Premedication Drugs Research Articles

Using ondansetron as an oral premedication drug for prevention of postanesthesia shivering

Introduction Postanesthesia shivering (PAS) is one of the most common complications after surgeries. There are two methods to reduce the shivering, including pharmacological and nonpharmacological methods. Aim This study compared the efficacy and safety of 4-mg oral ondansetron premedication on preventing PAS, perioperative core body temperature changes, and hemodynamic stability. Patients and methods This prospective, observational study consisted of 100 adult patients scheduled for general surgery or interventional structural heart disease. The patients were randomized into two groups of 50 patients each. Group I received 4 mg of oral ondansetron, and group II received an oral placebo 60–90 min before the operation. All patients were assessed for perioperative hemodynamic changes, core body temperature changes, and PAS. Results Regarding the efficacy of the preoperative administration of oral ondansetron, this study reports the valuable preventive effect on shivering for ondansetron group (8.1%) compared with control group (44.3%), and there was a highly significant difference between both groups according to the incidence and scoring of shivering. On the contrary, we found no significant difference between groups according to heart rate, systolic blood pressure, and diastolic blood pressure. However, reduction in systolic blood pressure and diastolic blood pressure was recorded in both groups after induction, which came back up at the end of surgery. In addition, tympanic temperature reduction was recorded intraoperatively and came back up during the recovery period, with no statistically significant differences between groups. Conclusion Oral ondansetron premedication adequately decreases PAS compare with placebo. Ondansetron does not have any significant effect on the core or peripheral temperature.

Universal premedication and therapeutic drug monitoring for asparaginase-based therapy prevents infusion-associated acute adverse events and drug substitutions.

Asparaginase is a critical component of lymphoblastic leukemia therapy, with intravenous pegaspargase (PEG) as the current standard product. Acute adverse events (aAEs) during PEG infusion are difficult to interpret, representing a mix of drug-inactivating hypersensitivity and noninactivating reactions. Asparaginase Erwinia chrysanthemi (ERW) is approved for PEG hypersensitivity, but is less convenient, more expensive, and yields lower serum asparaginase activity (SAA). We began a policy of universal premedication and SAA testing for PEG, hypothesizing this would reduce aAEs and unnecessary drug substitutions. Retrospective chart review of patients receiving asparaginase before and after universal premedication before PEG was conducted, with SAA performed 1week later. We excluded patients who had nonallergic asparaginase AEs. Primary end point was substitution to ERW. Secondary end points included aAEs, SAA testing, and cost. We substituted to ERW in 21 of 122 (17.2%) patients pre-policy, and 5 of 68 (7.4%) post-policy (RR, 0.427; 95% CI, 0.27-0.69, P=0.028). All completed doses of PEG yielded excellent SAA (mean, 0.90 units/mL), compared with ERW (mean, 0.15 units/mL). PEG inactivation post-policy was seen in 2 of 68 (2.9%), one silent and one with breakthrough aAE. The rate of aAEs pre/post-policy was 17.2% versus 5.9% (RR, 0.342; 95% CI, 0.20-0.58, P=0.017). Grade 4 aAE rate pre/post-policy was 15% versus 0%. Cost analysis predicts $125779 drug savings alone per substitution prevented ($12402/premedicated patient). Universal premedication reduced substitutions to ERW and aAE rate. SAA testing demonstrated low rates of silent inactivation, and higher SAA for PEG. A substantial savings was achieved. We propose universal premedication for PEG be standard of care.

Comparative study between intravenous dexmedetomidine and clonidine as premedication in pediatric patients undergoing spinal anesthesia

