Low-dose Midazolam Research Articles

Use Of Ketamine In Refractory Status Epilepticus With Hemodynamic Instability

The use of benzodiazepines, such as midazolam, as a last-resort treatment for refractory status epilepticus is widely practiced, particularly in patients who are hemodynamically stable. However, as the dosage of this antiepileptic agent is increased, it potentiates γ-aminobutyric acid (GABA) activity, which can lead to hypotension and subsequently necessitate the administration of vasopressor agents, especially in cases involving hemodynamic instability, as illustrated by this case where a young man who arrived at the emergency department with complaints of epileptic seizures and was already on regular anti-epileptic medications. During a seizure episode in the department, he was administered intravenous Lorazepam according to standard protocol to stop the seizure, and then placed on an IV infusion of Midazolam. However, his hemodynamics became unstable due to the side effects of the benzodiazepines administered. To address this instability, the decision was made to initiate an infusion of Ketamine along with a low dose of Midazolam. This combination successfully terminated the epileptic activity and stabilized his hemodynamics. In these instances, either concurrent or standalone administration of N-methyl-D-aspartate (NMDA) receptor antagonists might prove beneficial for managing refractory status epilepticus. For example, ketamine infusion can inhibit the reuptake of catecholamines into the systemic circulation, thereby aiding in the maintenance of blood pressure in hemodynamically unstable patients. The initial application of a combined third-line therapy, which involves blocking NMDA receptors while simultaneously enhancing GABAergic activity, appears promising for the management of refractory status epilepticus

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis.

Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs. This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status. A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs. The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Intrahospital Transport of Critically Ill Patients with Subarachnoid Hemorrhage-Frequency, Timing, Complications, and Clinical Consequences.

Patients with subarachnoid hemorrhage (SAH) often necessitate intra-hospital transport (IHT) during intensive care treatment. These transfers to facilities outside of the neurointensive care unit (NICU) pose challenges due to the inherent instability of the hemodynamic, respiratory, and neurological parameters that are typical in these patients. In this retrospective, single-center cohort study, a total of 108 IHTs were analyzed for demographics, transport rationale, clinical outcomes, and pre/post-IHT monitoring parameters. After establishing clinical thresholds, the frequency of complications was calculated, and predictors of thresholds violations were determined. The mean age was 55.7 (+/-15.3) years, with 68.0% showing severe SAH (World Federation of Neurosurgical Societies Scale 5). IHTs with an emergency indication made up 30.8% of all transports. Direct therapeutic consequences from IHT were observed in 38.5%. On average, the first IHT occurred 1.5 (+/-2.0) days post-admission and patients were transported 4.3 (+/-1.8) times during their stay in the NICU. Significant parameter changes from pre- to post-IHT included mean arterial pressure, systolic blood pressure, oxygen saturation, blood glucose levels, temperature, dosages of propofol and ketamine, tidal volume, inspired oxygen concentration, Horovitz index, glucose, pH, intracranial pressure, and cerebral perfusion pressure. Relevant hemodynamic thresholds were violated in 31.5% of cases, while respiratory complications occurred in 63.9%, and neurological complications in 20.4%. For hemodynamic complications, a low heart rate with a threshold of 61/min (OR 0.96, 95% CI 0.93-0.99, p = 0.0165) and low doses of midazolam with a threshold of 17.5 mg/h (OR 0.97, 95% CI 0.95-1.00, p = 0.0232) significantly predicted adverse events. However, the model did not identify significant predictors for respiratory and neurological outcomes. Conclusively, IHTs in SAH patients are associated with relevant changes in hemodynamic, respiratory, and neurological monitoring parameters, with direct therapeutic consequences in 4/10 IHTs. These findings underscore the importance of further studies on the clinical impact of IHTs.

