 in group P(P<0.05). The incidence of cerebral oxygen desaturation was 12% in group P, and cerebral oxygen desaturation was not detected in group S. Conclusion Sevoflurane-based anesthesia produces no effect on rSO2, however, propofol-based anesthesia can decrease rSO2 in the patients undergoing gynecological laparoscopic surgery, and sevoflurane-based anesthesia is more suitable for gynecological laparoscopic surgery. Key words: Anesthetics, inhalation; Propofol; Laparoscopy; Brain; Oxygen

Comparison of Butorphanol with Fentanyl for reducing Etomidate-induced myoclonus: A Prospective, Randomised Clinical Trial

Background and Aims: Etomidate is frequently used nowadays as an inducing agent in patients with compromised cardiovascular function, but it leads to undesirable side effect like myoclonus and pain on injection during induction in unpre-medicated patients. Several drugs are considered alone and in combination, before induction to reduce the incidence of myoclonus. This prospective, randomized study was aimed to compare butorphanol and fentanyl administered before the induction of etomidate to reduce the myoclonic movements. Material and Methods: Sixty patients of ASA I-II, aged 18-50 years undergoing surgeries in general anaesthesia were divided into two groups and pretreated either with intravenous butorphanol 0.02mg/kg and iv midazolam 1mg(Group BM) or intravenous fentanyl 1mcg/kg and iv midzolam(Group FM) followed by induction with etomidate until loss of eyelash reflex. Incidence and severity of myoclonus, pain on injection, apnoea and postoperative nausea and vomiting were noted. Induction dose of etomidate and induction time were observed and compared between the two groups. Results: Study results showed the incidence of myoclonus of grade 1 were 6.7% and 10% in group BM and group FM respectively(p=1.000). The mean dose of etomidate for induction and induction time were found to be 10.00±1.5mg and 32±4.50 seconds in group BM as compared to 12.00±1.8mg and 40±5.00seconds respectively in group FM.(p

Optimum dose of oxycodone inhibiting responses to tracheal intubation with a double-lumen endobronchial tube in patients undergoing one-lung ventilation

Objective To determine the optimum dose of oxycodone inhibiting responses to tracheal intubation with a double-lumen endobronchial tube in patients undergoing one-lung ventilation (OLV). Methods Sixty adult patients aged 55-64 yr, weighing 60-80 kg, with American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective thoracic surgery requiring OLV, were randomly divided into 3 different doses of oxycodone groups (O1-3 groups, n= 20 each). Anesthesia was induced with iv midazolam 0.05 mg/kg, oxycodone 0.30, 0.35 and 0.40 mg/kg (O1-3 groups, respectively), propofol 1.5 mg/kg and rocuronium 0.9 mg/kg.The patients were tracheally intubated using a double-lumen endobronchial tube and mechanically ventilated.Before anesthesia induction (T0), immediately before and after intubation (T1, 2), and 1 and 5 min after intubation (T3, 4), arterial blood samples were taken to determine the concentrations of serum norepinephrine (NE) and epinephrine (E) using high-performance liquid chromatography.The occurrence of bucking, body movement, hypertension, and tachycardia were observed. Results The concentrations of serum NE and E were significantly increased at T2, 3 than at T1 in group O1(P 0.05). Conclusion The optimum dose of oxycodone inhibiting responses to tracheal intubation with a double-lumen endobronchial tube is 0.35 mg/kg in patients undergoing OLV. Key words: Oxycodone; Respiration, artificial; Intubation, intratrachel; Stress

Infraslow Status Epilepticus: A new form of subclinical status epilepticus recorded in a child with Sturge Weber Syndrome

Background: Analysis of infraslow EEG activity (ISA) has shown potential in the evaluation of patients with epilepsy and in differentiating between focal and generalized epilepsies. The purpose of this report is to present a girl with Sturge-Weber Syndrome (SWS) who was identified to have infraslow status epilepticus (ISSE), which successfully resolved after Midazolam administration Methods: The continuous EEG recording of a 5-yr-old girl with known Structural Epilepsy due to Sturge-Weber is presented. The patient presented to the ED with acute confusion, eye deviation and right hemiparesis similar to two previous admissions. ltm-eeg showed diffuse slowing. DWI obtained within 72-hr showed no ischemic changes, analysis of the EEG nfraslow (ISA) activity was undertaken using LFF 0.01 AND HFF of 0.1 Hz respectively. Results: Continuous subclinical unilateral rhythmic ictal ISA was identified. This was only evident in the left hemisphere which correlated with the structural changes due to SWS. A trial of continuous IV midazolam resulted in immediate resolution of the contralateral hemiparesis and encephalopathy. Conclusion: Continuous prolonged rhythmic ictal Infraslow activity (ISA) can cause super-refractory subclinical focal status epilepticus. This has not previously reported, and we propose this should be called Infraslow status epilepticus (ISSE). ISA analysis should be performed in all patients with unexplained subclinical status epilepticus.

