Mg Of Midazolam Research Articles

Effect of Ginkgo biloba special extract EGb 761® on human cytochrome P450 activity: a cocktail interaction study in healthy volunteers

PurposeWe assessed the human in vivo metabolic drug interaction profile of Ginkgo biloba extract EGb 761® with respect to the activities of major cytochrome P450 (CYP) enzymes.MethodsA single-center, open-label, randomized, three-fold crossover, cocktail phenotyping design was applied. In random order, the following treatments were administered to 18 healthy men and women for 8 days each: placebo twice daily, EGb 761® 120 mg twice daily, and EGb 761® 240 mg in the morning and placebo in the evening. In the morning of day 8, administration was performed together with the orally administered phenotyping cocktail (enzyme, metric): 150 mg caffeine (CYP1A2, paraxanthine/caffeine plasma ratio 6-h postdose), 125 mg tolbutamide (CYP2C9, plasma concentration 24-h postdose), 20 mg omeprazole (CYP2C19, omeprazole/5-hydroxy omeprazole plasma ratio 3-h postdose), 30 mg dextromethorphan (CYP2D6, dextromethorphan/dextrorphan plasma ratio 3-h postdose), and 2 mg of midazolam (CYP3A, plasma concentration 6-h postdose). Formally, absence of a relevant interaction was assumed if the 90% confidence intervals (CIs) for EGb 761®/placebo ratios of the metrics were within the 0.70–1.43 range.ResultsEGb 761®/placebo ratios for phenotyping metrics were close to unity for all CYPs. Furthermore, respective CIs were within the specified margins for all ratios except CYP2C19 for EGb 761® 120 mg twice daily (90% CI 0.681–1.122) and for CYP2D6 for EGb 761® 240 mg once daily (90% CI 0.667–1.281). These findings were attributed to the intraindividual variability of the metrics used. All treatments were well tolerated.ConclusionEGb 761® has no relevant effect on the in vivo activity of the major CYP enzymes in humans and therefore has no relevant potential to cause respective metabolic drug–drug interactions.

Diverticulosis Does Not Adversely Affect Cecal Intubation Rates, Procedure Times, or Sedation Requirements During Colonoscopy

Purpose: Diverticulosis is a commonly diagnosed condition in patients undergoing colonoscopy. The presence of colonic diverticula can make performing colonoscopy more challenging. However, it is unclear if diverticulosis adversely affects cecal intubation rates, scope insertion times, withdrawal times, or sedation requirements in patients undergoing total colonoscopy. Our aim was to determine if the presence of colonic diverticulosis is associated with differences in cecal intubation rates, scope insertion times, withdrawal times, or sedation requirements during colonoscopy. Methods: A retrospective, single-center, cohort study was conducted that included patients who underwent colonoscopy by one of five experienced attending gastroenterologists (without the assistance of trainees) at an outpatient surgical center. Patients were identified using a hospital database and electronic medical records were reviewed. Univariate and multivariate analyses (adjusted for colorectal preparation quality) were conducted. Results: 300 consecutive patients (190 women) with a median age of 57 years (range: 23-70 years) who underwent colonoscopy for various indications were reviewed. 108 (36%) of these patients had diverticulosis (in any colonic segment) found on colonoscopy. The rate of total colonoscopy (successful cecal intubation) was 99.1% in patients with colonic diverticula and 97.4% in patients without colonic diverticula (P=0.42). Median scope insertion time was 6 min (range: 2-37 min) in patients with diverticulosis and also 6 min (range: 2-34 min) in patients without diverticulosis (P=0.34). Median scope withdrawal time was 11 min (range: 4-24 min) in patients with diverticulosis and also 11 min (range: 5-43 min) in patients without diverticulosis (P=0.50). Table 1 shows no statistically significant difference in scope insertion or withdrawal times in either group. Analysis of the amount of midazolam and fentanyl administered to perform colonoscopy showed no statistically significant difference in the amount of medication required in patients with or without diverticulosis (Table 2). We also analyzed the amount of drug administered using “dose equivalents” with 1 dose equivalent = 1 mg of midazolam = 25 mcg of fentanyl = 25 mg of diphenhydramine. Using this method, there was also no statistically significant difference in the amount of drugs administered to patients with or without diverticulosis (Table 2).Table 1: Colonoscopy insertion and withdrawal times stratified by diverticulosis statusTable 2: Amounts of sedative medications required to provide adequate conscious sedation in patients undergoing colonoscopyConclusion: The presence of colonic diverticulosis did not adversely affect cecal intubation rates, scope insertion times, scope withdrawal times, or sedation requirements in patients undergoing total colonoscopy. A large prospective study is warranted to confirm these findings.

