Combination Of Midazolam Research Articles

Clinical evaluation of combination of dexmedetomidine and midazolam vs. dexmedetomidine alone for sedation during spinal anesthesia.

BackgroundDexmedetomidine is a useful sedative agent for spinal anesthesia. However, it has been reported to decreases heart rate in a dose-dependent manner. In the present study, we compared the bolus dose of midazolam and bolus loaded dexmedetomidine over 10 min to determine additional sedation methods.MethodsA total of 100 patients who were classified as American Society of Anesthesiologists physical status I–II undergoing spinal anesthesia were randomly divided into two groups. In the combination of midazolam and dexmedetomidine group (group MD), 10 min after bolus loading of 0.05 mg/kg midazolam, 0.5 μg/kg/h dexmedetomidine was infused. In the dexmedetomidine group (group D), 1 μg/kg bolus dose of dexmedetomidine was infused over 10 min, and then 0.5 μg/kg/h dexmedetomidine was infused continuously.ResultsAt 10 min, the sedation depth of the two groups was approximately the same. In both groups, the bispectral index (BIS) was within the optimal range of 55–80 and the Ramsay Sedation Scale score was within the optimal range of 3–5. Both patient and surgeon satisfaction with sedation did not differ between groups. At 10 min, heart rate (beats/min) was significantly lower (P < .01) in group D and mean blood pressure (mm Hg) was significantly lower (P < .01) in group MD. The prevalence of bradycardia (P = .714), hypotension (P = .089), and hypoxia (P = .495) did not differ statistically between the two groups.ConclusionsMidazolam bolus and dexmedetomidine continuous infusion may be a useful additional sedation method for patients who have severe bradycardia.

Effects of a Caudal Epidural Anesthesia Using Midazolam With or Without Lidocaine to Perform an Endometrial Biopsy in Mares

The aim of the study was to evaluate the effectiveness of midazolam in combination with lidocaine to induce caudal analgesia and cervical dilation to facilitate endometrial biopsy procedures. Eighteen mares undergoing endometrial biopsy were randomly allocated to three treatments groups that received epidural anesthesia (n = 6): 0.9% saline solution (SS) (6 mL, control group); midazolam maleate (MID) (0.05 mg/kg); and midazolam maleate (0.05 mg/kg) plus 2% lidocaine (MIDLID) (0.1 mg/kg). Systemic parameters, behavior, and motor blockade were measured at baseline and at 10, 30, and 60 minutes after treatments. A subjective score system was used to assess pain and cervical dilation during the reproductive procedures at the same time points. Satisfactory analgesia was recorded for both epidural midazolam treatment groups 8 ± 4 minutes postadministration of the drug; analgesia remained satisfactory until the end of the trial period (60 minutes, P > .05). All animals in the control group showed evident pain (P = .001) due to the analgesic tests and reproductive procedures. Cervical dilation (P = .0001) occurred 20 minutes after epidural injections for both treatment groups with midazolam, but this effect did not occur in the control treatment group. Systemic effects were not observed (P > .05) in baseline values or among treatment groups following caudal epidural administration of midazolam or midazolam/lidocaine treatments. Epidural analgesia using midazolam alone or the combination of midazolam and lidocaine may be a good alternative for painful reproductive and gynecologic procedures in mares.

What Would You Like to Start With? Choice of Initial Dose of Moderate Sedation and Impact on Time to Endoscope Insertion