Effect of butorphanol combined with dexmedetomidine on postoperative hyperalgesia induced by remifentanil

Objective To evaluate the effect of butorphanol combined with dexmedetomidine on postoperative hyperalgesia induced by remifentanil in patients. Methods One hundred and twenty patients, of ASA physical status Ⅰ or Ⅱ, aged 20-64 yr, weighing 45-88 kg, undergoing elective gynecological laparoscopic surgery, were randomly allocated into 4 groups(n=30 each)using a random number table: control group(group C), butorphanol group(group B), dexmedetomidine group(group D)and dexmedetomidine + butorphanol group(group B+ D). In group D, dexmedetomidine 1.0 μg/kg was infused at 10 min before induction of anesthesia, followed by continuous infusion at 0.7 μg·kg-1·h-1 until the end of operation.In group C, the equal volume of normal saline was given instead before skin incision.In group B, butorphanol 20 μg/kg was injected immediately before skin incision.In group B+ D, dexmedetomidine 0.5 μg/kg was infused at 10 min before induction of anesthesia, followed by continuous infusion at 0.5 μg·kg-1·h-1 until the end of operation, and butorphanol 15 μg/kg was injected immediately before skin incision.Anesthesia is induced with iv midazolam 0.05 mg/kg, sufentanyl 0.2-0.3 μg/kg, rocuronium 0.7 mg/kg and propofol 2.0 mg/kg.After tracheal intubation, all the patients are mechanically ventilated, and PETCO2 was maintained at 35-45 mmHg.Anesthesia was maintained with iv infusion of remifentanil 0.3 μg·kg-1·min-1 and propofol 4-6 mg·kg-1·h-1 and intermittent iv boluses of rocuronium 0.3 mg/kg.BIS value was maintained at 40-60.Patient-controlled intravenous analgesia(PCIA)with sufentanil was used after operation, and VAS score was maintained≤3.At 30 and 60 min and 6, 12, 24 and 48 h after operation, the sufentanil consumption was recorded.The development of bradycardia and hypotension during operation and postoperative nausea and vomiting, dizziness and somnolence was recorded. Results Compared with group C, the sufentanil consumption and incidence of nausea and vomiting were significantly decreased in B, D and B+ D groups, the incidence of dizziness and somnolence was increased in group B, and the incidence of bradycardia and hypotension was increased in group D. There was no significant difference in sufentanil consumption between B, D and B+ D groups.The incidence of dizziness and somnolence was significantly lower in group B+ D than in group B. The incidence of bradycardia, hypotension and somnolence was significantly lower in group B+ D than in group D. Conclusion Butorphanol combined with dexmedetomidine provides better efficacy than either alone in reducing postoperative hyperalgesia induced by remifentanil in patients. Key words: Dexmedetomidine; Butorphanol; Piperidines; Hyperalgesia; Postoperative complications

Effect of dexmedetomidine on quality of wake-up test in patients undergoing posterior osteotomy correction surgery

