Premedication Drugs Research Articles

Premedication and Therapeutic Drug Monitoring (TDM) for Pegaspargase: A Prospective Multicenter Multi-Ethnic Study of Pediatric and Adolescent Patients

Background: Pegaspargase (PEG) is integral in the treatment of patients with acute lymphoblastic leukemia/lymphoma (ALL/LBL). However, full exposure to all doses of PEG can be limited by hypersensitivity reactions (HSR), which necessitate a switch to alternative asparaginase formulations. Previous studies in the pediatric population evaluating the use of premedication with antihistamines (H1 and H2) to decrease the incidence of HSR have largely been retrospective and showed mixed results. We conducted the first prospective, multicenter study to evaluate the efficacy of premedicating pediatric and adolescent patients receiving PEG with H1 and H2 blockers to decrease the rate of HSR. We report on our interim analysis with a special focus on ethnic disparities in asparaginase activity and HSR. Methods: We enrolled patients with ALL/LBL treated according to a Children's Oncology Group protocol at six centers across the US. Starting with the first dose of PEG in consolidation and subsequently, patients received an H1 blocker (diphenhydramine) and an H2 blocker (ranitidine, famotidine or cimetidine) 30-60 minutes prior to every dose of PEG, which was infused over 60-120 minutes. TDM was performed at 7-10 and 14-17 days post each PEG infusion. Therapeutic asparaginase activity was defined as ≥ 0.1 IU/mL (≥100 IU/L ) at 7-10 days post infusion and greater than the lower level of quantification at 14-17 days. We observed for silent inactivation (subtherapeutic levels without symptoms) and accelerated clearance (levels below quantification at 14-17 days without symptoms). Ethnicity differences were assessed using Chi-square and independent t-tests, increased odds of HSR by GLM procedure, and average asparaginase activity across treatments using GEE analyses. Results: We report on the 74 patients enrolled from 10/2019 to 7/2021 who completed all PEG therapy at the time of analysis. The median age at diagnosis was 7.7 years [range 1.3-19.8], 63.5% were male, 90.5% had B-ALL, 35.1% were NCI High Risk (HR) at diagnosis, and 8.1% had Down Syndrome (Table 1). A majority self-identified as Hispanic ethnicity (56.8%). We noted a disparity in obesity/overweight status by ethnicity. Overall, 50.0% of Hispanics were obese (31.0%) or overweight (19.0%) compared to 12.6% of non-Hispanics (6.3% obese and 6.3% overweight), p=.007. The average body mass index (BMI, kg/m2) in Hispanic compared to non-Hispanic patients was 20.7 (SD=6.5) vs. 16.9 (SD=2.7), p=.001. A total of 157 infusions of PEG was administered to 74 patients. The average dose of PEG was 2780 IU with an average time of infusion of 128 minutes in those without HSR. The incidence of HSR for Hispanic patients was 31% compared to 18.8% for non-Hispanics, although this was non-significant (p=0.234). In 19 patients who experienced HSR, 84% were Grade 3 and one was a Grade 4. Most HSR occurred during consolidation (79.9%). Silent inactivation occurred in 3 patients (4%) and one patient experienced delayed clearance. The average asparaginase activity level at 7-10 and 14-17 days was 1.03 IU/mL (SD=0.35) and 0.71 IU/mL (SD=0.30), respectively. There was no significance in asparaginase activity levels between Hispanics and non-Hispanics (p>.05). Overall, 81% of all patients achieved a (-) minimal residual disease (MRD) at the end of induction with no difference in Hispanic (83.3%) versus non-Hispanics (78.1%). In an adjusted analysis to evaluate potential determinants of HSR, we noted that NCI HR at diagnosis (p=0.019) was associated with increased incidence of HSR, while obesity, sex and ethnicity were not (Table 2). Interestingly, age >8 years was associated with higher odds of HSR unadjusted for NCI HR (OR=3.83, p=.016). Conclusion: We found that the two factors which increase the odds of HSR are age > 8 years and NCI high risk at diagnosis. We will be able to confirm the efficacy of premedication with a larger cohort upon the completion of all patients enrolled. Both silent inactivation and delayed clearance was infrequent. Although the standard therapeutic asparaginase activity is widely accepted to be ≥ 0.1 IU/mL, we observed supratherapeutic levels at 1 and 2 weeks post PEG at 1.03 IU/mL and 0.71, respectively. We are currently performing additional analysis to evaluate PEG related toxicity in various ethnic groups, determining the single nucleotide polymorphisms (SNPs) involved in HSR and toxicity, and creating a dose model based on pharmacokinetic analysis. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Anesthetic and analgesic techniques used for dogs undergoing ovariohysterectomies in general practice in the United States