TitleComparative study between intravenous dexmedetomidine and clonidine as premedication in pediatric patients undergoing spinal anesthesia.BackgroundMany techniques and drug regimens, with partial or greater success, have been tried from time to time to eliminate the anxiety component and to prolong the postoperative analgesia during regional anesthesia. In pediatric patients, anxiety and lack of cooperativeness for the regional procedure is the major problem in providing spinal anaesthesia. Alpha2-adrenergic agonists have both analgesic and sedative properties, when used as an adjuvant to regional anesthesia. They eliminate the anxiety, provide conscious sedation, lower the level of agitation and improve patient satisfaction. We designed a prospective, randomized, double-blind study, to evaluate and compare the efficacy of intravenous dexmedetomidine with clonidine as a premedication drug during spinal anaesthesia using intrathecal bupivacaine.Materials and methodsIn this prospective, randomized, double-blind study, 60 pediatric patients 4–10 years of age of the American Society of Anesthesiologists status I, scheduled for uro-genital surgery under spinal anesthesia, were randomly allocated into two groups of 30 each. Group DE received dexmedetomidine 1 μg kg−1 and group CL received clonidine 1 μg kg−1 diluted in 20 ml of normal saline intravenously over 10 min, 40 min before subarachnoid anaesthesia with 0.5% hyperbaric bupivacaine. The patients were monitored every 5 min for 1st 20 min and then every 10 min interval vitals were noted. Acceptable sedation score, parental separation anxiety level and degree of mask acceptance were assessed. Highest level of sensory blockade, time of two segment regression and time of first request of analgesic were also noted. Data was analyzed using Fisher’s exact test or Chi-square test and the value of P < 0.05 was considered statistically significant.ResultsGroup DE and CL had comparable sedation score (p > 0.05). However, parental separation anxiety score and mask acceptance score, were better in DE than CL group (p < 0.05). There was no significant haemodynamic differences between the groups (p > 0.05). Duration of analgesia was also prolonged in DE group.ConclusionDexmedetomidine is superior to clonidine as a premedication drug in pediatric patients undergoing spinal anesthesia.

Effects of Ibuprofen Compared to Other Premedication Drugs on the Risk and Intensity of Postendodontic Pain: A Systematic Review.

Objective:This systematic review aims to evaluate the effects of ibuprofen compared to other drugs on the risk and intensity of postoperative pain resulting from endodontic treatment in adult patients.Methods:A systematic search was carried out through Medline databases (Pubmed, Scopus, Web of Science, Cochrane, Lilacs, and BBO). There was no restriction on the publication year or idiom. The gray literature was explored. The Periodicos Capes Theses Databases and ProQuest Dissertations were also searched, as well as the unpublished and ongoing trials registry and the IADR abstracts (1990–2016). Solely randomized clinical trials that compared the risk or intensity of pain resulting from endodontic treatment in adult patients were included in this systematic review. The risk of bias of the articles was evaluated using the Cochrane Collaboration’s tool. A random-effect meta-analysis was conducted for ibuprofen versus placebo and ibuprofen versus other drugs at 6, 8, and 24 hours. The GRADE approach was used to assess the quality of the evidence.Results:A total of 1132 studies were identified, and only seven meet the eligibility criteria. No difference between the groups was detected in any of the meta-analysis. An exception was observed when one study was removed from the meta-analysis of pain intensity at 24 hours for ibuprofen versus placebo, favoring ibuprofen (SMD −0.67; 95% CI −1.05 to −0.17). The quality of evidence in all meta-analyses was graded as low or very low.Conclusion:Results of the present systematic review indicate that there is no clear evidence supporting that preoperative ibuprofen is better than other drugs in reducing the risk and intensity of postendodontic pain.

Effect of xylazine, medetomidine and dexmedetomidine on cardiac conduction in pigs

The majority of anaesthetics used in studies regarding heart arrhythmias may affect the cardiac conduction system, thus influencing the results. In veterinary medicine, xylazine, medetomidine and dexmedetomidine are commonly used for premedication in laboratory and companion animals. To date, there have been no studies assessing the effect of these substances on the cardiac conduction system. The aim of this study was to assess the effect of xylazine, medetomidine and dexmedetomidine on the parameters of the cardiac conduction system in pigs. The study was carried out on 18 Great White Polish male pigs weighing from 21 to 40 kg. The animals were divided into three equal groups. The animals from the first group received xylazine at a dose of 2 mg/kg i.v.; those from the second group received medetomidine at 40 mcg/kg i.v.; and those from the third group received dexmedetomidine at 10 mcg/kg i.v. The electrophysiological activity of the heart was analysed using an invasive electrophysiological study (EPS). During the EPS, a decrease in the heart rate after substance administration was observed in all animals, but there were no statistically significant differences in the cardiac conduction parameters. A pro-arrhythmic effect of xylazine was observed, but no statistically significant changes in the EPS parameters were noted. Our results indicate that medetomidine and dexmedetomidine may be used as standard premedication drugs in electrophysiological studies in pigs. Their use may facilitate animal preparation procedures without affecting study results..

