Preoperative Sedation Research Articles

Clinical implications of midazolam in preoperative anxiety and sedation: a review

Preoperative anxiety, a common reaction to the unfamiliar setting of medical procedures, affects 60-80% of patients and can lead to significant psychological and physiological stress. This stress can exacerbate hemodynamic instability during surgery, complicate anesthetic management, and contribute to adverse postoperative outcomes such as increased pain perception, longer recovery times, and extended hospital stays. Midazolam, a short-acting benzodiazepine, is frequently used to address these issues due to its rapid onset and effective anxiolytic and sedative properties. By acting on GABA-A receptors, midazolam provides relief from preoperative anxiety and facilitates smoother anesthesia induction. However, its use is not without risks, including potential respiratory depression, paradoxical reactions, and oversedation, which may be particularly concerning in vulnerable populations. These concerns have prompted exploration of non-pharmacological approaches, such as cognitive-behavioral therapy and mindfulness-based interventions, which can reduce anxiety without the side effects associated with pharmacological agents. This review aims to critically evaluate the clinical implications of midazolam use for preoperative anxiety and sedation, highlighting its efficacy, safety profile, and the growing interest in alternative non-pharmacological strategies.

A retrospective study of the safety and efficacy of peritoneal dialysis catheter placement under combined local infiltration anesthesia and monitored anesthesia care

ObjectiveGiven the lack of global consensus on anesthesia selection for peritoneal dialysis catheter (PDC) placement via open surgery, this study investigates the safety and efficacy of combining local infiltration anesthesia (LIA) with monitored anesthesia care (MAC) in patients with end-stage renal disease (ESRD).MethodsThis retrospective analysis of ESRD patients who underwent open surgical placement of PDC in the Department of Nephrology, the First Affiliated Hospital of the Army Medical University from 1 August 2020 to 31 May 2022. Patients were categorized into two groups based on anesthesia method: LIA group and LIA + MA group. MA was defined as preoperative sedation (0.2–0.7 µg/kg/h) with dexmedetomidine injection (Huidrican trade name, DEX), and intraoperative analgesia with dexrazoxane injection (Garonin trade name, DEZ) as appropriate according to the patients’ pain scores. We compared the general clinical data of the two groups of patients, the changes in blood pressure and heart rate during the whole operation, the intraoperative and postoperative pain, the total duration of the operation and the immediate postoperative complications.ResultsThe study included 123 patients (59 in the LIA + MAC group and 64 in the LIA group). The LIA + MA group exhibited lower pain scores measured by Visual Analogue Scale(VAS) during surgery (skin incision, subcutaneous adipose tissue dissection, anterior fascia, muscle traction, posterior fascia, peritoneum, and catheterization) compared to the LIA group(p<0.05). In terms of surgical incisions, to intraoperative pain scores (VRS), the LIA + MA group showed higher score level I and lower score level II compared to the LIA group (p = 0.002, 0.004, respectively). The LIA + MA group experienced lower postoperative resting pain (NRS) and VAS than the LIA group (p = 0.001,0.003, respectively). The surgical duration for the LIA + MA group was shorter than that of the LIA group (p<0.001). Preoperative systolic and diastolic blood pressures (SBP and DBP) were higher in the LIA + MA group compared to the LIA group (p<0.001,<0.001, respectively). Postoperative heart rate and DBP were lower in the LIA + MA group (p<0.001, 0.004, respectively). The LIA + MA group exhibited greater changes in heart rate, SBP, and DBP during and after surgery compared to the LIA group (p = 0.009, <0.001,<0.001, respectively). In terms of immediate postoperative complications, the proportion of patients requiring analgesics within 24 h post-surgery was significantly lower in the LIA + MA group (p = 0.031).ConclusionOpen surgery for PDC placement under LIA + MAC is both safe and effective.