ObjectiveTo acquire information about anesthesia and analgesia protocols used by United States (US) veterinarians in primary care practices when performing routine ovariohysterectomy in dogs. Study designCross-sectional survey. PopulationPrimary care veterinarians in the US. MethodsAn online anonymous survey, originally created in New Zealand, was modified with permission and made available to Veterinary Information Network (VIN) members. The survey asked questions about performing ovariohysterectomy in healthy adolescent dogs in the categories of preanesthetic evaluation, premedication and induction protocols, maintenance protocols and monitoring equipment, and postoperative analgesic and sedation protocols and pain assessments. ResultsA total of 1213 US veterinarians completed the survey. Respondents (n; %) reported performing preoperative laboratory tests [packed cell volume (135; 11%), complete blood cell count (889; 73%) and biochemistry panels (1057; 87%)] and preanesthetic examinations on the morning of surgery (1083; 90%). The most commonly administered drugs for premedication were acepromazine (512; 42%), hydromorphone (475; 39%) or butorphanol (463; 38%), with propofol (637; 67%) for induction of anesthesia and isoflurane (882; 73%) for maintenance of anesthesia. Most veterinarians reported placing intravenous catheters (945; 78%), administering electrolyte solutions (747; 67%) and providing heat support (1160; 96%). Perioperative and postoperative analgesia included local anesthetics (545; 45%), opioids (844; 70%) and non-steroidal anti-inflammatory drugs (NSAIDs) (953; 79%); NSAIDs were dispensed for home use (985; 81%). Dogs were most frequently discharged on the day of surgery (1068; 88%) and the owners were contacted (914; 75%) for follow-up within 1–2 days. Conclusions and clinical relevanceAnesthetic management for routine ovariohysterectomy in dogs varies among US veterinary VIN members. Information from this study is useful for all veterinarians for comparison with their practice management and for teachers of veterinary anesthesia to continue to emphasize options for analgesia.

Airway Foreign Bodies in Patients that Underwent Bronchoscopies with General Anesthesia in Dr. Soetomo General Academic Hospital Surabaya

Introduction: Airway foreign body (AFBs) is the most common emergency for ENT-HN (Ear, Nose, Throat-Head Neck) that requires immediate treatment. The gold standard management for AFBs is a bronchoscopy performed under general anesthesia (GA). Objective: This study aims to determine the profile of AFBs patients who underwent bronchoscopies with GA at Dr. Soetomo General Hospital Surabaya from January 2018 – December 2019. Methods and Materials: This is a descriptive, retrospective study that uses data from medical records. Microsoft Excel was used to analyze the data. 22 patients met the inclusion criteria. Results: The most common ages were 11 to 20-year-olds (73%), 55% were female, and 45% were male. The patients were from outside (73%) and inside (27%) Surabaya. As much as 67% of the sampled patients had coughs and 23% were symptomless. The foreign bodies found were pins (67%), clipboard nails (14%), and nuts (9%). These AFBs were located in the left main bronchus (45%), trachea (32%), and right main bronchus (18%), and in 5% of these cases, the AFBs could not be located. The duration between the event and the bronchoscopy was mostly less than 1 day (54%), 2 days (32%), and 3 days (14%). Most cases (90%) were without AFBs complications, but some had obstruction (5%), and hemoptysis (5%). Most patients also had an uncomplicated bronchoscopy (81%), however, some suffered lesions (14%) and bleeding (5%). A majority of the patients were also ASA I (68%), and the remainder were classified as ASA II (18%), and III (14%). The premedication drugs administered were fentanyl (41%), and a combination of fentanyl and midazolam (41%). Meanwhile, the most frequently maintained anesthetic agent was Isoflurane+O2 (27%). Most patients also did not have any comorbid factors (85%), but some had anemia (5%), obstruction (5%), as well as obesity followed by sputum retention and hypernatremia (5%). Conclusion: Most AFB patients who underwent bronchoscopy under GA were 11-20 years old, female, and had a cough as a clinical symptom. Most AFBs were pins at the left main bronchus. The duration between the incident and the bronchoscopy was less than 1 day. There were also mostly no complications of AFBs and bronchoscopies. The most common physical status in patients was ASA I, with fentanyl only or fentanyl and midazolam as a premedication drug. The most common agent used to maintain the anesthesia was a combination of isoflurane and O2. Most patients also had no comorbid factors for GA.