Effect of Catheter Gauge on the Success of Intravenous Catheter Placement by Veterinary Students.

The purposes of this study were to determine if senior veterinary students find it easier to place a smaller-bore catheter, and to relate patient variables with student success in catheter placement. For dogs between 10kg and 20kg, the catheter size options were 20gauge or 22gauge. For dogs larger than 20kg, the catheter size options were 18gauge or 20gauge. Variables recorded included time for catheter placement, number of catheterization attempts, number of catheters used, number of legs used, difficulty of catheterization, student success, and patient characteristics including signalment, weight, body condition score, premedication drugs given, tentative diagnosis, and procedure. If the student could not place an IV catheter after three attempts, it was graded as a student catheter placement failure. For the 55 students participating in the study over 28 months, we recorded 192 individual catheterization attempts. In small patients, students were successful in 19/20 attempts with 22-gauge catheters and in 24/30 with 20-gauge catheters. In large patients, students were successful in 59/68 attempts with 20-gauge catheters and 61/74 with 18-gauge catheters. The overall success rate was 164/192 (85%). Students were more likely to be successful when attempting placement in those dogs receiving acepromazine than in those not receiving acepromazine (p=.02). There were no significant differences among any of the other variables for difficulty, placement time, number of attempts, or student success. Clinicians and educators may select a size catheter for the patient without concern for the effects on student catheter placement success.

Premedication considerations for dogs undergoing general anaesthesia

The selection of appropriate pre-anaesthetic drugs prior to general anaesthesia will provide a smoother induction and maintenance phase of anaesthesia. Catecholamine release will be reduced, subsequently reducing anxiety and problems associated with catecholamine release such as cardiac arrhythmias. Intravenous catheter placement and pre-oxygenation can prove less challenging. Analgesia can be provided pre-emptively, which is especially helpful in dogs with chronic pain, reducing the risks of central sensitisation. An ideal pre-anaesthetic medication provides sedation, has minimal effects on the cardiovascular and respiratory systems, provides analgesia and is reversible. Unfortunately, no single drug has all of these properties, therefore a multi-modal approach is required to fulfil a patient's needs. There are several drugs from different pharmacological groups that are commonly used when premedicating dogs in veterinary practice including: opioids, phenothiazines, alpha-2-adrenoreceptor agonists, benzodiazepines and anaesthetic agents. Understanding the mode of action, dose ranges, contraindications, effects and side effects of these drugs allows selection of the most appropriate premedication drug combination for individual patients. It also allows provision of the safest anaesthetic environment possible for the patient and enables veterinary professionals to be prepared for potential complications. Anaesthetic complications cannot be entirely avoided but their risk can be reduced dramatically by understanding fully the drugs that are being used.

Completeness of handwritten preanaesthetic records at two veterinary referral institutions

ObjectiveTo retrospectively analyse handwritten preanaesthetic records for completeness at two veterinary referral institutions: a university veterinary teaching hospital and a private veterinary referral hospital. To evaluate if emergency records were less complete compared with non-emergency records. Animal or Animal Population Two hundred and fifty preanaesthetic records at each referral institution. Materials and MethodsHandwritten preanaesthetic records were analysed for completeness. Data was described as complete or incomplete. In order to be classified as complete information had to be present, legible and correct. Sections of the preanaesthetic record analysed included the date, anaesthetist, clinician, presenting problem, procedure, time food withheld, temperature, pulse rate (PR), respiratory rate (fR), American Society of Anesthesiologists-Physical Status Classification (ASA-PSC), premedication drug name, premedication drug dose, premedication route of administration, premedication time, effect of premedication, induction drug name, induction drug dose, induction time, induction quality, maintenance anaesthetic agent, endotracheal tube (ET) diameter, anaesthetic breathing system and monitoring equipment. ResultsAt both referral institutions 250 records were analysed. Completeness of data was generally poor, however, several differences did exist. Completion rates were generally higher at the university veterinary teaching hospital. A mix of structured and unstructured (requiring free text) data fields were poorly complete. Emergency records were significantly less complete with respect to: Time food withheld (p = 0.006) and Temperature (p = 0.0275). ConclusionsDifferences observed may be due to anaesthetic record design, anaesthetic caseload, case discussion, education or quality assurance programmes. Clinical relevance Increased emphasis on education and implementation of quality assurance programmes should be considered in order to improve completeness of preanaesthetic records.