Teaching Patience

Teaching Patience

Intrathecal Midazolam as Supplementary Analgesia for Chronic Lumbar Pain—15 Years' Experience

The antinociceptive effect of intrathecal midazolam is based on its affecting spinal gamma-amino butyric acid receptors. To evaluate pain relief in patients with chronic low back pain and failed back surgery syndrome after a single-shot intrathecal administration of midazolam. A prospective, open-label study. The analgesic effect was determined using a patient questionnaire during subsequent visits to the pain therapy service. We classified at least a 50% pain reduction with improved quality of life and improved functional condition as a positive outcome. Between 1995 and 2010, we performed 500 administrations: 227 administrations in 57 male patients and 273 administrations in 69 female patients. We performed 81 administrations for chronic low back pain and 419 administrations for failed back surgery syndrome. The average age of our patients was 50 years (range 28 to 86). The dose administered ranged from 2 to 5 mg of midazolam. The analgesic effect lasted 9.7 weeks on average, ranging from 1 week to 3 years; the most common reported duration was between 4 and 12 weeks (3 months). In 65% of patients, we achieved pain relief lasting 4 weeks or longer; in 13%, the administration provided no analgesic effect at all. The incidence of side effects (drowsiness, nausea, headache, or transient worsening of complaints) was rather low. Intrathecal midazolam is a useful supplement to standard analgesic therapy with opioids, non-opioids, or spinal steroids.

A rare cause of status epilepticus

Dear Editor, Status epilepticus (SE) has a long list of potential causes. In about 15% of cases, no cause is identified [1]. We report on a patient who presented with convulsive SE due to concomitant reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) in the early postpartal period. A 44-year-old nulliparous pregnant woman was admitted for labor induction at gestational week 41. Intravaginal prostaglandin gel was applied but emergency caesarean section was then performed because of recurrent fetal bradycardia. Her initial blood pressure was 110/70 mmHg. Spinal anesthesia was associated with maternal hypotension and bradycardia, which responded to ephedrine 60 mg and atropine 0.75 mg boluses followed by intravenous administration of 500 mL of crystalloids. Her blood pressure then reached up to 162/82 mmHg. She also received oxytocin 10 IU intravenously during caesarean section followed by a continuous infusion of 10 IU over the next 6 h. During the cesarean section, she experienced a thunderclap headache. Immediately after delivery, her blood pressure increased to 160/85 mmHg requiring nicardipine infusion. She experienced a first tonic–clonic seizure less than 3 h after the caesarean section, when her blood pressure was 110/60 mmHg. A second seizure occurred rapidly and stopped only after an intravenous bolus of 2 mg of midazolam and 2 g of magnesium over 30 min. A continuous 2 g/day magnesium infusion was started. A third seizure during transportation to the radiology suite required an additional intravenous bolus of 1 mg of midazolam. Figure 1a, d shows results of the first cerebral magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). She was transferred to the ICU with a diagnosis of SE related to both RCVS and PRES. On ICU admission, blurred vision was the only abnormal clinical finding. Blood pressure was 120/62 mmHg. Routine electroencephalogram was normal. On day 2, her hemodynamic status was stable, her vision was normal, and her seizures were controlled. The continuous magnesium infusion was stopped. Intravenous administration of nimodipine (2 mg/h) was started to treat

Comparison the efficacy of adding clonidine, chloropromazine, promethazine and midazolam to morphine pumps in postoperative pain control of addicted patient