Comparative study of gabapentin versus pregabalin as a premedication in patients undergoing FESS under general anaesthesia

Introduction: Functional endoscopic sinus surgery (FESS) is a minimally invasive procedure which is usually done under general anaesthesia. Laryngoscopy and tracheal intubation may induce an intense sympathetic hemodynamic response which is dangerous in patients with comorbidities. So an effective and safe premedication drug to attenuate this response is very much necessary. Objectives: The present study was designed to compare the effects of oral gabapentin and oral pregabalin as a premedication to produce sedation and attenuate haemodynamic response to laryngoscopy and endotracheal intubation in patients undergoing FESS under general anaesthesia. Methods: This prospective, randomized study was undertaken in ENT operation theatre in a Government teaching hospital, Karnataka between July 2020 and June 2021. Group A received gabapentin 600 mg and Group B received pregabalin 150 mg orally one hour prior to induction of general anaesthesia. Results: Patients in both group A and group B were sedated after premedication but the degree of sedation achieved in group B was higher compared to group A (p <0.05). Attenuation of HR and MAP was also higher in group B compared to group A (p <0.05). Conclusion: Premedication with both oral pregabalin 150mg and oral gabapentin 600mg, given 1 hour before general anaesthesia in patients undergoing FESS produce sedation and attenuate hemodynamic response to laryngoscopy and intubation. But premedication with oral pregabalin 150 mg is more effective than oral gabapentin 600 mg in producing sedation and attenuating the hemodynamic responses to laryngoscopy and intubation. Keywords: gabapentin; pregabalin; FESS; anaesthesia

Efficacy of a Standardized Premedication and Therapeutic Drug Monitoring Protocol for Pegaspargase to Prevent Hypersensitivity Reactions.

The purpose of this study was to evaluate the efficacy of a standardized premedication and therapeutic drug monitoring (TDM) protocol to prevent hypersensitivity reactions from pegaspargase infusions. Pegaspargase is an essential therapeutic agent used for the treatment of acute lymphoblastic leukemia (ALL) in pediatric patients. This study was a retrospective cohort study conducted at Wolfson Children's Hospital, Jacksonville, Florida, and included pediatric ALL patients 0 to 21 years old. Patients were excluded if they had not received the appropriate premedication after protocol implementation or had received premedication before protocol implementation. Patients were separated into 2 groups: those who received premedication before pegaspargase infusion and those who did not. The primary endpoint was the incidence of documented hypersensitivity reactions. Observational data endpoints included incidence of silent inactivation and cost savings from reducing complicated drug substitutions. A total of 38 patients (50 doses in no premedication group; 80 doses in premedication group) were evaluated. There was not a significant reduction in the incidence of hypersensitivity reactions for patients receiving premedication and TDM (5.3% vs 6.4%, p = 1.0). A trend towards patients reacting earlier with more severe reactions in the post-implementation group was observed. There were no incidences of silent inactivation. Observational cost analysis predicts potential drug cost savings of $106,550.45. A standardized premedication protocol did not reduce the incidence of hypersensitivity reactions. Premedication to prevent hypersensitivity reactions may provide a potential drug cost savings. Further investigation is warranted to assess the efficacy of a standardized premedication and TDM protocol to prevent hypersensitivity reactions.

Frequency of Prescribing and Administering Premedication in Paediatric Surgical Patients at a Tertiary Care Hospital: An Observational Study.