Feasibility of neck electrical impedance tomography to monitor upper airway dynamics during sleep

BackgroundThere is a lack of non-invasive methods for monitoring the upper airway patency during sleep. Electrical impedance tomography (EIT) is a non-invasive, radiation-free tool that has been validated to monitor lung ventilation. We hypothesized that electrical impedance tomography (EIT) can be used for monitoring upper airway patency during sleep.MethodsSleep was induced in 21 subjects (14 males, age 43 ± 13 years, body mass index 32.0 ± 5.3 kg/m2) with suspected obstructive sleep apnea (apnea-hypopnea index: 44 ± 37 events/h, range: 1–122 events/h) using low doses of midazolam. Patients wore a nasal mask attached to a modified CPAP device, allowing variable and controlled degrees of upper airway obstruction. Confirmation of upper airway patency was obtained with direct visualization of the upper airway using nasofibroscopy (n = 6). The changes in total neck impedance and in impedance in four cranio-caudal regions of interest (ROIs) were analyzed.ResultsTotal neck impedance varied in concert with breathing cycles and peaked during expiration in all patients. Group data showed a high cross-correlation between flow and impedance curves (r = −0.817, p < 0.001). Inspiratory peak flow correlated with simultaneous neck impedance (r = 0.866, p < 0.001). There was a high correlation between total neck impedance and velopharynx area (r = 0.884, p < 0.001), and total neck impedance and oropharynx area (r = 0.891, p < 0.001).ConclusionsNeck EIT is sensitive and captures pharyngeal obstruction under various conditions. Neck EIT is a promising method for real-time monitoring of the pharynx during sleep.

Comparative Study of Effects of Low-dose Midazolam and Low-dose Dexmedetomidine on Hemodynamic Variables and Surgical Conditions in Hypertensive Patients Undergoing Cataract Surgery under Regional Anesthesia: A Prospective Comparative Study

Comparative Study of Effects of Low-dose Midazolam and Low-dose Dexmedetomidine on Hemodynamic Variables and Surgical Conditions in Hypertensive Patients Undergoing Cataract Surgery under Regional Anesthesia: A Prospective Comparative Study

Effect of Using Midazolam and Propofol in Low Doses for Intraoperative Nausea and Vomiting Prevention in Pregnant Women Underwent Cesarean Section under Regional Anesthesia

Aim: To investigate if and how severe intraoperative nausea and vomiting occur following elective cesarean sections performed under spinal anesthesia using sub-hypnotic dosages of midazolam and propofol.
 Study Design: Clinical trial.
 Methodology: The current study was conducted at the Gynecology and Obstetrics Department of a Teaching Hospital in Baghdad, Iraq. The study included 90 full-term pregnant women with single viable fetuses who underwent elective C/S by spinal anesthesia and were randomly assigned to one of three groups: group A included 30 women who received propofol, group B included 30 women who received midazolam, and Group C included 30 women who received placebo. The Bellville scoring score was used to assess nausea and vomiting. The Richmond Agitation Sedation Score (RASS) was used to assess sedation intraoperatively.
 Results: Patients in group C had the highest prevalence of nausea and vomiting (56.7%), which was significantly different from groups A (16.7%, P=0.001) and B (13.3%, P=0.001); however, there was no statistically significant difference between groups A and B (P= 0.717). The group B patients had the highest prevalence of drowsiness (20%), which was substantially different from group C (3.3%, P=0.044), whereas there were no statistically significant differences between groups A and B (P= 0.278) or A and C (P= 0.3).
 Conclusion: Low doses of midazolam or propofol administered after cesarean section (after the umbilical cord has been clamped) can lessen intraoperative nausea and vomiting without significantly lowering blood pressure or heart rate, with midazolam being more effective than propofol in this regard.

Comparison of the effect of a combination of low dose ketamine and dexmedetomidine with a combination of low dose ketamine and midazolam on hemodynamic changes and pain in electroconvulsive therapy.