Background: Addicted patients present difficulties for pain management because they have another problem besides their pain. Adding adjuvants to opioid pumps to intensify quality, control other problems, lengthen analgesia, and reduce side effects has been considered in the field. Objectives: The objective of this study was to evaluate the analgesic effects of adding clonidine, promethazine, chlorpromazine, and midazolam to morphine in patient-controlled intravenous analgesia (PCIA) in orthopedic patients with addiction problems. Patients and Methods: 90 patients with histories of substance abuse were enrolled in this randomized controlled trial. Patients were randomly divided into three groups. The first group received 20 mg of morphine sulfate +50 mg of chlorpromazine + 50 mg of promethazine +10 mg of midazolam (M20P). The second group received the first group’s regimen plus 150 micrograms of clonidine (M20PC). The third group received 40 mg of morphine sulfate (M40). A pump with a flow rate of 5 mL/h was chosen. Patients were evaluated every 12 hours, and VAS, VRS, extra opioid usage, nausea and vomiting, and sedation scores were recorded. Results: Patients’ nausea and vomiting and sedation scores were not statistically different between the three groups. Mean VAS and VRS scores were found to be statistically lower in the M20PC group than in the other groups. Extra opioid usage between the three groups was statistically lower in the M20PC group than in the other groups. The percentage of patients satisfaction was significantly higher in the M20PC group than in the other two groups. Conclusions: This study showed that, compared to simply increasing the dose of morphine, adding chloropromazine, promethazine, midazolam, and clinidine to morphine significantly controlled pain scores and increased treatment satisfaction in addicted patients without notable side effects.

Rhabdomyolysis induced by severe levodopa induced dyskinesia in a patient with Parkinson’s disease

A 74-year-old man with Parkinson’s disease (PD) who had been regularly taking levodopa for 17 years developed severe generalized dyskinesia of choreiform movement. He began to show bradykinesia and rigidity in right limbs at age 57 years. Levodopa treatment dramatically improved his parkinsonian symptoms. Three years after levodopa treatment, he began to feel wearing-off. At age 72 years, he suffered from levodopa-induced dyskinesia (LID) during levodopa on period and was immobile during the off period. Seven days before his first visit to emergency room, he began to feel deterioration of his symptoms with levodopa/ carbidopa 250/25 mg q.i.d. and controlled-release form of levodopa/benserazide 100/25 mg q.i.d. Although peak dose dyskinesia gradually worsened, he gradually increased the dosage until he was taking 12 tablets of levodopa/carbidopa 250/25 mg and four tablets of levodopa/benserazide 100/25 mg per day. The dyskinesia violently affected all four of his limbs and the trunk, and he could not stand or sit in a chair without support. His body temperature was 36.1 C, and serum creatine kinase (CK) level was 215 IU/L. The Unified Parkinson’s Disease Rating Scale (UPDRS) motor score was 64. Although the dosage of levodopa was lowered to levodopa/carbidopa 250/25 mg t.i.d. and controlled-release form of levodopa/benserazide 100/25 mg t.i.d., the violent dyskinesia persisted. We intermittently gave him 2 mg of midazolam intravenously, but failed to stop the dyskinesia when he was awake. After 2 days, he still showed dyskinesia with the same severity, but his mentality was clear. In contrast to his violent dyskinesia and immobility, he showed very mild rigidity in his arms and neck. His body temperature and serum CK level rose up to 38.2 C and 24,651 IU/L, respectively. Urine myoglobulin was markedly increased to 48.1 nmol/L. Leukocyte count in peripheral blood was 18,680/mm. Serum creatinine level was 176.8 lmol/L and serum potassium level 6.9 mmol/L. Rhabdomyolysis with acute renal failure was suspected. All dopaminergic medications were stopped and midazolam was continuously infused intravenously at a rate of 0.4–0.8 lg/min/kg. Five hours after the infusion, body temperature rapidly decreased to normal range. After 21 h of infusion, dyskinesia completely disappeared even without midazolam. Serum CK level decreased to 7,961 IU/L and normalized after following 5 days (Fig. 1). Because dyskinesia reappeared even with the trial of a levodopa/carbidopa 100/25 mg, he had to be maintained with selegiline, amantadine and pergolide. UPDRS motor score measured 1 month after this acute exacerbation of dyskinesia was 55. He was stabilized afterwards without recurrence of dyskinesia. In movement disorders, various causes of rhabdomyolysis have been reported, including status dystonicus, myoclonus, generalized chorea and parkinsonism-hyperpyrexia syndrome (PHS) in patients with parkinsonian diseases [1–4]. In PD, LID leading to rhabdomyolysis is a very rare phenomenon [5]. Two previously reported patients developed rhabdomyolysis by severe LID and C. H. Lyoo Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, 712 Eonjuro, Gangnam-gu, Seoul, South Korea e-mail: lyoochel@yuhs.ac