Introduction: Preoperative period is a stressful event, especially for paediatric patients undergoing surgery. Stress may lead to the development of perioperative maladaptive behaviour, activation of stress responses, and susceptibility to postoperative infections. To alleviate preoperative stress, the use of a multimodal approach including preoperative pharmacological premedication in the ward is recommended. We conducted an observational study to determine the frequency of prescribing and administering premedication in paediatric surgical patients.Methods: This three-month retrospective observational study was conducted in the main operating room of the Aga Khan University Hospital, Karachi, from October to December 2014. It included all paediatric patients (aged 1-16 years) coming for elective surgery. Patients’ preoperative forms and medical records were reviewed, and data recorded for written orders of premedication and the timing of administration of the premedication drug in the inpatient ward/surgical day care ward. A p-value <0.05 was considered statistically significant.Results: This study included 125 paediatric patients. Premedication was not prescribed to 40% (50/125) patients. In these patients, drug and dose were properly mentioned in 98.7% (74/75) of cases while the route and time of administration were not mentioned in 26.6% and 12% prescription orders, respectively. The premedication drug was administered in 67 out of 75 patients (89.3%) by ward nurses as per prescription. The administration of premedication was documented in 95.5% patients, but the time was missing in 46.3% of cases.Conclusion: A significant number of patients were not prescribed preoperative premedication by the anaesthetist. Moreover, the route and timing of administration of drug were not mentioned especially in cases when premedication was prescribed in the wards.

Behavioral outcome of oral midazolam premedication in pediatric dental general anesthesia: A systematic review

Aim: This systematic review explores the postoperative behavior outcomes of oral midazolam (OM) premedication in pediatric dental general anesthesia (DGA). Premedication drug assists in the reduction of negative psychological impact during the general anesthesia induction, thus influence the behavior, particularly in pediatric patients. OM is one of the common premedications given due to its efficacy and well accepted administration. Materials and Methods: This review was registered under the International Prospective Register of Systematic Reviews (PROSPERO). Studies published in the databases including PubMed Central, Cochrane, Web of Science, Google Scholar and others between January 1980 and December 2020 were analyzed using Preferred Reporting Items for Systematic Review and Meta‐analysis (PRISMA) guidelines. Risks of bias and evidence levels were determined on each selected study. Results: Seven out of 6944 studies, were scrutinized for final analysis, which involved a total of 392 children in experimental groups and 89 children in placebo groups. OM had shown both positive and negative behavior outcomes post DGA using different assessment tools, in comparison to other premedications. It also showed less side effect post consumption. Conclusions: OM premedication demonstrated very limited evidence for positive behavior outcomes in pediatric DGA. The 0.5 mg/kg body weight dosage of midazolam yields the most favorable behavior postoperatively. Based on this collective review, there is still limited evidence for positive behavior outcomes in OM premedication.

Effectiveness of Single Dose Premedication of Piroxicam and Prednisolone on Post Endodontic Pain in One Visit Root Canal Treatment: A Randomized Clinical Trial.

The objective of this study was to compare the effectiveness of premedication drugs including single dose Piroxicam and Prednisolone in regard to post endodontic pain at different time intervals (24, 48, 72 and 96 hours) after single visit root canal treatment. This randomized clinical trial (registration no. NCT04124822) was performed in operative dentistry department of a private clinical institute. One hundred twenty patients identified with symptomatic irreversible pulpitis were included in the study. The pain intensity levels were marked through the use of visual analog scale (VAS) before the commencement of treatment. The participants were randomly allocated in three groups, Group I (n=40) received no medication (control), Group II (n=40) received Piroxicam (20 mg) and Group III (n=40) received Prednisolone (20 mg). The drugs were administered thirty minutes before the endodontic procedure was initiated. Root canal treatmentwas carried out followed by placement of provisional restoration in a single appointment. The patients were instructed to continue marking their pain intensity levels after 24, 48, 72 and 96 hours using VAS. All patients were called for follow up after 4 days for clinical evaluation and the placement of permanent restoration. The effectiveness of each drug over different time interval was studied employing ANOVA test. The significance level was set at P≤0.05. The results of the present study revealed that a higher percentage of patients in all 3 groups, reported no post-operative pain at all evaluated time durations (24, 48, 72, and 96 hours). However, the long term effectiveness (96 hours) of both drugs to reduce post-endodontic pain was observed to be statistically insignificant. There was no significant difference in demographic data in terms of age (P=0.14), gender (P=0.12), whilst tooth type (P≤0.05) showed statistically significant value. Pre-medication with either single dose piroxicam or prednisolone was able to prevent post-endodontic pain in patients with symptomatic irreversible pulpitis.