Objective To evaluate the effect of dexmedetomidine on quality of wake-up test in the patients undergoing posterior osteotomy correction surgery. Methods Ninety-seven patients of both sexes, aged 17-59 yr, of ASA physical status Ⅰor Ⅱ, with body mass index 18.5-25.0 kg/m2 and global kyphosis angle>60°, scheduled for elective posterior osteotomy correction surgery under general anesthesia, were randomly divided into 2 groups using a random number table: control group C (n=46) and group D (n=51). In group D, dexmedetomidine 1.0 μg/kg was infused over 15 min before induction of anesthesia, and group C received the equal volume of normal saline instead.Anesthesia was induced with iv midazolam, propofol, fentanyl, vecuronium and dexamethasone in C and D groups.Mechanical ventilation was performed after tracheal intubation.Anesthesia was maintained with infusion of cisstracurium, propofol and remifentanil.Dexmedetomidine 0.3 μg·kg-1·h-1 was infused throughout the surgery in group D, and meanwhile normal saline was given throughout the surgery in group C. The anesthetic drugs for maintenance except dexmedetomidine were discontinued at the beginning of the wake-up test.The wake-up time was recorded and the wake-up quality was assessed.Ramsay sedation scores and Riker sedation-agitation scale scores were also recorded when all the patients were successfully awakened.The development of cardiovascular events during wake-up test and intraoperative awareness was recorded. Results The wake-up quality was significantly higher, Riker sedation-agitation scale scores were lower, Ramsay sedation scores were higher, the incidence of nausea and vomiting was lower, and no significant change was found in wake-up time in group D. No intraoperative awareness was observed in the two groups. Conclusion Dexmedetomidine can raise wake-up quality without prolonging wake-up time and with stable hemodynamics and fewer side effects in the patients undergoing posterior osteotomy correction surgery. Key words: Dexmedetomidine; Wake-up Test; Orthopedic Procedures

Efficacy of dexmedetomidine versus midazolam for prevention of emergence agitation after sevoflurane-based anesthesia in pediatric patients undergoing minor surgery

Objective To compare the efficacy of dexmedetomidine versus midazolam for prevention of the emergence agitation after sevoflurance-based anesthesia in the pediatric patients undergoing minor surgery.Methods Sixty ASA physical status Ⅰ or Ⅱ patients of both sexes,aged 4-8 yr,weighing 15-30 kg,scheduled for elective bilateral tonsillectomy and adenoidectomy,were randomly divided into 2 groups (n =30 each) using a random number table:midazolam group (group M) and dexmedetomidine group (group D).Anesthesia was induced with iv midazolam 0.1 mg/kg and dexmedetomidine 0.5 μg/kg in M and D groups,respectively.Tracheal intubation was performed after induction of anesthesia.Anesthesia was maintained with inhalation of 2％-3％ sevoflurane and remifentanil infusion (0.5 μg· kg-1· min-1).HR and mean arterial pressure (MAP) were recorded before induction of anesthesia (baseline),at the end of operation,at extubation,and at 5 and 10 min after extubation.Riker sedation-agitation scale scores were recorded at extubation and pain was assessed using the Face,Legs,Activity,Cry,Consolability (FLACC) scale at 30 min after extubation.Results Compared with group M,MAP,HR,Riker sedation-agitation scale scores,FLACC scale scores and the incidence of agitation were significantly decreased at extubation and 5 and 10 min after extubation in group D.Conclusion Dexmedetomidine provides better efficacy than midazolam for prevention of the emergence agitation after sevoflurance-based anesthesia in the pediatric patients undergoing minor surgery. Key words: Dexmedetomidine; Midazolam ; Anesthesia recovery period ; Child ; Agitation ; Sevoflurane

Evaluation of mivacurium-induced release of histamine in patients undergoing general anesthesia

Objective To evaluate mivacurium-induced release of histamine in the patients undergoing general anesthesia.Methods Eighty patients of both sexes,aged 19-58 yr,weighing 42-75 kg,of ASA physical status Ⅰ or Ⅱ,undergoing ureteroscopy under general anesthesia,were randomly divided into 2 groups (n =40 each) using a random number table:rocuronium group (group R) and mivacurium group (group M).Anesthesia was induced with iv midazolam 0.04 mg/kg,fentanyl 3 μg/kg,etomidate 0.3 mg/kg,and mivacurium 0.20 mg/kg (group M) or rocuronium 0.75 mg/kg (group R).Streamlined liner of the pharynx airway (SLIPA) was inserted for mechanical ventilation.PET CO2 was maintained at 35-40 mmHg.Anesthesia was maintained with fentanyl and propofol.Before muscle relaxant administration,at 3 min after muscle relaxant administration and at 5 min after insertion of SLIPA,venous blood samples were collected for determination of plasma histamine concentrations (by HPLC) and the histamine release was classified.Results Compared with group R,the plasma histamine concentration and histamine release were increased at 3 min after muscle relaxant administration in group M.No fatal responses caused by histamine release were found in the two groups.Conclusion Although mivacurium induces release of histamine,it can still be safely used for the patients undergoing ureteroscopy under general anesthesia. Key words: Androstanols ; Histamine ; Anesthesia, general