Background: Currently, electroconvulsive therapy (ECT) is used as an effective treatment method in many psychiatric disorders. The basis of a successful electroshock session is to create a seizure with the precise intensity, quality and duration. In addition to the appropriate method of shock induction, appropriate anesthesia methods should be used to cause such seizures. The present study compared a combination of low-dose ketamine and dexmedetomidine (Ketodex) with a combination of low-dose ketamine and midazolam (Ketomid) on hemodynamic changes in electroshocks applied to patients referred from the psychiatric ward.
 Methodology: This study was a randomized triple-blind clinical trial performed after obtaining permission from the Medical Ethics Committee of the Isfahan University of Medical Sciences. For this purpose, 70 patients were selected for electroshock therapy and randomly distributed into two groups of 35 people. In the first group, 0.04 mg/kg midazolam was combined with ketamine 0.1 mg/kg and in the second group, 0.5 μg/kg dexmedetomidine with 0.1 mg/kg ketamine. The patients were placed under complete cardiovascular monitoring. Hemodynamic changes of patients were measured and recorded before injection, after injection, after shock, and at 5 and 10 min after the end of seizures.
 Results: In this study, 70 patients who were candidates for receiving ECT were equally divided into two groups of 35: one group received a mixture of Ketodex and the second group a combination of Ketomid. The two study groups showed no significant difference in terms of systolic pressure (P = 0.883), diastolic (P = 0.443), mean arterial pressure (P = 0.443), oxygen saturation (P = 0.018), and heart rate (P = 0.286). Complications such as headache, muscular pain (P = 0.01), bradycardia, nausea and vomiting were reported in the dexmedetomidine and ketamine groups.
 Conclusion: Our study showed that although systolic, diastolic and mean arterial blood pressure, heart rate and oxygen saturation were significantly reduced in both study groups, no significant difference was observed between the two groups in terms of hemodynamic changes and neither drug group in our study population was different from the other in terms of these parameters. In addition, neither option was superior to the other. However, due to the fact that complications such as headache, muscular pain, bradycardia, nausea and vomiting were reported in the dexmedetomidine and ketamine groups, the combination of midazolam and ketamine appeared to be a more appropriate combination in patients undergoing electroconvulsive therapy.
 Key words: Electroshock therapy; Midazolam; Ketamine; Dexmedetomidine; Hemodynamic changes; Headache pain
 Citation: Nazemroaya B, Manian N. Comparison of the effect of low dose ketamine plus dexmedetomidine vs low dose ketamine plus midazolam on hemodynamic changes and pain in electroconvulsive therapy. Anaesth. pain intensive care 2023;27(3):364−370; DOI: 10.35975/apic.v27i3.1981
 Received: September 02, 2022; Reviewed: December 03, 2022; Accepted: April 23, 2023

Sub-hypnotic dose of midazolam is effective in reducing intraoperative nausea and vomiting during cesarean sections under spinal anesthesia

Background & Objectives: Intra and postoperative nausea and vomiting under regional anesthesia is a common problem in cesarean sections. Globally, the incidence has been documented to be from 40−80%, and various drugs have been used to control it. We aimed to determine if a subhypnotic dose of midazolam will be effective to reduce intraoperative nausea and vomiting during an elective cesarean section under spinal anesthesia.
 Methodology: A randomized interventional study was done through a period of 6 months from March 11, 2019 to September 11, 2019 and included 100 full term pregnant women undergoing elective cesarean sections (CS) under spinal anesthesia. The participants were allocated to one of two groups: Midazolam group (received midazolam 1 mg bolus then 1.0 mg/h infusion after umbilical cord clamping), and placebo group (received normal saline). Bellville score was used to evaluate nausea and vomiting (N/V). The hemodynamic parameters were monitored at three-minute intervals.
 Results: No statistically significant differences were noted between study groups regarding mean arterial pressure, heart rate and total ephedrine used in the two groups. Intraoperative nausea and vomiting were recorded midazolam (81.6%) with a significant association between prevention of intraoperative N/V and receiving midazolam. Insignificant association was noticed between the level of sedation and receiving midazolam.
 Conclusion: Administration of low dose of midazolam during cesarean sections under spinal anesthesia can lessen intraoperative nausea/vomiting without significantly effect on blood pressure or heart rate and without any negative side effects.
 Abbreviations: BMI – Body Mass Index; CS - Cesarean Section; LA – Local Anesthesia; N/V - Nausea/Vomiting; RASS - Richmond Agitation Sedation Score SA - Spinal Anesthesia
 Key words: Nausea; Vomiting; Anesthesia, Spinal; Midazolam; Cesarean Section
 Citation: Ibrahem IG. Sub-hypnotic dose of midazolam is effective in reducing intraoperative nausea and vomiting during cesarean sections under spinal anesthesia. Anaesth. pain intensive care 2023;27(4):485−489; DOI: 10.35975/apic.v27i4.2087
 Received: October 12, 2022; Reviewed: May 16, 2023; Accepted: June 23. 2023

The association between midazolam premedication and postoperative delirium - a retrospective cohort study

Study objectiveTo evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DesignRetrospective cohort study. SettingA single tertiary academic medical center. PatientsPatients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. InterventionsMidazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MeasurementsThe primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. Main resultsIn total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82–1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. ConclusionsOur results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.