Comparison of Dexmedetomidine and Midazolam for Preoperative Sedation in Patient Under Going Surgeries Under Spinal Anaesthesia

Preoperative anxiety is a frequent condition. Generally, it starts two days before the operation and reaches its peak just prior to induction of anesthesia. Anxiety, stress, and fear that arise just before the operation and anesthesia may lead to psychological trauma and increase the levels of stress hormones, resulting in undesirable metabolic responses before anesthesia. In our study primary objective was to compare the effectiveness of dexmedetomidine and midazolam with control group in preoperative sedation prior to surgical procedures. Considering the sample size and methodology of the seed article a sample size of 207 was obtained This prospective, hospital based, comparative study was conducted in Department of Anesthesia, Mahatma Gandhi Medical College &amp; Hospital, Jaipur over a period from March 2023 to august 2024. Group C was control, Group D was dexmedetomidine, and Group M was the midazolam group. Patients of Group C were given 100 ml of physiological saline over 10 min. patients of Group D were given 0.25 µg/kg dexmedetomidine in 100 ml physiological saline over 10 min. Group M were given 0.03 mg/kg midazolam in 100 ml physiological saline over 10 min. Group D (dexmedetomidine group) has significantly lower bromage score, Anxiety, and VAS scores, demonstrating better overall recovery, reduced anxiety, and less pain as compare to other two group. Also group D patient show better stabilization of vital parameter.

Intranasal esketamine versus esketamine-dexmedetomidine combination for premedication in pediatric patients undergoing strabismus surgery: a randomized controlled trial.

Preoperative fear and anxiety are prevalent in children undergoing surgery. The combination of esketamine and dexmedetomidine has been proposed as a promising premedication for enhancing preoperative sedation and analgesia. This study compared the premedication efficacy of intranasal esketamine alone and esketamine-dexmedetomidine combination in pediatric patients undergoing strabismus surgery. One hundred and eighty preschool children aged 2-6 years scheduled for strabismus surgery were enrolled and randomly assigned to one of the three groups: intranasal premedication with esketamine 2 mg/kg (Group K), esketamine 1 mg/kg and dexmedetomidine 1 µg/kg (Group KD1), or esketamine 0.5 mg/kg and dexmedetomidine 2 µg/kg (Group KD2). The primary outcome was the level of sedation following the intervention, as measured by the modified Yale preoperative anxiety scale (mYPAS) and sedation scale (SS). Secondary outcomes included onset time of sedation, the successful rate of peripheral intravenous cannulation, parental separation anxiety scale (PSAS), mask acceptance scale (MAS), wake-up time, duration of stay in the post-anesthesia care unit (PACU), and premedication-related adverse effects. After premedication, the mYPAS score gradually decreased in the three groups, with lower values in Group K than in Group KD1 and Group KD2 patients in 1, 5, and 10 min. SS in Group KD1 and Group KD2 steadily increased until 40 min after premedication, while SS in Group K increased in the first 5 min after premedication and maintained consistent levels during the remaining time. Sedation onset was substantially faster in Group K patients (11.4±7.8 min) than Group KD1 (18.1±7.5 min, P=0.006) and Group KD2 (18.4±6.8 min, P<0.001). PSAS, separation status, the successful rate of peripheral intravenous cannulation, and MAS were comparable among groups. There was no significant difference in terms of emergence time or duration of stay in the PACU among groups. More gastrointestinal events were observed in Group K (P<0.001). Intranasal premedication with 2 mg/kg esketamine produced a more rapid onset of sedation accompanied by more gastrointestinal reactions compared with a combination of esketamine and dexmedetomidine. ClinicalTrials.gov identifier: NCT04757675.

Perioperative Analgesic and Sedative Effects of Cannabidiol in Cats Undergoing Ovariohysterectomy.

The aim of this study was to evaluate the perioperative analgesic and sedative effects of oral CBD in cats undergoing ovariohysterectomy. Twenty-two cats were assigned to receive either oral cannabidiol oil (2 mg/kg, CBD group, n = 12) or placebo oil (0.1 mL/kg, Placebo group, n = 10) 60 min before the premedication. The anesthetic protocol included dexmedetomidine/meperidine, propofol, and isoflurane. Intravenous fentanyl was given to control cardiovascular responses to surgical stimulation. Pain was assessed at 0.5, 1, 2, 4, 6 and 8 h post-extubation using the UNESP-Botucatu multidimensional composite pain scale and the Glasgow feline composite-measure pain scale. Sedation scores were assessed at the same timepoints and at 15 min after the premedication. Morphine was administered as rescue analgesia. Higher sedation scores were recorded in the CBD group at 15 min after premedication (p = 0.041). Intraoperatively, more cats required fentanyl in the Placebo group than in CBD group (p = 0.028). The pain scores did not differ between groups, except at 0.5 h post-extubation when lower scores were detected in the CBD group (p = 0.003-0.005). Morphine was required in 100% of the animals in both groups. CBD increased preoperative sedation and decreased intraoperative analgesic requirements, with minimal evidence of postoperative analgesic benefits over the placebo.