Introduction: Midazolam and fentanyl are the most frequently used agents for endoscopy sedation. Guidelines recommend slow incremental dosing to prevent oversedation, however the choice of initial sedative and dose is at the discretion of the endoscopist. We aimed to describe practice patterns in the choice of initial dose and determine whether initial dose is associated with time to endoscope insertion (induction time). Methods: We performed a single-center retrospective cohort study on adults who underwent upper endoscopy and lower endoscopy under moderate sedation from 2008-2016. Multiple procedures on the same day were excluded. The choice of sedative agents, doses, and times of administration were noted. The initial dose was defined as the combination of sedatives given within the first minute of sedation. Induction time was defined as minutes from initiation of sedation to the insertion of the endoscope. Reversal agent use was noted. Patient age, sex and race were recorded and adjusted for. Results: A total of 14,631 upper and 24,281 lower endoscopies were included (Table 1). Midazolam and fentanyl were used in over 95% of cases. A variety of initial sedation combinations were prevalent (Figure 1). The combination of midazolam 2 mg and fentanyl 50 mcg was the most common initial sedation for all age groups. Induction time was lowest for midazolam 2 mg and fentanyl 75 mg across all ages. Induction time for “2 and 50” was consistently longer than for “1 and 75” and for “2 and 75.” Single-agent midazolam 2 mg was associated with the longest induction times of 6 minutes or more. Reversal agents were required in 14 patients who had received “2 and 50” versus 7 patients who had received “2 and 75” (0.08% vs 0.08%, p=0.99). After adjusting for demographics, initial choice of “1 and 75” or “2 and 75” resulted in 1.1 and 1.5 minute decreases respectively in induction time compared to initial use of midazolam 2 mg and fentanyl 50 mcg (p < 0.01, Table 2).Figure: Bars: Initial sedation dose combinations, in order of frequency, stratified by age group. Lines: mean induction time for each initial sedation dose combination.Table: Table. Characteristics of 38,912 Patients Who Underwent Upper and Lower Endoscopy under Moderate SedationTable: Table. Linear Regression Model for Sedative Induction Time in Minutes, with Most Frequent Initial Sedative Doses Combinations, Adjusted for Patient Demographics.Conclusion: There is significant variability in the choice of initial sedative dose, even within age categories. Midazolam appears to have slower onset compared with fentanyl, as evidenced by longer induction times for midazolam-predominant combinations. The initial use of midazolam 2 mg and fentanyl 75 mg was associated with shorter time to endoscope insertion than other combinations, and was not associated with an increased use of reversal agents.

A combination of alfaxalone, medetomidine and midazolam for the chemical immobilization of Rhesus macaque (Macacamulatta): Preliminary results.

Chemical immobilization of non-human primates can be required to perform scientific or veterinary procedure with different invasiveness degrees. This preliminary study was undertaken to assess the clinical effects of a combination of alfaxalone, medetomidine and midazolam (AMM). Seven rhesus macaques were chemically immobilized, for invasive veterinary procedures, with alfaxan 2mg kg-1 , medetomidine 20μg kg-1 and midazolam 0.3mg kg-1 injected subcutaneously. The alfaxalone combination induced surgical anaesthesia, with a complete absence of response to noxious stimuli, for at least 20minutes. The total duration of anaesthesia was 56±7minutes, and the administration of atipamezole, to partially reverse the combination effects, did not appear to alter the depth of anaesthesia. In conclusion, the AMM combination produced rapid onset general anaesthesia, following subcutaneous administration of a relatively low volume (0.28mL/kg) of injectate.

Non-anesthesiologist-administered Propofol is not Related to an Increase in Transcutaneous CO2 Pressure During Flexible Bronchoscopy Compared to Guideline-based Sedation: A Randomized Controlled Trial

IntroductionEvidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO2 pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events. MethodsIn this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico. ResultsNinety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60min of transcutaneous capnometry monitoring, mean transcutaneous CO2 pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]mmHg, P=.281). Propofol was related with a high Aldrete score at 5, 10, and 15min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], P=.006; 9 [8•10] vs. 10 [IQR 10•10], P<.001 and 10 [IQR 9•10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], P=.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, P=.47). ConclusionCompared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO2 pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction. Clinical trial RegistrationNCT02820051.

Histone Deacetylase Inhibitor Entinostat (MS-275) Restores Anesthesia-induced Alteration of Inhibitory Synaptic Transmission in the Developing Rat Hippocampus.