A national survey of premedication for transfusion reactions in Japan

BackgroundPremedication before transfusion is commonly administered in clinical practice despite a lack of evidence for its efficacy. The aim of this study was to clarify the status of premedication and evaluate expert opinions regarding its use in Japanese medical institutions. MethodBetween May and July 2016, we conducted a questionnaire survey on premedication before transfusion in 252 medical institutes that were certified by an academic society or employed transfusion experts. ResultsA total of 141 institutes (54.2%) responded, and hematologists (n=113) comprised the most frequent respondents. The purpose of premedication was to prevent urticaria, pruritus, and fever, and washed blood products were used for anaphylactic shock or refractory transfusion reactions before. Drugs for premedication were intravenously administered either just before or 30min before transfusion. Both inpatients and outpatients were premedicated in a similar manner, and institutional guidelines were not established. More than half of the experts recognized premedication as efficient and necessary, and premedication for previous transfusion reactions was frequently implemented, particularly for platelet transfusion or in patients with hematological diseases. Some institutions administered one or more drugs for premedication from the first transfusion. Antihistamines and hydrocortisone were the most frequently used as premedication. ConclusionOur study reports the current status of premedication for transfusion in Japan. Antihistamines and hydrocortisone were most commonly used for premedication despite a lack of evidence of their use. These findings may help clarify the indications for premedication and the use of washed blood products.

Effect of Alprazolam on Redox Status in Renal Transplantation Donors and Recipients.

BACKGROUND Benzodiazepines are the most popular premedication drugs thought to act through the GABA/benzodiazepine receptor complex and alprazolam is one of the most potent benzodiazepines that have a quick onset. While there is a growing body of evidence supporting alprazolam in the amelioration of redox status in animals, no study has been performed concerning its antioxidant activity in humans. The purpose of this investigation was to determine the effect of alprazolam on redox status. MATERIAL AND METHODS This study was a four-group randomized controlled trial. Participants were recruited from Acibadem University Acibadem International Hospital and included a convenience sample of 82 donors and recipients undergoing renal transplantation. Patients were randomly divided into four groups. While donors and recipients in experimental groups (G1 and G3) were administered alprazolam 0.5 mg orally one hour before the operation, those in control groups (G2 and G4) were not. Serum advanced oxidative protein products, total thiol, free hemoglobin, ischemic modified albumin, and sialic acid levels at different time points were measured to evaluate the redox status. RESULTS All oxidative stress parameters were higher in the alprazolam premedication groups (G1, G3) at all time points than in the control groups (G2, G4). Basal values of oxidative parameters (at time point T1) in patients with CKD (G3, G4) were lower than in healthy donors (G1, G2). CONCLUSIONS Alprazolam premedication in donors and end-stage renal failure patients undergoing renal transplantation does not improve redox homeostasis but further experimental studies are needed.