Effect of diabetes mellitus on cisatracurium-induced neuromuscular block when combined with sevoflurane anesthesia

Objective To evaluate the effect of diabetes mellitus (DM) on cisatracurium-induced neuromuscular block when combined with sevoflurane anesthesia.Methods Thirty patients of both sexes,aged 30-60 yr,with body mass index of 18-25 kg/m2,scheduled for elective endoscopic sinus surgery,of ASA physical status Ⅰ or Ⅱ,were included in the study.The patients with type 2 DM and course of disease ＞ 3 yr served as DM group (n =15).Another 15 non-diabetic patients were included in thisstudy as control group (n =15).Neuromuscular block was monitored with TOF-Watch(R) SX Monitor.The response of the adductor pollicis to TOF stimulation of the ulnar nerve was recorded after loss of consciousness.Anesthesia was induced with iv midazolam 0.05-0.10 mg/kg,fentanyl 3-5 tg/kg and propofol 1-2 mg/kg,and maintained with inhalation of.sevoflurane (endtidal concentration of 2 ％) and infusion of remifentanil 0.1-0.3μg· kg-1 · min-1.No response time (duration of T1 =0),clinical duration (time from end of injection to 25 ％ recovery of T1),and recovery index (T1 from 25 ％-75 ％) were recorded.Results Compared with C group,no response time,clinical duration,and recovery index were prolonged in DM group.Conclusion DM can prolong the duration of action of cisatracurium when combined with sevoflurane anesthesia and inhibit the recovery of neuromuscular block. Key words: Diabetes mellitus; Atracurium; Neuromuscular blockade; Anesthetics,inhalation

A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study.

We aimed to compare the effectiveness and safety of ketamine-midazolam and ketamine-propofol combinations for procedural sedation in endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). Sixty patients who were undergoing EBUS-TBNA were included in this study. Patients were randomly divided into two groups. Group 1 was given 0.25 mg/kg intravenous (iv) ketamine, 2 min later than 0.05 mg/kg iv midazolam. Group 2 received 0.125 mg/kg ketamine-propofol mixture (ketofol), 2 min subsequent to injection of 0.25 mg/kg each. Sedation was maintained with additional doses of ketamine 0.25 mg/kg, and ketofol 0.125 mg/kg each in Group 1 and Group 2, respectively. Blood pressure, heart rate (HR), peripheral oxygen saturation, respiratory rate (RR), Ramsay Sedation Score (RSS), and severity of cough were recorded prior to and after administration of sedation agent in the beginning of fiberoptic bronchoscopy (FOB) and every 5 min of the procedure. The consumption of the agents, the satisfactions of the bronchoscopist and the patients, and the recovery time were also recorded. HR in the 10(th) min and RSS value in the 35(th) min of induction in Group 1 were higher than the other group (P<0.05). The recovery time in Group 1 was statistically longer than Group 2 (P<0.05). There was no statistically significant difference between groups with respect to other parameters (P>0.05). It was concluded that both ketamine-midazolam and ketamine-propofol combinations for sedation during EBUS-TBNA were similarly effective and safe without remarkable side effects.

High-dose midazolam infusion for refractory status epilepticus

This study compares 2 treatment protocols allowing low vs high continuous IV midazolam (cIV-MDZ) doses. We compared adults with refractory status epilepticus treated with a protocol allowing for high-dose cIV-MDZ (n = 100; 2002-2011) with those treated with the previous lower-dose cIV-MDZ (n = 29; 1996-2000). We collected data on baseline characteristics, cIV-MDZ doses, seizure control, hospital course, and outcome. Median maximum cIV-MDZ dose was 0.4 mg/kg/h (interquartile range [IQR] 0.2, 1.0) for the high-dose group and 0.2 mg/kg/h (IQR 0.1, 0.3) for the low-dose group (p < 0.001) with similar duration of infusion. Median time from status epilepticus onset to cIV-MDZ start was 1 day (IQR 1, 3) for the high-dose group and 2 days (IQR 1, 5) for the low-dose group (p = 0.016). "Withdrawal seizures" (occurring within 48 hours of discontinuation of cIV-MDZ) were less frequent in the high-dose group (15% vs 64%, odds ratio 0.10, 95% confidence interval 0.03-0.27). "Ultimate cIV-MDZ failure" (patients requiring change to a different cIV antiepileptic medication) and hospital complications were not different between groups. Hypotension was more frequent with higher cIV-MDZ doses but was not associated with worse outcome. Discharge mortality was lower in the high-dose group (40% vs 62%, odds ratio 0.34, 95% confidence interval 0.13-0.92 in multivariate analysis). High-dose cIV-MDZ treatment of refractory status epilepticus can be performed safely, is associated with a lower seizure rate after cIV-MDZ discontinuation, and may be associated with lower mortality than traditional lower-dose protocols. This study provides Class III evidence that midazolam at higher infusion rates is associated with a reduction in seizure recurrence within 48 hours after discontinuation and may be associated with lower mortality.