A comparative study of efficacy of oral pregabalin and clonidine for attenuation of pressor response to intubation

Background: Endotracheal intubation is associated with hemodynamic stress responses. Various drugs have been used in the past to attenuate the pressor response; however, none has been proved to be ideal. Present study was planned to evaluate the oral pregabalin 150 mg and clonidine 200 µg for attenuation of pressor response to intubation.Methods: The study was conducted on 100 adult patients of either gender scheduled to undergo elective surgeries under general anaesthesia (GA). The patients were randomly allocated into 2 groups. In group A patients received pregabalin 150mg and in group B patients received clonidine 200µg orally. The hemodynamic parameters were recorded until 10 minutes after intubation. The sedation, anxiety and side effects were also assessed.Results: In clonidine group, the mean HR remained below the baseline value at all the time intervals. In pregabalin group, the mean HR remained below the baseline value at most of the time intervals but increased above baseline just after intubation (T0i) and 1 minute after intubation (T1i) where increase was only 1.488±1.20% and 0.45±1.16% respectively from baseline. In both pregabalin and clonidine groups, the mean SBP and MAP remained below the baseline value (Tb) at all the time intervals from T0.5 to T10i. Both clonidine and pregabalin provided adequate anxiolysis and sedation with pregabalin providing more pronounced sedation and anxiolysis than clonidine.Conclusions: Both clonidine and pregabalin are effective oral premedication drugs for attenuation of the pressor response to laryngoscopy and endotracheal intubation.

Endotracheal Intubations in Emergency Department: A Clinical Audit at a Tertiary Health Centre in South India

Background: Endotracheal intubation in the emergency department is challenging. Hence, regular audits can help us improve our critical airway management skills. Our study aimed to evaluate the practice of endotracheal intubations performed in the emergency department.&#x0D; Materials and Methods: A retrospective cross-sectional study was conducted among the patients intubated in our teaching hospital's emergency department. The study period was from November 1, 2019, to August 31, 2020. We analyzed first attempt success rates, drug use, indication, and complications.&#x0D; Results: We analysed 90 endotracheal intubations, out of which 70(77.8%) were performed by emergency physicians and 20(22.2%) by anaesthetists. The first attempt success rate was 81.11% (n=73) and had significant differences between the both departments. (p value= 0.003, χ2= 7.48). More patients had medical indications compared to trauma for intubation (n=88 vs n=32) among which respiratory failure (n=25, 27.78%) was the most common indication. Rapid Sequence Intubation( RSI) adherence was 82.22% (n=74). Lignocaine (n=16, 19.75%), etomidate (n=35, 43.2%) and succinylcholine (n=65, 80.25%) were the commonly used drugs for premedication, induction and as relaxants respectively. 17(18.89%) out of 90 intubation had complications. Desaturation (n=10, 11.11%), bradycardia (n=1, 1.11%), hypotension (n=4, 44%), dental trauma (n=5, 5.55%) and oesophageal intubation (n=3, 3.33%) were observed in our study.&#x0D; Conclusion: Our study is the first from India which describes the characteristics of endotracheal intubations done in the Emergency Department along with data on RSI adherence. The first attempt success rate, indications, and complications were comparable with other studies in the literature. We recommend future prospective studies to analyze success rates between different specialties and resident doctors to improve the airway management skills in the Department

Comparison of post-operative analgesic effect between Pregabalin and Gabapentin given as premedication drugs for patients undergoing laproscopic cholecystectomy

Currently most of the anesthetist prefer the usage of multimodal analgesia technique to improve the degree of pain relief without inducing any side effects. Pregabalin and gabapentin when given in higher doses reduces the preoperative anxiety and induce sedation without causing undesirable side effects.To compare and evaluate the effects of premedication drugs Pregabalin or Gabapentin versus placebo for attenuation of postoperative pain among patients undergoing laparoscopic cholecystectomy under general anaesthesia.A prospective comparative study was conducted for a period of 6 months in the department of anesthesiology of our medical college hospital. A total of 90 patients posted for elective laproscopic cholecystectomy in the age group between 20 and 60 years were taken as our study subjects. The entire study subjects were randomized into three groups of 30 each. Group B subjects received 3 tablets of Beplex forte (as placebo), Group G subjects received 3 tablets of Gabapentin 300mg (total 900mg) and Group P subjects received 3 tablets of Pregabalin 50mg (total 150mg). Post-operatively degree of pain, requirement for rescue analgesia, sedation score and adverse events occurred was monitored and analysed between the three groups.Pain score was less in the pregabalin group at all intervals compared to gabapentin and placebo group and the difference was found to be statistically significant. Maximum amount of tramadol requirement as a part of rescue analgesia was seen in the placebo group followed by gabapentin group and minimal dose requirement was needed for pregabalin group and the difference was found to be statistically significant. The occurrence of adverse events such as somnolence and dizziness was almost similar in all the three groups whereas the incidence of nausea and vomiting was less in pregabalin group compared to gabapentin and placebo group.Pregabalin can be effectively used as a part of the multimodal analgesic to prevent acute postoperative pain among patients undergoing elective laproscopic cholecystectomy.