Effect of Fentanyl and Morphine on Gallbladder Dimensions in Newborns Admitted to the Neonatal Intensive Care Unit: A Randomized Double-Blinded Clinical Trial

Background: The effect of fentanyl and morphine, two most frequently used drugs for premedication in general anesthesia, on gallbladder of newborns, has not been sufficiently investigated. Intubation and mechanical ventilation in a neonatal respiratory distress syndrome are stressful procedures, in which these two drugs are used to reduce stress and pain. We studied the effect of these drugs on neonatal bile system during these procedures Objectives: The present study aimed at determining the effect of fentanyl and morphine on gallbladder dimensions among newborns admitted to the neonatal intensive care unit (NICU). Methods: Thirty-two newborns with the gestational age between 26 and 38 weeks, undergoing intubation and mechanical ventilation, were selected for this randomized, double-blinded, clinical trial study. They were randomly divided into two groups; group 1 received morphine and group 2 received fentanyl. Gallbladder measurements (width, depth, length and volume) were compared between the two groups by ultrasound evaluation. The data were collected between Nov 2012 and Oct 2013 at the NICU of the Children’s hospital in Bandar Abbas, Iran. Results: There were no significant differences between the two groups in the evaluated parameters when demographic variables were compared. We found statistically differences between width, depth and volume of the newborns’ gallbladders. However, there was no significant differences with regard to gallbladder length (P = 0.19). Conclusions: Morphine caused gallbladder dilatation more than fentanyl. However, it should be considered that total parenteral nutrition (TPN) which is common in NICU leads to gallbladder dilatation. Therefore, it seems that fentanyl could be considered as a preferred short-term analgesic with less adverse effects than morphine. A larger study is needed to confirm these results.

Separation Time of Children From Parents: A Randomized Comparison Between oral versus Atomized Intranasal Administration of Midazolam

Background: Sedation has become more common for children undergoing procedures in the emergency department, dentistry, and day care surgery. A desirable sedative agent has a rapid onset with short duration of action and is effective and safe. Midazolam as a sedative agent that fulfills these criteria. However controversy surrounds regarding its route of administration, particularly with respect to its ease of administration and patient acceptance. Although the oral route of administration is the most popular among pediatric surgeons and dentists, confrontation and frustration often arise when children refuse to accept the sedative medication.Objectives: To evaluate the outcome (satisfactory anxiolysis and smooth early parental separation) between oral midazolam (OM) and intranasal midazolam(INM)spray in children for conscious sedation before general anaesthesia.Methods: Children aged 1 – 6 years scheduled for routine elective surgery were included to receive midazolam as premedication drug. A total of 80 children were recruited consecutively. Of them 40 were randomly assigned to either single dose of 0.5 mg/kg via oral route (OM0) or 0.5 mg/kg of body weight by intranasal spray(INM). The outcome variables were smooth separation of children from their parents at the level of conscious sedation and time to smooth separation.Results: No change in sedation score was evident in first 3 minutes following midazolam administration. Then the sedation score of INM group increased sharply to assume a mean score of 2 at 9 minutes. No demonstrated change was further noted up to the end of observation. Meanwhile the sedation score of OM group began to increase steadily up to the end of observation when it assumed a mean score of 1.5. The INM group attained a good level of sedation much earlier than its OM counterpart. The mean sedation scores were significantly higher in the former group than those in the latter group. During the first 3 minutes of midazolam administration no change in anxiolysis was noted. Then the score began to increase in both the INM and OM groups, but INM group experienced a much faster increase than the OM group so that the former group reached a mean score of almost 3 and the latter group to a mean score of nearly 2 at 15 minutes interval. The levels of anxiolysis attained by the intranasal group were significantly higher compared to those attained by the oral midazolam group (table II).All but 1 children (97.5%) in the INM group were separated from their parents smoothly as opposed to 90% in the OM group (p = 0.148). In the INM group 12.8% of children were separated at 9 minutes, 69.2% from 10 – 12 minutes (over two-thirds) and 18% from 15 – 18 minutes. In the OM group 13.9% were separated at 15 minutes, about 39% at 18 – 21 minutes, 22.3% at 24 minutes and the rest 11.1% at 27 minutes after premedication. Overall more than 80% of the children in the INM group were separated at 9 – 12 minutes following midazolam administration when none of the children in the OM group was separated (p &lt; 0.001). Complications like nasal irritation was staggeringly higher in the INM group shown on table IV.Conclusion: Despite the intranasal route causes a substantial proportion of children to suffer from nasal irritation, it is the preferred route over oral route, because intranasal route induces much faster sedation and anxiolysis and helps easy and smooth separation of children from their parents.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 17-23

Clinical Features of Oxaliplatin Induced Hypersensitivity Reactions and Therapeutic Approaches.