Comparison of the effects of child-centered playful companionship and pharmacological sedation in alleviating preoperative anxiety in preschool children

Objective: To investigate the effectiveness of child-centered playful companionship and sedative medication in alleviating preoperative anxiety in preschool children. Methods: A retrospective analysis was conducted on 3 825 preschool children (3-6 years) who underwent elective surgery at Shanghai Children's Medical Center from April 2021 to March 2022. The children were divided into three groups based on the preoperative anxiolytic intervention: child-centered playful companionship group (n=2 198), pharmacological sedation group (n=1 281), and no intervention group (n=346). The pharmacological sedation group received intranasal dexmedetomidine at 2 μg/kg or oral midazolam syrup at 0.5 mg/kg. The child-centered playful companionship group received care from certified preoperative sedation nurses using a child-centered playful nursing model. The no intervention group did not receive any anti-anxiety measures due to various subjective and objective reasons. Preoperative separation anxiety scores (PSAS), sedation medication usage, and Ramsay sedation scores were recorded for all children. The primary outcome was the success rate of separation based on PSAS scores across different anxiolytic intervention groups, while the secondary outcome was the Ramsay sedation score. Results: The child-centered playful companionship group included 1 462 boys and 736 girls, with a median age [M (Q1, Q3)]of 59 (49, 69) months. The pharmacological sedation group included 824 boys and 457 girls, with a median age of 52 (42, 61) months; and the no intervention group included 212 boys and 134 girls, with a median age of 57 (48, 69) months. The success rate of separation in the child-centered playful companionship group was 95.6% (2 102/2 198), and in the pharmacological sedation group was 93.8% (1 202/1 281), both significantly higher than the 43.6% (151/346) of the no intervention group (all P<0.05). Among the 1 281 children in the pharmacological sedation group, 785 received oral midazolam and 496 received intranasal dexmedetomidine. Compared to the intranasal dexmedetomidine group, the oral midazolam group was younger, had a lower body weight and a higher proportion of American Society of Anesthesiologists (ASA) class Ⅲ (all P<0.05). The success rate of separation was 93.4% (733/785) in the oral midazolam group and 94.6% (469/496) in the intranasal dexmedetomidine group, with no statistically significant difference (P=0.392). The Ramsay sedation score was 2 (2, 2) in the intranasal dexmedetomidine group, better than the 2 (2, 2) of the oral midazolam group (P=0.024). Conclusion: Both child-centered playful companionship and pharmacological sedation effectively alleviate preoperative anxiety in preschool children.

Median effective dosage of midazolam oral solution for preschool children in preoperative sedation

AbstractThis study aimed to detect median effective dosage (ED50) of midazolam oral solution (MOS) for preschool children in preoperative sedation. Thirty children (3–6 years old, with a body mass index (BMI) of 18–28 kg/m2, American Society of Anesthesiologists status (ASA) I‐II) scheduled for the hidden penis correction surgery under general anesthesia were selected. The effective dosage of MOS for preschool children in preoperative sedation was measured by sequential method. The initial dose was set at 0.5 mg/kg, with a concentration gradient of 0.1 mg/kg. Sedation was deemed successful if the patients’ Ramsay sedation scores were ≥4 and Frankl treatment compliance rating scale was ≥3, without any grade III or higher adverse events during anesthesia. If these criteria were met, the dosage for the next patient was reduced by one gradient based on the last patient's dosage, otherwise, the dosage for the next patient was increased by one gradient. This process was repeated until the 7th inflection point from unsuccessful to successful sedation was reached, at which point the trial was terminated. Probit regression analysis was used to calculate the ED50, 95% effective doses (ED95) and 95% confidence interval (CI) of MOS. Adverse reactions such as bradycardia, nausea, vomiting, and blurred vision were recorded during sedation. This study revealed that the ED50 and ED95 of MOS for preschool children preoperative sedation are 0.627 mg/kg (95% CI 0.582–0.669 mg/kg) and 0.795 mg/kg (95% CI 0.712–1.211 mg/kg), respectively, providing a reference for the administration of MOS in this population.

A Comprehensive Review on the Role of Melatonin's Anesthetic Applications in Pediatric Care.