Premedication prior to PEG-asparaginase is cost-effective in pediatric patients with acute lymphoblastic leukemia.

PEG-asparaginase is critical in pediatric acute lymphoblastic leukemia (ALL) therapy but is highly immunogenic. Severe allergic reactions lead to substitution of further PEG-asparaginase with Erwinia. Erwinia is associated with more frequent dosing, increased expense, and limited availability. Premedication may reduce rates of allergic reactions. This Markov model evaluated the cost-effectiveness of three strategies: premedication plus therapeutic drug monitoring (TDM), TDM alone, and no premedication or TDM. We modeled two scenarios: a standard-risk (SR) B-ALL patient receiving two asparaginase doses and a high-risk (HR) patient receiving seven asparaginase doses. The model incorporated costs of asparaginase, premedication, TDM and clinic visits, and lost parental wages associated with each additional Erwinia dose. We incorporated a five-year time horizon with a societal perspective. Outcomes were Erwinia substitutions avoided and differences in quality-adjusted life years (QALYs). Probabilistic and one-way sensitivity analyses evaluated model uncertainty. In both scenarios, premedication was the least costly strategy. In SR and HR scenarios, premedication with monitoring resulted in 8% and 7% fewer changes toErwiniacompared with monitoring alone and 3% and 2% fewer changes compared with no premedication/monitoring, respectively. Premedication resulted in the most QALYs gained in the SR patients. Individual variation of model inputs did not change premedication/monitoring favorability for either scenario. In probabilistic sensitivity analyses, premedication/monitoring was favored in >87% of iterations in both scenarios. Compared with other strategies, premedication use and asparaginase level monitoring in children with B-ALL is potentially cost-saving.

PREANAESTHETIC MEDICATION WITH DIFFERENT DOSES OF INTRANASAL MIDAZOLAM: A RANDOMIZED CLINICAL STUDY IN CHILDREN

Background: Midazolam is often used for premedication in children. We investigated the efficacy of different doses of intranasal midazolam for premedication in 75 children, ASA physical status I and II, aged 3 to 10 years of either sex undergoing various elective surgical procedures. Methods: In a randomized, double blind, placebo controlled design, all children were allocated to one of the three groups of 25 each. Group – A received 0.2 mg/kg intranasal midazolam (5mg/ml). Group – B received 0.3 mg/kg intranasal midazolam (5mg/ml). While Group – C received intranasal normal saline. After 20 minutes of premedication, sedation scores and ease of separation from parents were noted. Children’s response at the time of intravenous cannulation and face mask application was also measured. Results: Sedation scores in group A and B were excellent (3.64 ±0.5 & 3.76 ±0.7 respectively) compared to group C (1.24 ±0.4). Separation of children from their parents was easier in group A & B than in Group C. In group A & B, children were calm on intravenous cannulation and face mask application. Conclusion: We conclude that intranasal midazolam is effective and very well accepted premedication drug in children. Key words: Children, Premedication, Intranasal route and Midazolam.

Volume and pH of Gastric Contents in Patients Undergoing Gynecologic Laparoscopic Surgery during Emergence from General Anesthesia: A Prospective Observational Study