Oxaliplatin, a third generation novel platinum compound is the most effective first line chemotherapeutic agent for colorectal cancer (CRC) in combination with 5FU and leucovorin. It is indicated for pancreatic, gastric and testicular cancers combined with bevacuzimab, capecitabine, irinotecan and other cytotoxic agents. However, moderate to severe hypersensitivity reactions (HSR) during or after oxaliplatin infusion usually require cessation of chemotherapy or substitution of the key therapeutic drug which largely interferes with improved patient prognosis. This mini- review showcases recent and accepted opinions/approaches in oxaliplatin induced HSR management. Physicians and oncologists have varying attitudes regarding the decision to rechallenge the patient after an HSR experience, efficacy of desensitization protocols, effectiveness and selection of drugs for premedication and possibilities of cross sensitivity to other platinum agents (e.g. carboplatin). A brief insight into underlying molecular mechanisms and clinical manifestations of oxaliplatin induced HSR is offered. We have also discussed the management of oxaliplatin induced HSR and risk stratification for a successful and complete chemotherapeutic plan.

Premedication and Chemotherapy Agents do not Impair Imgatuzumab (GA201)-Mediated Antibody-Dependent Cellular Cytotoxicity and Combination Therapies Enhance Efficacy.

Imgatuzumab (GA201) is a novel anti-EGFR mAb that is glycoengineered for enhanced antibody-dependent cellular cytotoxicity (ADCC). Future treatment schedules for imgatuzumab will likely involve the use of potentially immunosuppressive drugs, such as premedication therapies, to mitigate infusion reactions characteristic of mAb therapy and chemotherapy combination partners. Because of the strong immunologic component of mode of action of imgatuzumab, it is important to understand whether these drugs influence imgatuzumab-mediated ADCC and impact efficacy. We performed a series of ADCC assays using human peripheral blood mononuclear cells that were first preincubated in physiologically relevant concentrations of commonly used premedication drugs and cancer chemotherapies. The ability of common chemotherapy agents to enhance the efficacy of imgatuzumab in vivo was then examined using orthotopic xenograft models of human cancer. A majority of premedication and chemotherapy drugs investigated had no significant effect on the ADCC activity of imgatuzumab in vitro Furthermore, enhanced in vivo efficacy was seen with imgatuzumab combination regimens compared with single-agent imgatuzumab, single-agent chemotherapy, or cetuximab combinations. These data indicate that medications currently coadministered with anti-EGFR therapies are unlikely to diminish the ADCC capabilities of imgatuzumab. Further studies using syngeneic models with functional adaptive T-cell responses are now required to fully understand how chemotherapy agents will influence a long-term response to imgatuzumab therapy. Thus, this study and future ones can provide a framework for designing imgatuzumab combination regimens with enhanced efficacy for investigation in phase II trials. Clin Cancer Res; 22(10); 2453-61. ©2015 AACR.

Retrospective Analysis on the Use of Amphotericin B Lipid Complex in Neutropenic Cancer Patients with Suspected Fungal Infections in Lebanon, a Single Center Experience and Review of International Guidelines.

Immunocompromised patients carry a high risk for invasive fungal disease (IFD), which is associated with high mortality. This is a retrospective chart review of a 4-year experience of amphotericin B lipid complex (ABLC) utilization for the management of suspected IFD at the Hematology/Oncology and Bone Marrow Transplantation unit at Makassed General Hospital, Beirut, Lebanon between January 2011 and December 2014. We focused on treatment strategy, response rate, and adverse drug events associated with ABLC therapy. We also reviewed ABLC indications in international guidelines beyond its Food and Drug Administration approval. A total of 89 patients received ABLC therapy for suspected fungal infection. Forty-eight percent were treated for a possible fungal infection, 19% for a problable fungal infection, 12% based on hospital guidelines, and 20% based on treating physician's recommendations. The overall response rate was 71%. Nephrotoxicity occurred in 24% of patients and serum creatinine improved in 10% of these patients. Moderate hypokalemia was observed in 61% of the patients and severe hypokalemia in 10% but was corrected in both cases. Hepatotoxicity was observed in 12% of the patients throughout ABLC therapy. Infusion-related reactions were observed in 36% of the patients. There was a decrease in the incidence of these reactions upon using combination of premedication drugs. In this study, ABLC proved to be an effective and safe option in the management of suspected IFD in immunocompromised patients failing previous therapies.