Peri-procedural anesthesia and patient pain experience in pulmonary vein isolation by means of very high power short duration radiofrequency ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background Very high-power short-duration (vHPSD) temperature-controlled radiofrequency ablation (vHPSD) may reduce ablation times and improve patient tolerability, permitting pulmonary vein (PV) isolation under mild conscious sedation. Purpose Evaluate the anesthetic drugs use and patients ‘pain experience during vHPSD PV isolation. Methods Thirty-three consecutive patients, with paroxysmal atrial fibrillation (AF), treated with QDot Micro catheter and vHPSD (90 w for 4 s) (vHPSD Group), were compared with the last 33 consecutive patients, with paroxysmal AF, treated with a surround flow contact force-sensing catheter guided by the ablation index (450 at anterior and superior sites at 50 W, 330 at posterior and inferior sites at 40 W) (AI Group). Anesthetic drugs (midazolam and fentanyl) use were compared as well as pain experience, measured using a 0-10 scale. Results All PVs were isolated. PV isolation ablation time in the vHPSD Group (5.9±1.4 min) was shorter than in the AI Group (25±11 min, p<0.001). Pain experience was significantly lower in vHPSD group (4.5±2 vs 6.6±1.8, p< 0.001). No patients required general anesthesia; fentanyl use was required in 4 vHPSD Group patients vs 25 AI Group patients (p<0.001). A lower dose of midazolam was required in vHPSD Group (2.3±1.2 mg vs 3.6±1.7 mg, p < 0.001). Conclusions vHPSD radiofrequency ablation for PVI can be performed under conscious sedation using only benzodiazepine in most of patients without compromising patient pain experience.

Low dose midazolam and ketamine in aliquots for sedation during procedures in paediatric hematology oncology

Low dose midazolam and ketamine in aliquots for sedation during procedures in paediatric hematology oncology

The safety and efficacy of alfentanil combined with midazolam in fiberoptic bronchoscopy sedation: A randomized, double-blind, controlled trial.

Sedation is recommended by most guidelines to be offered to all patients undergoing diagnostic flexible bronchoscopy (DFB) without contraindications, and the most commonly reported regimen is midazolam in combination with a short-acting opioid (fentanyl or alfentanil) to provide both sedative and antitussive effects. However, the optimal dose or ideal regimen of the combination therapy with midazolam and opioids has not yet been found. So this randomized, double-blinded clinical trial was designed and registered (ChiCTR2100049052) to assess the safety and efficacy of midazolam combined with different doses of alfentanil in DFB sedation. Our study showed that relative high doses of alfentanil (10-25μg/kg) combined with a fixed low dose of midazolam can markedly reduce hemodynamic fluctuations, cough reactions, patients' discomforts, and improve their satisfaction in a dose-dependent manner during DFB, with no significant increase in the desaturation risks.

Symptom Control and Survival for People Severely ill With COVID: A Multicentre Cohort Study (CovPall-Symptom).