Recent evidence strongly supports the idea that common general anesthetics (GAs) such as isoflurane (Iso) and nitrous oxide (N2O; laughing gas), as well as sedative drugs such as midazolam are neurotoxic for the developing mammalian brain having deleterious effects on neural circuits involved in cognition, learning and memory. However, to date, very little is known about epigenetic mechanisms involved in GA-induced plasticity of synaptic transmission in the hippocampus, the main memory-processing region in the brain. Here, we used patch-clamp recordings of miniature inhibitory post-synaptic currents (mIPSCs) from hippocampal neurons in slice cultures exposed to the clinically relevant GA combination. We found that in vitro exposure to a combination of midazolam, 0.75% Iso, and 70% N2O for 6h leads to lasting increase in frequency of mIPSCs, while amplitudes and kinetics of the events were spared. Importantly, co-application of entinostat (MS-275), a selective inhibitor of class I histone deacetylases (HDAC), completely reversed GA-induced synaptic plasticity. Furthermore, when given in vivo to P7 pups exposed to GA with midazolam, Iso and N2O for 6h, MS-275 reversed GA-induced histone-3 hypoacetylation as shown by an increase in Ac-H3 protein expression in the hippocampus. We conclude that exposure to a combination of Iso with N2O and midazolam causes plasticity of mIPSCs in hippocampal neurons by epigenetic mechanisms that target presynaptic sites. We hypothesize that GA-induced epigenetic alterations in inhibitory synaptic transmission in the hippocampus may contribute to altered neuronal excitability and consequently abnormal learning and memory later in life.

Device-assisted enteroscopy in the UK: description of a large tertiary case series under conscious sedation

ObjectiveDevice-assisted enteroscopy (DAE) has developed rapidly, particularly with the advent of double-balloon enteroscopy (DBE). This study reports a case series from a UK tertiary centre for DAE across two modalities—DBE...

Optimum Drug Combinations for the Sedation of Growing Boars Prior to Castration

Simple SummaryPigs are notoriously challenging patients. They are difficult to handle so the use of predictable and safe sedation techniques is required for husbandry and surgical procedures. Various combinations of sedative and analgesic drugs have been previously investigated in this species, though the combination of midazolam and detomidine with either butorphanol or morphine has not been reported for sedation in pigs. The use of these combinations was investigated in the context of adequate sedation to allow castration of boars with the aid of local anaesthetic infiltration. The combination of midazolam, detomidine with butorphanol provided a more reliable sedation combination than that including morphine. It is proposed that this combination of drugs would be useful for sedation during painful husbandry procedures in pigs.Juvenile male pigs were sedated for castration. Eight five-month old boars were sedated twice (two weeks apart) with a combination of detomidine (0.1 mg/kg), midazolam (0.2 mg/kg) and either butorphanol (0.2 mg/kg) (Group MDB, n = 8) or morphine (0.2 mg/kg) (Group MDM, n = 8) intramuscularly. The boars were positioned in lateral recumbency and lidocaine (200 mg total) was injected into the testicle and scrotal skin. Castration of a single testicle was performed on two occasions. Sedation and reaction (to positioning and surgery) scores, pulse rate, respiratory rate, haemoglobin oxygen saturation, body temperature, arterial blood gas parameters and the times to immobility and then recovery were recorded. Atipamezole was administered if spontaneous recovery was not evident within 60 min of sedative administration. Data were compared with either a paired-sample t-test or a Wilcoxon-Signed Rank Test. There was no difference in sedation score, body temperature, respiratory rate and haemoglobin oxygen saturation between MDB and MDM. Mild hypoxaemia was noted in both groups. There was less reaction to castration after MDB. The pulse rate was higher after MDM sedation. The times to immobility and then recovery were similar. The combination of MDB provided more reliable sedation than MDM. MDB may be useful for sedation for short procedures in pigs, though oxygen supplementation is recommended to avoid hypoxaemia.