Premedication effect of dexmedetomidine and alfentanil on seizure time, recovery duration, and hemodynamic responses in electroconvulsive therapy.

Introduction:Electroconvulsive therapy (ECT) is an effective treatment for many mental disorders, especially severe and persistent depression, bipolar disorder, and schizophrenia. The aim of this study is to compare the effect of dexmedetomidine and alfentanil on agitation, satisfaction, seizure duration, and patients hemodynamic after ECT.Materials and Methods:In a three phase crossover randomized clinical trial, 75 patients aged between 18 and 50 years and candidate for ECT were enrolled and assigned into three groups (25 patients in each group). All patients, respectively, took premedication of dexmedetomidine, alfentanil, or saline in three consecutive phases. Patients received 0.5 μg/kg dexmedetomidine, 10 μg/kg alfentanil or normal saline intravenously, 10 min before induction. Finally, seizure and recovery duration, satisfaction and agitation score, and hemodynamic parameters were evaluated.Results:There was no significant difference about seizure duration, agitation score, and hemodynamic parameters between groups but recovery duration was significantly lower in the control group than dexmedetomidine (P = 0.016) and alfentanil group (P = 0.0001). Patients’ satisfaction was significantly higher in intervention groups (alfentanil and dexmedetomidine groups) (P = 0.0001).Conclusion:Given the equal effects of alfentanil and dexmedetomidine, it seems that choosing one of these two drugs for premedication of patients undergoing ECT is appropriate. Drug choice is influenced by numerous factors such as accessibility of each drug and the dominance of anesthesiologist and psychiatrist.

A Comparison of oral Clonidine versus oral Diazepam premedication for maintaining haemodynamic stability during craniotomy

Background: Clonidine is an alpha-2 adrenergic agonist, which is a centrally acting antihypertensive drug. The recent reviews had shown that clonidine has sedative, anxiolytic, analgesic, and anesthetic-sparing properties which would stabilises the circulatory system and maintains the perioperative stress response at a lower level. Aim: To compare the efficacy between oral clonidine and oral diazepam as a premedication in maintaining the hemodynamic stability during craniotomy surgeries. Materials and Methods: Fifty patients with various types of intracranial tumours who were planned for elective surgical excision were included for the study. Group 1 patients (n=25) received 0.2mg/kg of diazepam and the Group 2 patients received 3.5mcg/kg body weight of clonidine orally 90mts before induction. Recordings of systolic, diastolic, mean blood pressure and heart rate was done from the arterial tracing, the transducer kept at the level of the external auditory meatus. It was made every 10mts for the first 2hours from the time of dural opening. Results: Of all the various hemodynamic parameters the heart rate alone had shown a statistically significant reduction over the period of 2 hours in patients among the clonidine group. The blood pressure parameters in both the groups had also shown reduction from base line in the first 60minutes and later on over the period of 2 hours the values had come back to that of the base line values and no statistically significant difference had occurred between the two groups and also the antisialagogue activity is more with clonidine than diazepam. Conclusion: The hemodynamic response during craniotomy was better controlled with clonidine which has shown a better response in controlling tachycardia and maintaining the systolic, diastolic and mean arterial pressures than diazepam. So clonidine can be considered as a good drug for premedication in craniotomy surgeries in comparison with diazepam. Keywords: Clonidine, Diazepam, Hemodyn

The cost of systemic therapy for metastatic colorectal carcinoma in Slovenia: discrepancy analysis between cost and reimbursement.