A study of effectiveness of midazolam sedation for prevention of myocardial arrhythmias in endosseous implant placement

The study aimed to assess electrocardiographic alterations during oral implant placement surgeries under local anesthesia (lidocaine chlorhydrate with epinephrine), using 15 mg of midazolam as an anxiolytic premedication. The study randomly selected 20 patients, aged 21-50 years old, requiring bilateral mandibular dental implants. Each patient was assessed using placebo on one side and midazolam on the contralateral side, with random, double-blinded distribution. The electrocardiogram recorded 12 static leads every 2 min, while D2 derivations were recorded continuously. No statistically significant differences were observed between the placebo and midazolam when analyzing the morphological behavior of the electrocardiographic wave and the presence of arrhythmias during the experiment. However, under sedation, assessment of the behavior of electrocardiographic parameters during different stages of the procedure revealed statistically significant differences (P<0.05) for heart rate, P-wave amplitude and duration of the RR and QTc intervals. The arrhythmias detected were considered low risk for patients without systemic alterations and were observed in 53.3% of patients. The most frequently occurring alterations were tachycardia, bradycardia, supraventricular and ventricular extrasystoles and blocked atrial extrasystole, which were similar for both placebo and midazolam, with the greatest incidence during the initial, incision and bone drilling stages. The use of 15 mg of midazolam made no difference compared with the placebo. The use of 15 mg of midazolam did not show an advantage in the incidence of arrhythmias The anxiolytic premedication does not prevent myocardial arrhythmias in endosseous implant placement. The clinical significance of the arrhythmias may not represent serious risks.

Comparison of Midazolam Alone versus Midazolam Plus Propofol during Endoscopic Submucosal Dissection

Background/AimsFor proper sedation during endoscopic submucosal dissection (ESD), propofol has been widely used. This study aimed to compare the levels of sedation and tolerance of patients treated with midazolam (M group) and a combination of midazolam and propofol (MP group) during ESD.MethodsA total of 44 consecutive patients undergoing ESD were randomly assigned to the two groups. In the M group, 2 mg of midazolam was given repeatedly to maintain after a loading dose of 5 mg. The MP group initially received 5 mg of midazolam and 20 mg of propofol. Then, we increased the dosage of propofol by 20 mg gradually.ResultsThe average amount of midazolam was 12 mg in the M group. In the M group, 10 patients were given propofol additionally, since they failed to achieve proper sedation. The average amount of propofol was 181 mg in the MP group. Procedure time, vital signs and rates of complications were not significantly different between two groups. Movement of patients and discomfort were lower in the MP group.ConclusionsDuring ESD, treatment with propofol and a low dose of midazolam for sedation provides greater satisfaction for endoscopists compared to midazolam alone.

The Fallacy of a Lifesaving Sublingual Injection of Flumazenil

The Fallacy of a Lifesaving Sublingual Injection of Flumazenil

Reversible Lactic Acidosis and Electrocardiographic Changes in a Neurosurgical Patient During Propofol Anesthesia

Reversible Lactic Acidosis and Electrocardiographic Changes in a Neurosurgical Patient During Propofol Anesthesia

Continuous Spinal Anesthesia with High Dose of Local Anesthetics

Better control of the level, intensity, and duration of spinal analgesia represents the greatest advantages of continuous spinal anesthesia. With the advent of intermediate catheters (over-the-needle catheter) and its low incidence of headaches and neurological symptoms, the technique has been gaining credibility. The objective of this paper is to report the possible safety of the new catheter with a large dose of hyperbaric 0.5% bupivacaine with 1.6% glucose associated with hyperbaric 2% lidocaine with 1.6% glucose. Male patient, 78 years old, 85 kg, 168 cm, physical status ASA III, with hypertension, coronary artery disease, and chronic renal failure. The patient was candidate for surgery for huge bilateral inguinal and umbilical hernias, being submitted to preoperative pneumoperitoneum for one week to stretch abdominal cavity. After venoclysis with an 18G catheter, he was monitored with cardioscope, non-invasive blood pressure, and pulse oximetry; he was sedated with 1 mg of midazolam and 100 μg of fentanyl intravenously, and placed in left lateral decubitus. He underwent continuous spinal anesthesia by a median puncture in L₃-L₄ with a set with a 27G cut-bevel needle and 22G catheter. The total dose of anesthetic used was 25mg of 0.5% bupivacaine (hyperbaric, with 1.6% glucose), 160 mg of 2% lidocaine (hyperbaric, with 1.6% glucose), and morphine (100 μg). The patient was followed-up until the 30th postoperative day without neurological complaints. Recently, the poor distribution of the local anesthetic through the microcatheter was attributed as the cause of cauda equina syndrome. This case report showed that, with the administration of high doses of hyperbaric anesthetics through the new catheter, poor distribution or risk of cauda equina syndrome were not observed.