Efficacy of Intravenous Midazolam &amp; Ketamine Combination in the Treatment of Shivering after Spinal Anaesthesia – A Comparative Study with Intravenous Midazolam &amp; Pethidine Alone

Background: Post spinal shivering is very distressing for patients and may induce a variety ofcomplications.1 The principal reasons for hypothermia are - it leads to an internal redistribution of heatfrom the core to the peripheral compartment, loss of thermoregulatory vasoconstriction below the level ofthe spinal block and altered thermoregulation due to vasodilation and shivering thresholds3,4,5,21. Presentstudy demonstrated that the combination of midazolam and ketamine treats the hypothermia that isoften less effective with midazolam or pethidine alone. Objectives: To assess the effectiveness of midazolam-ketamine combination over midazolam &amp; pethidinealone in post spinal shivering. Methods: This hospital based randomized double blind controlled study. One hundred fifty patients,classified by (ASA) physical status category I-II, were randomized by card method in three groups of 50patients each. Subarachnoid (spinal) anaesthesia was performed . The patients were randomly allocatedto receive 0.025 mg/kg midazolam + 0.25 mg/kg Ketamine (Group A), 0.035 mg/kg i/v midazolam(Group B), and 0.5 mg/kg i/v pethidine (Group C). After development of shivering, it graded and recorded.1st dose of drugs given as coded in syringe A,B,C. If the grade 3 or 4 after 15 min from the administrationof the study drug, the prophylaxis was regarded as ineffective and pethidine 25 mg intravenously wasadministered. Result: Patients characteristics in respect of age, residence, others socio-demographic characteristics,ASA status and type of surgery were similar between the groups. Heart rate and mean arterial bloodpressure values were less and close to base levels without requirement of any other rescue medicationand remained stabilized throughout the intraoperative period in midazolam &amp; ketamine (Group A)patient. Conclusion: The most effective measures for prevention and treatment of post-spinal shivering are forcedair warming, fluid warming with combating pharmacological agents e.g. midazolam, ketamine, morphine,fentanyl, and pethidine etc. In our study midazolam plus metamine is more effective than other hadproven. JBSA 2017; 30(2): 75-82

Economic Evaluation of Midazolam-Droperidol Combination, Versus Droperidol or Olanzapine for the Management of Acute Agitation in the Emergency Department: A Within-Trial Analysis.

BackgroundThe combination of midazolam and droperidol has proven superior to droperidol or olanzapine monotherapy in the management of acute agitation in emergency departments (EDs).ObjectiveThis is the first economic analysis to evaluate the cost–benefit and cost effectiveness of the midazolam–droperidol combination compared with droperidol or olanzapine for the management of acute agitation in EDs.MethodsThis analysis used data derived from a randomised, controlled, double-blind clinical trial conducted in two metropolitan Australian EDs between October 2014 and August 2015. The economic evaluation was from the perspective of Australian public hospital EDs. The main outcomes included agitation management time and the agitation-free time gained. Sensitivity analyses were undertaken.ResultsThe midazolam–droperidol combination was the least costly regimen (Australian dollars [AU$]46.25 per patient) compared with the droperidol and olanzapine groups (AU$92.18 and AU$110.45 per patient, respectively). The main cost driver for all groups was the cost of the labour required during the initial adequate sedation. The combination afforded an additional 10–13 min of mean agitation-free time gained, which can be translated to additional savings of AU$31.24–42.60 per patient compared with the droperidol and olanzapine groups. The benefit–cost ratio for the midazolam–droperidol combination was 12.2:1.0, or AU$122,000 in total benefit for every AU$10,000 spent on management of acute agitation. Sensitivity analyses over key variables indicated these results were robust.ConclusionsThe midazolam–droperidol combination may be a cost-saving and dominant cost-effective regimen for the treatment of acute agitation in EDs as it is more effective and less costly than either droperidol or olanzapine monotherapy.

Intravital investigation of rat mesenteric small artery tone and blood flow.