Evidence of symptom control outcomes in severe COVID is scant. To determine changes in symptoms among people severely ill or dying with COVID supported by palliative care, and associations with treatments and survival. Multicentre cohort study of people with COVID across England and Wales supported by palliative care services, during the pandemic in 2020 and 2021. We analysed clinical, demographic and survival data, symptom severity at baseline (referral to palliative care, first COVID assessment) and at three follow-up assessments using the Integrated Palliative care Outcome Scale - COVID version. We included 572 patients from 25 services, mostly hospital support teams; 496 (87%) were newly referred to palliative care with COVID, 75 (13%) were already supported by palliative care when they contracted COVID. At baseline, patients had a mean of 2.4 co-morbidities, mean age 77 years, a mean of five symptoms, and were often bedfast or semiconscious. The most prevalent symptoms were: breathlessness, weakness/lack of energy, drowsiness, anxiety, agitation, confusion/delirium, and pain. Median time in palliative care was 46 hours; 77% of patients died. During palliative care, breathlessness, agitation, anxiety, delirium, cough, fever, pain, sore/dry mouth and nausea improved; drowsiness became worse. Common treatments were low dose morphine and midazolam. Having moderate to severe breathlessness, agitation and multimorbidity were associated with shorter survival. Symptoms of COVID quickly improved during palliative care. Breathlessness, agitation and multimorbidity could be used as triggers for timelier referral, and symptom guidance for wider specialities should build on treatments identified in this study.

Simulation-Based Gastrointestinal Endoscopy Sedations: A Novel Validation to Multidrug Pharmacodynamic Modeling.

Pharmacodynamic models have described the interactions between anesthetics. Applying the models to clinical practice is still problematic due to inherent limitations: 1. modeling conditions are different from practice. 2. One model can only describe one endpoint. To tackle these, we propose a new method of model validation for recovery and intraprocedural sedation adequacy with a three-drug pharmacodynamic model using six published clinical studies that contain midazolam, opioid, and propofol. Mean drug dose, intraprocedural sedation level, procedure, and recovery time are extracted from each study. Simulated drug regimens are designed to best approximate study conditions. A published deep sedation model is used for simulation. Model-predicted recovery time and intraprocedural sedation scores are compared with the original clinical study outcomes. The model successfully predicted recovery times in eight out of nine regimens. Lower doses of midazolam are associated with faster recovery. Model prediction of intraprocedural sedation level was compatible with the clinical studies in five out of seven regimens. The three-drug pharmacodynamic model describes the course of gastrointestinal endoscopy sedations from clinical studies well. Model predictions are consistent with the results from clinical studies. The approach implies that large scale validation can be performed repeatedly.

Midazolam for Conscious Sedation During Endoscopy: Cheaper and Safer Alternative for Resource-poor Settings

Upper gastrointestinal endoscopy is usually carried out using conscious sedation or general anesthesia all over the world. However, due to resource-poor conditions in countries like Bangladesh, physicians have to use topical anesthesia, which eventually leads to a painful and fearful endoscopic experience for most of the patients here. To improve this situation, a crosssectional study was carried out in a tertiary medical center near Dhaka, Bangladesh from March 2013 to October 2018. A total of 4557 patients were included in this study. Among them, 2236 patients were sedated with low dose Midazolam in a conscious sedation procedure, while 2321 patients underwent endoscopy with only topical anesthesia using Lidocaine gel and Lidocaine spray. It was found out that patient satisfaction with Midazolam was 99% compared to only 10% with lidocaine use. Besides, only 4% of patients were restless, but did not need anesthetic support, when Midazolam was used. In contrast, 35% of patients with topical anesthesia were found restless and were assisted. Midazolam is certainly a better and cheaper alternative in resource-poor settings and provides a painless, patient-friendly endoscopic experience without the need for anesthetic support. J Shaheed Suhrawardy Med Coll 2021; 13(1): 33-35

SWK-02. Palliative sedation in pediatric patients suffering from brain tumors: choosing the best drugs to improve end of life