General anaesthesia for external electrical cardioversion of atrial fibrillation: experience of an exclusively cardiological procedural management

External electrical cardioversion (EC) usually requires brief general anaesthesia involving anaesthetists. The aim of this study was to evaluate the feasibility and safety of inducing anaesthesia for EC of atrial fibrillation (AF) exclusively by the cardiologic team with anaesthetists on-hand. A retrospective analysis of 624 elective EC, over a 6-year period, was made. No patients were excluded due to the severity of pathology or comorbidities. The protocol of the intravenous anaesthesia was 5 mg bolus of midazolam and subsequent increasing doses of propofol starting from 20 mg to achieve the desired sedation level. After delivering DC shock, a direct observation period followed in order to assess the post-sedation recovery and to detect the procedure-related complications. Electrical cardioversion was effective in 98.9% of the cases. General anaesthesia was effective in 100% of cases with a dosage of propofol, ranging between 20 mg to a maximum of 80 mg, after 5 mg of midazolam was administered. All patients generally showed a fast recovery waking up in a few minutes. The anaesthesiology team was never called for assistance. All the procedures were carried out by the cardiologic team as planned. No thrombo-embolic and allergic complications were observed. Arrhythmic complications were uncommon and essentially bradyarrhythmias. A general anaesthesia for outpatient EC of AF can be safely handled by a cardiologist having adequate experience with anaesthetical agents. Moreover, the association of midazolam and a very small dosage of propofol, given their synergic action, is effective and safe in inducing anaesthesia. Arrhythmic complications are rare and limited to bradyarrhythmias.

General anaesthesia for a patient with Williams–Beuren syndrome: is sevoflurane and ketamine contraindicated?

General anaesthesia for a patient with Williams–Beuren syndrome: is sevoflurane and ketamine contraindicated?

Localization of upper airway stricture by CT scan in patients with obstructive sleep apnea syndrome during drug-induced sleeping

To evaluate the feasibility of multi-slice spiral CT scan to localize upper airway stricture in patients with obstructive sleep apnea syndrome (OSAS) during drug-induced sleeping. One hundred and fourteen patients diagnosed as OSAS by polysomnography were included in the study. Multi-slice spiral CT scan covering upper airway was performed at the end of inspiration and clear upper airway images were obtained in waking. After injecting 5 mg of midazolam intravenously slowly in 109 patients, CT scan was performed at apnea and clear upper airway images were obtained in sleeping. Cross-section area and minimal diameter of airway were measured and the parameters were compared under those two states. Upper airway was displayed intuitionisticly by using post-processing techniques. One hundred and nine patients with OSAS finished the examination with a success rate of 100 %. Airway obstruction at retropalatal level was observed in 62 patients, among whom 26 were associated with airway obstruction at retroglossal level, 27 with narrower airway at retroglossal level in sleeping compared with that in waking, and 9 with no significant change of the airway at retroglossal level after sleeping. Narrower airway at retropalatal level in sleeping compared with that in waking was observed in 40 patients, among whom 20 were associated with narrower airway at retroglossal level in sleeping compared with that in waking, 10 with complete airway obstruction at retroglossal level in sleeping, and 7 with no significant change of the airway at both retropalatal and retroglossal levels before and after sleeping. Minimal mean cross-section area of airway at retropalatal level was (72.60 +/-45.15)mm(2) in waking and (8.26 +/-18.16)mm(2) in sleeping; and minimal mean cross-section area of airway at retroglossal level was (133.21 +/-120.36)mm(2)in waking and (16.73 +/-30.21)mm(2) in sleeping (P <0.01). Minimal mean diameter of airway at retropalatal level was (6.91 +/-2.23) mm in waking and (1.18 +/-2.14) mm in sleeping; and minimal mean diameter of airway at retroglossal level was (8.68 +/-4.32) mm in waking and (1.68 +/-2.22) mm in sleeping (P <0.01). Multi-slice spiral CT with post-processing techniques can display the shape of the upper airway in patients with OSAS in sleeping, and can localize the upper airway stricture and assess its range accurately.