Substantial information on rat mesenteric small artery physiology and pharmacology based on in vitro experiments is available. Little is known about the relevance of this for artery function in vivo. We here present an intravital model where rat mesenteric small artery diameters are studied under isolated and controlled conditions in situ with simultaneous measurement of blood flow. The responses of the isolated arteries vary with the anaesthetic used, and they are quantitatively but not qualitatively different from the responses seen in vitro. Functional characteristics of rat mesenteric small arteries (internal diameter ∼150-200μm) have been extensively studied in vitro using isometric and isobaric myographs. In vivo, precapillary arterioles (internal diameter <50μm) have been studied, but only a few studies have investigated the function of mesenteric small arteries. We here present a novel approach for intravital studies of rat mesenteric small artery segments (∼5mmlong) isolated in a chamber. The agonist-induced changes in arterial diameter and blood flow were studied using video imaging and laser speckle analysis in rats anaesthetized by isoflurane, pentobarbital, ketamine-xylazine, or by a combination of fentanyl, fluanison and midazolam (rodent mixture). The arteries had spontaneous tone. Noradrenaline added to the chamber constricted the artery in the chamber but not the downstream arteries in the intestinal wall. The constriction was smaller when rats were anaesthetized by rodent mixture in comparison with other anaesthetics, where responses were qualitatively similar to those reported in vitro. The contraction was associated with reduction of blood flow, but no flow reduction was seen in the downstream arteries in the intestinal wall. The magnitude of different endothelium-dependent relaxation pathways was dependent on the anaesthesia. Vasomotion was present under all forms of anaesthesia with characteristics similar to in vitro. We have established an intravital method for studying the tone and flow in rat mesenteric arteries. The reactivity of the arteries was qualitatively similar to the responses previously obtained under in vitro conditions, but the choice of anaesthetic affects the magnitude of responses.

Entonox Efficacy for Procedural-Sedation and Analgesia in Pediatrics Undergoing Bone Marrow Aspiration: A Randomized Clinical Trial

Background: Bone marrow aspirations and biopsies are very painful diagnostic procedures in pediatric candidates and must be done under sedation or analgesia. Objectives: The current study aimed at investigating the effect of using Entonox gas during sedation and analgesia induction in pediatric candidates of bone marrow aspiration. Methods: It was a single-blind, randomized clinical trial. All pediatric candidates of first time bone marrow aspiration were included and allocated to either group 1 or 2, using a random number table. In group 1, a combination of midazolam, fentanyl, ketamine, and propofol was injected intravenously. In group 2, the mentioned combination was injected intravenously and Entonox gas was used for patients’ ventilation. The goal was to reach level 4 sedation based on the Ramsay sedation scale. If needed, extra propofol was injected intravenously every minute. Physician and the helping nurse satisfaction of the procedure were evaluated. Duration of the procedure, the administered dosage for each patient, occurrence of any complications, and the recovery time were recorded. Results: A total of 88 cases with the mean age of 6.8 ± 3.6 years, and mean weight of 25.4 ± 12.5 kg were included in the study (50% female). Baseline and demographic data of the groups showed no significant difference. Propofol consumption was significantly lower in group 2, for whom Entonox gas was prescribed, compared with group 1 (P-value < 0.001). Decrease of recovery time in group 2 compared with group 1 was evident (P-value < 0.001). Physician and nurse’s satisfaction was higher in group 2 compared to group 1, and the difference was statistically significant. Conclusions: It is likely that Entonox prescription during bone marrow aspiration in pediatric leads to decrease in consumption of propofol to provide proper sedation, shorter recovery time of the patients, and increased satisfaction in both the physician and nurse in charge of performing the procedure.

Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.