INTRODUCTION: For terminally-ill children with brain tumors care focuses on quality of life, and patient management fundamentally affects grieving families. We describe our experience of palliative sedation (PS) for children with refractory symptoms caused by solid tumors, focusing on BT (brain tumor). METHODS: Retrospective data on all children treated for cancer who died between 1/2016-12/2020 in our Institution were collected. RESULTS: Of the 29 patients eligible for the study, M/F 17/12, the median duration of disease was 12.5 months(range 3-51) and the median age at death was 8.5 years(range 1-22). Fifteen had BT (5 DIPG, 2 Ependymoma, 8 high-grade-glioma). The reasons for starting PS in BT were: seizures(5), central respiratory failure(6), locked-in-syndrome(1), decerebration(1). Midazolam was combined in 16 cases with other drugs (neuroleptics, alpha-2 agonists, antihistamines) to achieve adequate sedation. Ten/15 with BT received antiepileptic therapy, apart midazolam. BT patients received oral benzodiazepins before PS less frequently than those with other cancers (p = 0.0033). Throughout the period of PS and on the day of death, patients with BT were given lower doses of midazolam and morphine. Mean dose of midazolam was 0.027 mg/kg/h (range 0.0069-0.06) for patients with BT, 0.055 mg/kg/h (range 0.01-0.38) for the others, while the mean morphine doses were 0.048 mg/kg/h (range 0-0.08) and 0.09 mg/kg/h (range 0.013-0.13), respectively. CONCLUSIONS: BT patients require less intensive analgesic-sedative therapies because their already impaired state of consciousness. Optimizing pharmacological treatments demands a medical team that knows how drugs (even developed for other indications) work. Emotional-relational aspects are important too, any action to lower a patient’s consciousness should be explained to the family. Guidelines on PS in pediatrics could help, providing they acknowledge that any child’s death is always a unique case.

A prospective study evaluating the use of low-dose intravenous sedation and analgesia during radiofrequency ablation of symptomatic, benign thyroid nodules

BackgroundWe compared post-treatment pain, quality of recovery and complications between those who did not receive (Group I) and received (Group II) intravenous low-dose Midazolam (<0.05 mg/kg) and Pethidine (<0.5 mg/kg) during radiofrequency ablation (RFA) of benign thyroid nodules. MethodsBoth groups received local anesthesia. Post-treatment pain was rated by a 0–10 numerical rating scale (NRS). The Quality-of-Recovery-9 (QoR9) questionnaire was completed upon discharge. ResultsEach group included 25 patients. Baseline characteristics were comparable (p > 0.05). Group II had lower pain NRS than group I both immediately (0 (0–3.5) vs. 4 (3–5), p = 0.002) and 4 h after RFA (2 (0.5–4) vs 3.5 (2–5), p = 0.031). There were no differences in complications and QoR9 score (Group I: 15 (13–17) vs Group II: 16 (14–18), p = 0.254). Both groups were discharged within the same day. ConclusionLow dose intravenous sedation improved pain control without affecting recovery or safety in thyroid RFA.

Hypnosis and Sedation for Anxious Children Undergoing Dental Treatment: A Retrospective Practice-Based Longitudinal Study.

To assess whether the treatment of children with oral midazolam and pediatric hypnosis techniques can improve the compliance in consecutive sessions, a retrospective longitudinal practice-based observational study was designed and carried out. A total of 311 children between 3 and 12 years of age were treated under hypnosis and sedation with midazolam (0.40 mg/kg body weight). Treatments were performed in one to a maximum of three sessions. A total of 183 children received one, 103 received two and 25 children received three treatment sessions. The behavior of the children during the sessions was examined by means of the Venham score. The self-evaluation of the children was based on the Wong–Baker Scale. Child behavior using midazolam and hypnosis techniques showed little difference and good compliance between the sessions. Venham scores did not increase significantly regarding total treatment from the first (0.99 ± 1.41) to the second (1.17 ± 1.39) and to the third session (1.27 ± 1.20) (p > 0.05). However, considering the highest Venham scores that occurred in each case, the behavior of the children worsened significantly (p < 0.01) during the three treatment sessions, from 1.37 ± 1.31 (first) to 1.87 ± 1.74 (second) to 2.32 ± 1.33 (third). In 6.11% of the children, treatment was discontinued in the first session (n = 19), 0.96% in the second (n = 3) and 0% in the third. Treatment with low-dose midazolam, combined with hypnosis techniques, showed to be an effective option for dental treatment in children. Within the limitations of the current study, and with consideration of highest possible compliance, no more than two treatment sessions for pediatric dental treatment should be performed.