Combined Spinal Epidural Anesthesia during Colon Surgery in a High-Risk Patient. Case Report

Combined spinal epidural anesthesia (CSEA) has advantages over single injection epidural or subarachnoid blockades. The objective of this report was to present a case in which segmental subarachnoid block can be an effective technique for gastrointestinal surgery with spontaneous respiration. Patient with physical status ASA III, with diabetes mellitus type II, hypertension, and chronic obstructive pulmonary disease was scheduled for resection of a right colon tumor. Combined spinal epidural block was performed in the T5-T6 space and 8 mg of 0.5% isobaric bupivacaine with 50 microg of morphine were injected in the subarachnoid space. The epidural catheter (20G) was introduced four centimeters in the cephalad direction. Sedation was achieved with fractionated doses of 1 mg of midazolam (total of 6 mg). A bolus of 25 mg of 0.5% bupivacaine was administered through the catheter two hours after the subarachnoid block. Vasopressors and atropine were not used. This case provides evidence that segmental spinal block can be the anesthetic technique used in gastrointestinal surgeries with spontaneous respiration.

Early Cognitive Impairment After Sedation for Colonoscopy: The Effect of Adding Midazolam and/or Fentanyl to Propofol

The sedative drug combination that produces minimal cognitive impairment and optimal operating conditions during colonoscopy has not been determined. We sought to determine if the use of propofol alone results in less cognitive impairment at discharge than the use of propofol plus midazolam and/or fentanyl in patients presenting for elective outpatient colonoscopy. Two hundred adult patients presenting for elective outpatient colonoscopy were randomized to receive propofol alone or propofol plus midazolam, and/or fentanyl for IV sedation. Baseline cognitive function was measured using the computerized CogState test battery (Cogstate, Melbourne, Australia) before sedation. During the procedure, sedative drug doses, depth of sedation (via the bispectral index and observer's assessment of alertness/sedation score), complications, and treatability were recorded. Patients were interviewed about recall immediately after emerging from sedation, and cognitive testing was repeated at hospital discharge. Recovery times, quality of recovery, and satisfaction with care were also recorded. In the propofol plus adjuvants group, 84 patients received fentanyl 50 microg (25-100) (median [range]) and 57 patients received midazolam 2 mg (0.5-10). Patients' cognitive function at discharge was worse than their performance at baseline. However, the changes in cognitive function between discharge and baseline were not significantly different between the two groups. At discharge, 18.5% of patients were cognitively impaired to an extent equivalent to a blood-alcohol concentration of 0.05%. Sedation with propofol plus midazolam and/or fentanyl produced better operating conditions than sedation with propofol alone and was associated with shorter procedure times. Recovery times, recall, dreaming, quality of recovery, and patient satisfaction with care were similar between the groups. Administration of >2 mg of midazolam was a predictor of impaired cognitive function at discharge. Significant cognitive impairment was common at discharge from elective outpatient colonoscopy. However, the addition of midazolam and/or fentanyl to propofol sedation did not result in more cognitive impairment than the use of propofol alone. Furthermore, the use of adjuvants improved the ease of colonoscopy without increasing the rate of complications or prolonging early recovery times..