Preoperative anxiety management receives special attention in pediatric anesthesia. Different pharmacological and nonpharmacological techniques can be employed. This study was designed to assess three different strategies for childhood preoperative anxiolysis: midazolam premedication, midazolam in combination with portable Digital Video-Disk player, or video distraction strategy alone. In this prospective randomized study, children aged 2-12 years were assigned to one of the three study groups. The primary outcome was a change in preoperative children's anxiety, from baseline (before transfer to the preanesthetic holding area) to separation from parents, assessed by the Modified Yale Preoperative Anxiety Scale (mYPAS) and the Visual Analog Anxiety Scale (VAS-Anxiety). Delirium emergence, postoperative pain, and parental satisfaction were also collected. One hundred and thirty-five patients were enrolled. The three preventive strategies allowed control of preoperative distress. Within the three study groups, no significant change was objectified in the anxiety level from baseline to separation from parents (mean change in mYPAS midazolam group: 2.4 95% CI [-1.7 to 6.3]; midazolam+Digital Video-Disk group: -1.0 95% CI [-5.9 to 3]; and Digital Video-Disk group: 1.4 95% CI [-4 to 6.7]). Comparison of change in preoperative children's anxiety between the groups did not show any difference. Emergence delirium, postoperative pain scores, and analgesic consumption were similar between the groups and parents' satisfaction was excellent. Both pharmacological premedication and video distraction are effective strategies for controlling preoperative childhood anxiety. The combination of midazolam and Digital Video-Disk player was not better than either alone.

Application of minimally invasive intubation in parathyroidectomy during induction of general anesthesia

Objective To observe effects of minimally invasive intubation in parathyroidectomy during induction of general anesthesia. Methods One hundred patients with ASA category of Ⅲ or Ⅳ were enrolled for thyroid gland resection under general anesthesia. These cases were randomly divided into minimally invasive group(group L) and control(group C)(n=50). General anesthesia was induced by the combination of midazolam, etomidate, sufentanil and CIS-atracurium. Tracheal intubation was performed under the guidance of laryngoscopy. Two point five min after induction of general anesthesia, group L received 2% lidocaine spray on glottis, and an ID 7 tracheal tube was inserted. But an ID 7.5 tracheal tube was inserted in the group C patients 4 min after the induction of general anesthesia. We continuously pumped remifentanil and propofol, and intermittently infused CIS-atracurium to maintain anesthesia in patients. SBP, DBP, HR, and SpO2 were monitored before anesthesia induction(T0), immediately after induction(T1), before intubation(T2), 1 min after intubation(T3), 3 min after intubation(T4), respectively. At T1 and 10 min after intubation(T5), we extracted vein blood to measure adrenocorticotropic hormone(ACTH) and cortisol corticosteroid(CORT) in serum. Results During the intubation period, SBP, DBP, HR of group C increased significantly more than those of group L(P<0.05), and levels of serum ACTH and CORT in group L remained unchanged instead of increased in group C. Conclusions Minimally invasive catheterization technique can effectively reduce cardiovascular responses to tracheal intubation, and attenuate the release of stress hormones in patients receiving parathyroidectomy. These may improve the safety of the operation. Key words: Anesthesia, general; Endotracheal intubation; Parathyroidectomy

Comparison of Changes in Respiratory Dynamics Immediately After the Start of Propofol Sedation With or Without Midazolam

The aim of this study was to compare changes in respiratory dynamics starting immediately after administration of propofol alone or a combination of propofol and midazolam. Twenty-seven healthy adult volunteers participated in a randomized crossover study of undergoing sedation with propofol alone (P group) or with a combination of propofol and midazolam (PM group). In the P group, continuous infusion of propofol through a target-controlled infusion (TCI) pump was started with the target effect site (ES) concentration set at 1.2μg/mL. In the PM group, participants received a bolus administration of midazolam 0.02mg/kg simultaneously with the start of continuous infusion of propofol through a TCI pump with the target ES concentration set at 0.8μg/mL. The variables measured included the bispectral index (BIS) value, tidal volume (VT), percutaneous arterial oxygen saturation (SpO2), respiratory rate (RR), end-tidal carbon dioxide tension (ETCO2), estimated ES propofol concentration, and minute volume. BIS value, VT, SpO2, and ETCO2 decreased after sedative administration in the 2 groups. RR increased in the 2 groups. These changes occurred sooner in the PM group than in the P group. The ratio of change in VT to change in BIS value decreased in the 2 groups and was markedly smaller in the PM group than in the P group. Ratios of changes in SpO2, RR, and ETCO2 to change in BIS value increased in the 2 groups and were larger in the PM group than in the P group. Changes in respiratory dynamics occurred sooner in the PM group than in the P group. In the PM group, although VT began to decrease before the change in BIS value, the increase in RR caused the rate of decrease in SpO2 to be smaller than the rate of decrease in BIS value.