Effects of dexmedetomidine on hemodynamics and myocardial injury in patients with pulmonary hypertension undergoing mitral valve replacement

Objective To investigate the effects of dexmedetomdine on hemodynamics and myocardial injury in patients with pulmonary hypertension undergoing mitral valve replacement.Methods Forty ASA Ⅱ or Ⅲ patients with pulmonary hypertension,aged 18-64 yr,undergoing mitral valve replacement,were randomized into 2 groups (n =20 each):control group (group C) and dexmedetomidine group (group D).Anesthesia was induced with iv midazolam 0.05 mg/kg,sufentanil 1 μg/kg,etomidate 0.3 mg/kg and rocuronium 0.6 mg/kg and maintained with combined intravenous-inhalational anesthesia.Narcotrend index values were maintained at 40-50.The patients were tracheal intubated and mechanically ventilated.A loading dose of dexmedetomidine 1 μg/kg was injected intravenously over 10 min after intubation followed by infusion at 0.5 μg· kg-1· h-1 until the end of operation in group D.While the equal volume of normal saline was given in group C.Venous blood samples were taken immediately before dexmedetomidine administration,at 10 min after termination of cardiopulmonary bypass (CPB),at the end of operation,and at 6 and 24 h after operation for determination of plasma levels of creatine kinase MB (CK-MB) and cardiac troponin Ⅰ (cTnI) by ELISA.Before and after administration of dexmedetomidine,at skin incision,at sternum splitting,before and after CPB,and at the end of operation,HR,MAP,mean pulmonary arterial pressure (MPAP),cardiac output (CO),systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) were detected by using Swan-Ganz catheter and Vigilance Ⅱ monitor.The requirement for vasoactive drugs and condition of spontaneous heart beats were recorded.Results In group D,each hemodynamic parameter was maintained stable at skin incision and sternum splitting,and MPAP was decreased after CPB and maintained at a lower level.The plasma levels of CK-MB and cTnI,consumption of phenylephrine and dopamine,and requirement for epinephrine were significantly lower in group D than in group C (P ＜ 0.05).There was no significant difference in the consumption of milrinone and rate of spontaneous heart beat between the two groups (P ＞ 0.05).Conclusion During mitral valve replacement for patients with pulmonary hypertension,dexmedetomidine infused at 0.05 μg·kg-1· h-1 after a loading dose of 1 μg/kg is helpful in maintaining systemic circulation and pulmonary circulation stable and provides myocardial protection to some extent. Key words: Dexmedetomidine ; Hemodynamics; Heart valve prosthesis implantation; Myocardial injury

Serotonin Syndrome after Sertraline Overdose in a Child: A Case Report

Serotonin syndrome is a potentially life-threatening drug effect. It may be misdiagnosed because it has mostly been reported in adults. Case Report. An 8-year-old girl with behavioral problems and medicated with risperidone and sertraline was admitted in the emergency department after she had taken voluntarily 1500 mg of sertraline (50 mg/kg). At admission, she had marked agitation, visual hallucinations, diaphoresis, flushing, and tremor. She had fever and periods of hypertension. She also showed generalized rigidity and involuntary movements. She was treated with fluids and iv diazepam, midazolam, clemastine, and biperiden. As the patient presented a severe insomnia and a progressive rhabdomyolysis, she was transferred to pediatric intensive care unit (ICU), where she was under treatment with cyproheptadine, mechanical ventilation, and muscular paralysis for 11 days. She was discharged from hospital a few days later with no neurological sequelae. Conclusions. Serotonin syndrome is still not well recognized by physicians. In our patient, the diagnosis was made early due to the history of overdose with serotonin reuptake inhibitors and the triad of mental, neurological, and autonomic signs. Parents must be educated to prevent children from having free access to drugs, avoiding self-medication or overdose.