A110 FEASIBILITY OF EUS-GUIDED PORTAL PRESSURE GRADIENT MEASUREMENT WITHOUT DEEP SEDATION: A PATH TO ACCURATE PORTAL PRESSURE DETERMINATION

AimsHepatic venous pressure gradient (HVPG) is the gold standard for the diagnosis and staging of portal hypertension. Previous studies have shown that it underestimates pre-sinusoidal portal hypertension. Endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) can safely measure direct portal vein pressure (PVP) and bridge this diagnostic gap. However, EUS-PPG has so far been performed with patients under deep sedation which can alter HVPG measurement and lead to misclassification of portal hypertension. Ketamine, a conscious sedation agent, has minimal effect on portal hemodynamics. We present our center’s experience with EUS-PPG under ketamine and low dose midazolam.MethodsWe retrospectively reviewed consecutive patients undergoing EUS-PPG with conscious sedation using ketamine and low-dose midazolam (<0.02 mg/kg) at the McGill University Health Centre from February to May 2021. Patients were placed in the left lateral position. Hepatic vein and portal vein were located through EUS via a trans-gastric/hepatic approach. A through the scope 25-gauge needle attached to a manometer was advanced through the liver to measure hepatic vein pressure (HVP) and portal vein pressure (PVP). Three measurements were sampled per vessel and mean pressure differences calculated to obtain PPG. PPG was considered reliable if the differences between the values was no more than 1mmHg.ResultsThree patients underwent EUS-PPG for evaluation of pre-sinusoidal portal hypertension. Cirrhosis was excluded in all patients based on recent liver biopsy or transient elastography. The first patient is a 69-year-old man with splenomegaly and recanalization of the paraumbilical vein on imaging. He received 80 mg of ketamine and no midazolam. HVPG measured was 1 mmHg. EUS-PPG was successful with PPG of 6 mmHg (HVP= 7 mmHg, and PVP= 13 mmHg). The second patient is a 42-year-old woman with previous sleeve gastrectomy and known with portal cavernoma. She received 120 mg of ketamine and 1 mg of midazolam. EUS-PPG was technically difficult due to respiratory movements. The measurement was not considered reliable as differences in PPG were as high as 2mmHg. In this case, PPG was 0mmHg (HVP= 15mmHg, and PVP= 15mmHg). The third patient, a 74-year-old man with hepatic steatosis and splenomegaly received 70 mg of ketamine and 1 mg of midazolam. EUS-PPG was successful (HVP= 3mmHg, PVP= 3mmHg) yielding a PPG 0mmHg. All patients tolerated the procedure well with no procedural or sedation-related complicationsConclusionsOur early experience suggests that EUS-PPG can be successfully and safely performed in patients under conscious sedation with ketamine and low-dose midazolam. This combination may avoid deep sedation with high dose midazolam or propofol which are known to alter accuracy of HVPG. Measurement of HVP (left) and PVP (right)Funding AgenciesNone

Low-dose midazolam for anxiolysis for pregnant women undergoing cesarean delivery: a randomized trial

IntroductionAnxiety and fear are common among pregnant women undergoing cesarean delivery. In addition to psychologically unpleasant, they can elicit endocrine and metabolic changes. Administration of benzodiazepines in this patient group is uncommon and investigation focusing on the topic is rare. This study aimed to determine anxiolysis efficacy of low-dose midazolam administered preoperatively, right before cesarean delivery, and to evaluate whether its administration impacts neonatal vitality, maternal consciousness, and recall of the moment the baby was born. MethodsFifty pregnant women with indication for cesarean delivery were included in this randomized, double-blind, placebo-controlled clinical study and allocated into two groups of 25 participants each (Midazolam and Control group). Midazolam (0.0125 mg.kg-1) or a placebo solution was administered immediately before spinal anesthesia and the anxiolytic effect was assessed using a visual analogue scale before and after administration. We registered the Apgar score at 1 and 5 minutes, the Ramsay scale and recall of the moment of birth, that was assessed 90 minutes after birth. ResultsPregnant women from the Midazolam group presented a 1.3-point reduction in anxiety on the visual analogue scale, while the Control group showed virtually no change (p = 0.027). We observed no statistically significant changes in Apgar scores, level of maternal consciousness and recall of the moment of delivery. ConclusionsLow-dose midazolam can provide anxiety management in pregnant women undergoing cesarean delivery with no significant undesirable effects.