Comparison of subcutaneous dexmedetomidine–midazolam versus alfaxalone–midazolam sedation in leopard geckos (Eublepharis macularius)

ObjectiveTo compare dexmedetomidine–midazolam with alfaxalone–midazolam for sedation in leopard geckos (Eublepharis macularius). Study designProspective, randomized, blinded, complete crossover study. AnimalsNine healthy adult leopard geckos. MethodsGeckos were administered a combination of dexmedetomidine (0.1 mg kg−1) and midazolam (1.0 mg kg−1; treatment D–M) or alfaxalone (15 mg kg−1) and midazolam (1.0 mg kg−1; treatment A–M) subcutaneously craniodorsal to a thoracic limb. Heart rate (HR), respiratory rate (fR), righting reflex, palpebral reflex, superficial and deep pain reflexes, jaw tone and escape response were assessed every 5 minutes until reversal. Conditions for intubation and response to needle prick were evaluated. Antagonist drugs [flumazenil (0.05 mg kg−1) ± atipamezole (1.0 mg kg−1)] were administered subcutaneously, craniodorsal to the contralateral thoracic limb, 45 minutes after initial injection, and animals were monitored until recovery. ResultsHR, but not fR, decreased significantly over time in both treatments. HR was significantly lower than baseline at all time points in D–M and for all but the 5 and 10 minute time points in A–M. HR was significantly higher in A–M at all time points after drug administration when compared with D–M. Sedation scores between protocols were similar for most time points. All animals in A–M lost righting reflex compared with seven out of nine (78%) geckos in D–M. Geckos in A–M lost righting reflex for significantly longer time. Mean ± standard deviation time to recovery after antagonist administration was 6.1 ± 2.2 minutes for D–M and 56 ± 29 minutes for A–M, and these times were significantly different. Conclusions and clinical relevanceCombination D–M or A–M provided sedation of a level expected to allow physical examinations and venipuncture in leopard geckos. A–M provided a faster onset of sedation compared with D–M. Recovery was significantly faster following antagonist reversal of D–M, compared with A–M.

Analogosedation during flexible bronchoscopy using a combination of midazolam, propofol and fentanyl - A retrospective analysis.

BackgroundAccording to current guidelines flexible bronchoscopy is usually performed under sedation. Previously it has been demonstrated that combined sedation with e. g. the combination of midazolam and propofol or an opioid might have several advantages over sedation with just one sedative drug. However, little is known about the efficacy and safety of combined sedation with midazolam, fentanyl and propofol (MFP) compared to sedation with midazolam and fentanyl (MF) or midazolam and propofol (MP).MethodsWe carried out a retrospective analysis of bronchoscopies performed under triple (MFP) or double sedation (MF and MP) in an academic hospital. 1392 procedures were analyzed (MFP: n = 824; MF: n = 272; MP: n = 296). In particular, we compared the occurrence of complications and the dosage of administered sedative drugs between the groups.ResultsThe occurrence of adverse events (MFP vs. MF: odds ratio (OR) 1.116 [95% CI 0.7741 to 1.604]; MFP vs. MP: OR 0.8296 [95% CI 0.5939 to 1.16] and severe adverse events (MFP vs. MF: OR 1.581 [95% CI 0.5594 to 4.336]; MFP vs. MP: OR 3.47 [95% CI 0.908 to 15.15]; all p>0.05) was similar in all groups. The dosage of midazolam was lower in the MFP compared to the MF or MP group (MFP vs. MF: Cohen’s d 0.075; MFP vs. MP: Cohen’s d 0.225; all p<0.001). In addition patients in the MFP group received significantly less propofol compared to the MP group (Cohen’s d 1.22; p<0.001).ConclusionsIn summary we were able to demonstrate that triple sedation can safely be administered during flexible bronchoscopy and is associated with a reduced dosage of midazolam and propofol.