Objective: To find out the volumes and pH values of the digestive contents during emergence in patients undergoing elective gynecologic laparoscopic surgery under general anesthesia. Materials and Methods: One hundred patients scheduled for surgery under general balanced anesthesia with standard monitoring were allocated in the present study. Gastric volumes greater than 0.4 mL/kg and pH of less than 2.5 were set as cut-off points to establish the risk of aspirated pneumonitis. Prior to insufflation of CO₂ gas into the participants’ abdominal cavity and placing them in lithotomy or Trendelenburg position, anesthetists inserted an orogastric tube to deflate the patients’ stomach. Then gastric volumes and pH values were measured at hourly intervals through the operation. Results: Eighty-nine participants completed the study. The pH and gastric volumes of high-risk and non-high-risk groups showed statistically significant differences (p&lt;0.001), as 1.1±0.4 and 1.1±0.8 mL/kg, and 2.8±2.2 and 0.3±0.4 mL/kg, respectively. Though their ages (p=0.047), body mass index (BMI) (p=0.015), and pre-medication drugs (p&lt;0.001) showed significant differences, they were not apparent in the pre-fluid loading, fasting, and surgical time. Conclusion: During emergence from general anesthesia, 65.2% of the patients undergoing gynecologic laparoscopic surgery were exposed to a high risk of aspirated pneumonitis. The present study showed significant association with age, BMI, and pre-medication drugs. Investigators suggested that patients with a BMI greater than 25 kg/m², administering H₂ receptor antagonist or a proton pump inhibitor as premedication, and having gastric content drainage prior to endotracheal tube extubation should have a low risk of pulmonary aspiration. Keywords: Anesthesia, Gynecology, Gastric content, Laparoscopic surgery

Intranasal midazolam versus intranasal ketamine as premedication in paediatric patients: A comparative study

This study aims to compare the efficacy of intranasal midazolam and ketamine as premedication before anaesthesia in paediatric patients.Sixty pediatric patients scheduled for surgery between the age group of 2-8 years and belonging to the American Society of Anesthesiologists (ASA) grade I and II were selected for the study. Group A received midazolam (0.2 mg/kg) and Group B received ketamine (5 mg/kg), intranasally 30 minutes before surgery with monitored anesthesia care. Sedation score, parenteral separation reaction, intravenous cannula acceptance, mask acceptance, and hemodynamic parameters were measured.Patients of both the groups were calm and tranquil, but sedation scores were higher in the ketamine group (3.37±0.67) in comparison to midazolam group (2.60±0.67) at 30 minutes. Parenteral separation was easier in ketamine group compared to midazolam group with a significantly higher separation reaction scores (p&amp;#60;0.05). Venous cannulation and face mask acceptance was also better in the ketamine group with a significantly higher percentage of patients with satisfactory venous cannulation and face mask acceptance (p&amp;#60;0.05). Non-invasive blood pressure, oxygen saturation, and respiratory rate were maintained in both the groups throughout the study period, however tachycardia was observed in the ketamine group.Administration of the drug through the nasal route is an effective way for paediatric premedication. Both midazolam and ketamine gave a good level of sedation, however, level of sedation, venipuncture acceptance, and face mask acceptance were significantly better in the ketamine group. No adverse effects of the premedication drugs were observed in any of the groups.

Effect of Hypertonic Saline during Flexible Nasopharyngeal Laryngoscopy: A Double-Blinded, Randomized, Controlled Trial

Objectives Flexible nasopharyngeal laryngoscopy (NPL) is a cost-effective, simple procedure that provides visualization of the nasal airways. However, it involves a number of challenges for both the clinician and the patient. Hypertonic saline nasal wash is used to prevent nasal secretion in acute/chronic sinusitis and after nasal surgery. We aimed to determine the efficacy of hypertonic saline by comparing the clinician’s and patients’ experiences during NPL. Methods This prospective, double-blinded, randomized, controlled study was performed at a tertiary referral university hospital. Two hundred patients were randomly divided into hypertonic saline, lidocaine, xylometazoline, and isotonic saline groups. During NPL, the clinician’s experiences in terms of the quality of the field of view and the patients’ experiences in terms of pain and discomfort resulting from the 4 premedication drugs were compared. Results The groups differed significantly in terms of the clinician’s field of view, and patients’ pain scores and levels of discomfort (P < 0.025). The field of view results were the highest in the hypertonic saline group, and the lowest in the lidocaine group. The pain scores were the lowest in the lidocaine group, whereas they were the highest in the hypertonic saline group. The discomfort scores were the lowest in the xylometazoline group, but the highest in the lidocaine and isotonic saline groups. Conclusion The use of hypertonic saline facilitated the NPL procedure by improving the clinician’s field of view. Moreover, intranasal hypertonic saline reduced the patient’s discomfort. Intranasal hypertonic saline can be a good alternative to premedication before NPL.