Continuous Spinal Block In A Patient Undergoing Partial Gastrectomy. Case Report

Due to the high incidence of technical and neurological complications, continuous spinal blocks were not performed for several years. With the advent of intermediate catheters the technique has been used more often and gaining acceptance among anesthesiologists. The objective of this report was to demonstrate the usefulness of the technique as a viable alternative for medium and major size surgeries. This is a 58 years old female patient, weighing 62 kg, physical status ASA I, with a history of migraines, low back pain, and prior surgeries under spinal block without intercurrence. The patient was scheduled for exploratory laparotomy for a probable pelvic tumor. After venoclysis with an 18G catheter, monitoring with cardioscope, non-invasive blood pressure and pulse oximetry was instituted; she was sedated with 2 mg of midazolam and 100 (1/4)g of fentanyl, and placed in left lateral decubitus. The patient underwent continuous spinal block through the median approach in L3-L4; 9 mg of 0.5% hyperbaric bupivacaine and 120 (1/4)g of morphine sulfate were administered. Inspection of the abdominal cavity revealed a gastric stromal tumor that required an increase in the incision for a partial gastrectomy. A small dose of hyperbaric solution was required for the entire procedure, which was associated with complete hemodynamic stability. Postoperative admission to the ICU was not necessary; the patient presented a good evolution without complaints and with a high degree of satisfaction. She was discharged from the hospital after 72 hours without intercurrence. Intermediate catheters used in continuous spinal blocks have shown the potential to turn it an attractive and useful technique in medium and large size surgeries and it can even be an effective alternative in the management of critical patients to whom hemodynamic repercussions can be harmful.

Midazolam with meperidine or fentanyl for colonoscopy: results of a randomized trial

A combination of midazolam and opioid is usually used to achieve sedation and analgesia during colonoscopy. Two commonly used opioids are meperidine and fentanyl, but few studies have compared their efficacy. This randomized trial aimed to compare the efficacy and recovery time of 2 sedation regimens consisting of midazolam in combination with either meperidine or fentanyl. A total of 300 consecutive, unselected adults attending outpatient colonoscopy at a District General Hospital were enrolled with informed consent and randomized to receive midazolam with meperidine or fentanyl. Data for procedure times, perceived discomfort (according to standard 100-mm visual analog scales [VAS]), and recovery time were collected. Patients and all endoscopy staff directly involved with the procedure were blinded to the regimen used. Primary: patients' experience of pain (postrecovery VAS score); secondary: recovery time. A total of 287 patients (150 female, mean [SD] age 54 [17] years) were studied. Recovery time (in minutes) was significantly shorter in patients receiving fentanyl (n = 138) than in those receiving meperidine (n = 149, mean +/- SE: 13.7 +/- 1.8 vs 18.7 +/- 1.7, P = .03), whereas there was no difference in the patients', endoscopists', or nurses' perception of pain during the procedure between the 2 groups. Both groups received a median dose of 3 mg of midazolam (range 2-5 mg). In patients receiving lower doses (2-2.5 and 3-3.5 mg), recovery times were significantly faster with fentanyl (P < .01 and <.05, respectively), whereas at higher doses of midazolam (> or =4 mg) there was no difference between the 2 groups. The use of VAS scores and nurse assessment of recovery time were chosen in this study because, despite their subjectivity, these measures were felt to most closely reflect true clinical practice. The use of fentanyl in combination with low-dose midazolam results in significantly faster recovery from sedation compared with meperidine, without any apparent loss of analgesic effect.

Small dose of ketamine and midazolam for sedation in pediatric operation undergoing epidural anesthesia

Objective To compare and observe the effects of intravenous subsidiary narcotic drugs when using continuous epidural anesthesia in pediatric operations. Methods Sixty cases of 5～10 years old children that are able to cope with anesthesia procedure are chosen as subjects, and these children patients are performed with selective operation in the position below hypogastric zone. As the effects of epidural anesthesia are satisfied, the children are randomly divided into 2 groups and each group contains 30 cases. The first group: 100mg of ketamine and 10mg of diazepam are mixed and the subjects are performed with single intravenous injection according to 2.5mg/kg of ketamine. The second group: 100mg of ketamine and 5mg of midazolam are mixed and the subjects are performed with single intravenous injection according to 1mg/kg of ketamine. HR, BP, SpO2 and RR values of the children in each group are recorded before the medication, 1min, 5min, 15min after medica-tion and 5min after operation; the operation time, the case number of mask oxygen inhalation, the case number of boost medication, the case number of analepsia and children OAA/S score 5min after operation are recorded. Results The effects of sedation and inhibition of traction reaction are satisfied in both groups; BP, HR, SpaO2, RR in both groups is stable; OAA/S score in both groups is 4～5 points 5min after operation. Conclusion Small dose of ketamine and midazolam have the same small interference on the circulation and respiration systems of the children, in addition, the drugs consumption are small and these drugs are safe and practical. Key words: Epidural; Pediatric operation; Sedation; Small dose of ketamine and midazolam