Non-anesthesiologist-administered Propofol is not Related to an Increase in Transcutaneous CO2 Pressure During Flexible Bronchoscopy Compared to Guideline-based Sedation: A Randomized Controlled Trial

IntroductionEvidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO2 pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events. MethodsIn this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico. ResultsNinety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60min of transcutaneous capnometry monitoring, mean transcutaneous CO2 pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]mmHg, P=.281). Propofol was related with a high Aldrete score at 5, 10, and 15min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], P=.006; 9 [8–10] vs. 10 [IQR 10–10], P<.001 and 10 [IQR 9–10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], P=.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, P=.47). ConclusionCompared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO2 pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction. Clinical trial RegistrationNCT02820051.

Safety of hyperbaric oxygen therapy in mechanically ventilated patients.

To evaluate the epidemiology of patients who require mechanical ventilation during hyperbaric oxygen therapy. One-hundred-fifty patients who required mechanical ventilation during hyperbaric oxygen therapy were prospectively studied during a 6-year period in a French university hyperbaric centre. We analysed the indication of hyperbaric oxygen therapy, agent used for sedation, presence of a chest tube, need for vasopressor agents and tolerance and appearance of side effects. Finally, we compared the outcomes of patients according to the presence or absence of acute respiratory distress syndrome (ARDS). Eleven children and 139 adult patients were included (n = 150) in the study. In both populations, carbon monoxide poisoning (51%) and iatrogenic gas embolism (33%) were the two main causes of intubation and mechanical ventilation. The combination of midazolam and sufentanil was used in 85 (67%) patients. All of the patients were given a bolus of a neuromuscular blocker during the hyperbaric session, despite the presence of ARDS in 35 patients. Patient-ventilator asynchrony was the most frequent side effect in 6 (5%) patients and was often the consequence of suboptimal sedation. Mortality was higher in the group with ARDS (23%). Carbon monoxide poisoning and iatrogenic gas embolism are the two main diseases of the patients who required mechanical ventilation during hyperbaric oxygen therapy in this study. Mechanical ventilation is a safe method for patients during hyperbaric oxygen therapy. Sedation needs to be perfected to avoid patient-ventilator asynchrony.

Muscle power during intravenous sedation.

SummaryIntravenous sedation is effective to reduce fear and anxiety in dental treatment. It also has been used for behavior modification technique in dental patients with special needs. Midazolam and propofol are commonly used for intravenous sedation. Although there have been many researches on the effects of midazolam and propofol on vital function and the recovery profile, little is known about muscle power. This review discusses the effects of intravenous sedation using midazolam and propofol on both grip strength and bite force. During light propofol sedation, grip strength increases slightly and bite force increases in a dose-dependent manner. Grip strength decreases while bite force increases during light midazolam sedation, and also during light sedation using a combination of midazolam and propofol. Flumazenil did not antagonise the increase in bite force by midazolam. These results may suggest following possibilities; (1) Activation of peripheral benzodiazepine receptors located within the temporomandibular joint region and masticatory muscles may be the cause of increasing bite force. (2) Propofol limited the long-latency exteroceptive suppression (ES2) period during jaw-opening reflex. Thus, control of masticatory muscle contraction, which is thought to have a negative feedback effect on excessive bite force, may be depressed by propofol.