Utilizing a novel four-drug regimen to reduce the incidence of infusion-related reactions for first-dose rituximab infusions: An institutional review of rituximab infusion-related reactions in lymphoma patients.

e19148 Background: Rituximab is a chimeric monoclonal anti-CD20 antibody utilized in the treatment of several disease states including B-cell non-Hodgkins Lymphoma. Infusion-related reactions (IRR) with rituximab occur with an incidence of up to 77% during the first infusion. The occurrence of an infusion reaction adds to the cost and time of rituximab administrations, especially with prolonged chair time and increased nursing and physician support, and decreased quality of life. The University of Arizona Cancer Center (AZCC) initiated a four-drug premedication regimen consisting of dexamethasone, famotidine, diphenhydramine, and acetaminophen. Our study examined the frequency of first-dose rituximab infusion reactions with our premedication regimen as compared to other published regimens. Methods: A retrospective chart review for all first-dose rituximab infusions was conducted for lymphoma patients treated with BR or RCHOP regimens from 11/2013 through 6/2019 at the AZCC. Data points collected included baseline patient demographics as well as rituximab infusion data. Results: In our study, the median age of the patient population was 64 years (range 22-89), 60.5% were males, and the average BSA was 2 m2 (range 1.39-3.04). The average rituximab dose was 750 mg (range 521-1140) and the average infusion time was 301 minutes (range 197-512). IRR with first time Rituximab was seen in 19 patients out of 81 total patients (23.5%). Of these IRR, 52.6% occurred in BR versus 47.4% in RCHOP. The most frequent IRR symptoms seen included flushing, itching, feeling hot, and tingling. The average infusion time for IRR patients was 334 minutes versus 284 minutes in patients not experiencing IRR. Grade 2 reactions were reported in 14 patients (73.7%) with grade 3 IRR’s reported in 5 patients (26.3%). Onset of IRR occurred on average during the first 61.6 minutes of the start of infusion (range 10-108 minutes). Conclusions: A novel four drug premedication regimen consisting of corticosteroids, antihistamines H2RA antatagonist and analgesic, resulted in a much lower rituximab infusion reaction rate (23.5%) than what has been previously reported in literature using standard premedications ( &gt; 50%). The utilization of this four drug combination therapy provides the means to reduce first dose rituximab IRR in patients while maximizing patient care and increasing the number of patients who were able to receive Rapid Rituximab during their next cycle of chemotherapy.

Comments on: Dealing with a case of suspected drug abuse in the practice

Shanin Leeming is a final-year veterinary student at the Royal Veterinary College, London #### Dilemma You work in a small animal practice. One day, the nurse responsible for drug inventory...

Performance of the Parasympathetic Tone Activity (PTA) index to assess the intraoperative nociception using different premedication drugs in anaesthetised dogs

ABSTRACT The dynamic variations of the Parasympathetic Tone Activity (PTA) index were evaluated to assess nociception in dogs undergoing anaesthetic protocols with different premedication drugs. Sixty-six dogs, divided into three groups of 22 dogs each, were given different premedication drugs “morphine” (0.2 mg/kg), “morphine + medetomidine (5 μg/kg)”, “morphine + acepromazine (0.03 mg/kg)”, then similarly induced and maintained under general anaesthesia. The PTA, HR (heart rate) and MAP (mean arterial pressure) were assessed at S (steady-state), Cut (cutaneous incision), PTAE (PTA Event, assessed 1 min before a significant PTA decrease), HDR (Haemodynamic reaction, assessed 5 min before an increase of ≥ 20% in HR and/or MAP). For each group, the dynamic variation of PTA (ΔPTA) was calculated and a Receiver Operating Characteristics (ROC) curve was performed to detect if any of the premedication drugs may alter the performance of PTA index to predict intraoperative haemodynamic reactions. In all groups, a haemodynamic reaction was detected after Cut, PTAE and HDR and was preceded with a significant decrease of PTA, except for “morphine + medetomidine” group which showed a significant drop of PTA only at PTAE and HDR. The ΔPTA showed a fair performance in all groups (a mean [95% CI] AUC of 0.73 [0.62–0.82], 0.70 [0.59–0.79] and 0.71 [0.59–0.80] respectively in morphine, morphine + ACP and morphine + medetomidine). Although ΔPTA was rather altered by the premedication drug, it was able to predict, to a certain extent, haemodynamic reactions in all groups.

Limited duration of hypersensitivity reactions to contrast and exact documentation of such adverse events

With great interest, I read the paper by Benzon and colleagues.[1][1] They report on six patients with a history of a previous contrast medium (CM)-induced hypersensitivity reaction (HR). Without any...