Background.The aim of the study was to estimate the direct medical costs of metastatic colorectal cancer (mCRC) treated at the Institute of Oncology Ljubljana and to question the healthcare payment system in Slovenia.Methods.Using an internal patient database, the costs of mCRC patients were estimated in 2009 by examining (1) mCRC direct medical related costs, and (2) the cost difference between payment received by Slovenian health insurance and actual mCRC costs. Costs were analysed in the treatment phase of the disease by assessing the direct medical costs of hospital treatment with systemic therapy together with hospital treatment of side effects, without assessing radiotherapy or surgical treatment. Follow-up costs, indirect medical costs, and nonmedical costs were not included.Results.A total of 209 mCRC patients met all eligibility criteria. The direct medical costs of mCRC hospitalization with systemic therapy in Slovenia for 2009 were estimated as the cost of medications (cost of systemic therapy + cost of drugs for premedication) + labor cost (the cost of carrying out systemic treatment) + cost of lab tests + cost of imaging tests + KRAS testing cost + cost of hospital treatment due to side effects of mCRC treatment, and amounted to €3,914,697. The difference between the cost paid by health insurance and actual costs, estimated as direct medical costs of hospitalization of mCRC patients treated with systemic therapy at the Institute of Oncology Ljubljana in 2009, was €1,900,757.80.Conclusions.The costs paid to the Institute of Oncology Ljubljana by health insurance for treating mCRC with systemic therapy do not match the actual cost of treatment. In fact, the difference between the payment and the actual cost estimated as direct medical costs of hospitalization of mCRC patients treated with systemic therapy at the Institute of Oncology Ljubljana in 2009 was €1,900,757.80. The model Australian Refined Diagnosis Related Groups (AR-DRG) for cost assessment in oncology being currently used is probably one of the reasons for the discrepancy between pay-outs and actual costs. We propose new method for more precise cost assessment in oncology.

Multivariable analysis of anesthetic factors associated with time to extubation in dogs

The purpose of this study was to identify factors that prolong the time to extubation in dogs. Anesthetic records of 900 dogs at a university teaching hospital were searched. Multiple linear regression was used to compare independent predictors (patient demographics, anesthetic and intraoperative variables) with the dependent variable (time to extubation). Induction with propofol (P < 0.025) was associated with a shorter time to extubation, while premedication with acepromazine (P = 0.000) was associated with a longer time to extubation. Time to extubation was increased by 0.311 minutes for every kilogram increase in body weight (P = 0.000), 5.924 minutes for every 1 °C loss in body temperature (P = 0.0000), and by 0.096 minutes for every 1 minute increase in anesthetic duration (P = 0.000). Anesthetic variables, which can be manipulated by the anesthetist, include choice of premedication and induction drugs, hypothermia, and duration of anesthesia.

Subcutaneous vs intravenous administration of immunoglobulin in chronic inflammatory demyelinating polyneuropathy: an Italian cost-minimization analysis

Prior researches have suggested that home-based subcutaneous immunoglobulin (SCIG) is equally effective and can be less expensive than hospital-based intravenous immunoglobulin (IVIG) in treating chronic inflammatory demyelinating polyneuropathy (CIDP) patients. This economic evaluation aims at comparing costs of SCIG vs IVIG for CIDP patients in Italy. A 1-year model-based cost-minimization analysis basically populated via neurologists' opinion was undertaken from a societal perspective. Health care resources included immunoglobulin; drugs for premedication and complications (rash, headache, and hypertension) management; time of various health care professionals; pump for SCIG self-administration; infusion disposables. Non-health care resources encompassed transport and parking; losses of working and leisure time for patients and caregivers. Unit or yearly costs for resources valuation were mainly obtained from published sources. Costs were expressed in Euro (<euro>) 2013. An extensive one-way sensitivity analysis (OWSA) and a scenario SA tested the robustness of the base case findings. Overall costs per patient amount to <euro>49,534.75 (SCIG) and <euro>50,895.73 (IVIG); saving in favour of SCIG reaches <euro>1360.98. For both SCIG and IVIG, the cost driver was immunoglobulin (94.06 vs 86.06 % of the overall costs, respectively). Sensitivity analyses confirmed the consistency of the baseline results. SCIG may be a cost-saving therapy for Italian CIDP patients.