Anesthesia is critical to pediatric care, ensuring the safety and comfort of children undergoing medical procedures. With a growing interest in alternative anesthetic agents, melatonin has emerged as a promising candidate due to its sedative, analgesic, anti-inflammatory, and neuroprotective properties. This comprehensive review explores the potential applications of melatonin in pediatric anesthesia. We delve into the pharmacological characteristics of melatonin, its anesthetic properties, and its clinical applications in pediatric care, including preoperative sedation, adjunct to general anesthesia, postoperative pain management, and prevention of emergence delirium. Additionally, we discuss the safety profile of melatonin, potential adverse effects, and comparative analysis with traditional anesthetics. Finally, we highlight future research directions to provide insights into melatonin's role in pediatric anesthesia and its implications for clinical practice.

Comparison of the effects of two amino acids, Gamma-aminobutyric acid (GABA) and L-theanine, on sedation, anxiety, and cognition in preoperative surgical patients – A randomized controlled study

Abstract Background and Aims: Preoperational anxiety affects the outcome of anesthesia and surgery. Benzodiazepines impair psychomotor performance and cause excessive sedation. L-theanine is a unique amino acid found in green tea. It prevents stress, produces anxiolysis, modulates alpha activity, and provides beneficial effects on mental state, including sleep quality. Gamma-aminobutyric acid (GABA) is a non-proteinogenic amino acid and a phytochemical that is the main inhibitory neurotransmitter in the mammalian brain. It is beneficial in anxiety and stress regulation. Hence, alternative premedicants such as L-theanine and GABA will have a widespread appeal and are safer. The primary objective was to study and compare the effects of L-theanine and GABA on preoperative anxiety, sedation, and cognition in patients posted for major elective surgeries. The secondary objective was to study adverse reactions. Material and Methods: A total of 168 patients aged between 18 and 55 years, belonging to the American Society of Anesthesiologists physical status class I and II, and satisfying all inclusion criteria were randomly divided into three groups that received either oral L-theanine, oral GABA, or oral alprazolam 0.25 mg. The anxiety score, sedation score, and psychomotor and cognitive performance scores were noted 60 minutes before and after the administration of the drugs. Results: Alprazolam produced more sedation than GABA and L-theanine (P = 0.0001). Psychomotor and cognitive functions improved with L-theanine and GABA (P = 0.0001) and decreased with alprazolam (P = 0.0001). Conclusion: GABA and L-theanine result in effective preoperative anxiolysis with minimal sedation and improvement of cognitive skills.

Preoperative Anxiolytic and Sedative Effects of Intranasal Remimazolam and Dexmedetomidine: A Randomized Controlled Clinical Study in Children Undergoing General Surgeries.

Remimazolam, anultra-short-acting and fast-metabolized sedative, has only been sporadically investigated in children. This study was performed to determine the beneficial effects of intranasal remimazolam or dexmedetomidine on preoperative anxiety in children undergoing general surgeries. Ninety children were randomly and equally assigned to Group R (intranasal remimazolam 1.5mg kg-1), Group D (intranasal dexmedetomidine 2 mcg kg-1), and Group C (intranasal distilled water). The primary outcomes were the preoperative anxiety scores using the modified Yale preoperative anxiety scale (m-Ypas). The secondary outcomes included the cooperation behaviour of intranasal drug application, preoperative sedation levels, parental separation anxiety scores (PSAS), and mask acceptance scores (MAS). Group R showed a significant low anxiety at 10 min after intranasal premedication (vs group C, P=0.010; vs group D, P = 0.002) and at anaesthesia induction (vs group C, P = 0.004). Group D showed a significantly low anxiety score only prior to anaesthesia induction (vs group C, P = 0.005). Most children in group R achieved mild sedation at 10 min (vs group C, P < 0.001; vs group D, P < 0.001), with a few progressing to deep sedation afterwards, while group D tended toward deep sedation. Compared to Group C, patients in Group R performed significantly better on the MAS (P = 0.014) and PSAS (P = 0.008). However, remimazolam did cause poor cooperation behavior to the intranasal application due to its mucosal irritation (vs group C, P = 0.001; vs group D, P = 0.010). Both intranasal remimazolam and dexmedetomidine can effectively alleviate preoperative anxiety in children. While intranasal remimazolam has a rapid onset, it produces only mild sedation and causes substantial nasal irritation. NCT04720963, January 22, 2021, ClinicalTrials.Gov.

Comparison of Xylazine and Lidocaine Infusion versus Medetomidine Continuous Rate Infusion during General Anesthesia with Isoflurane in Horses Undergoing Emergency Laparotomy.

(1) The main goals of general anesthesia include pain management and a safe anesthetic protocol for smooth recovery. In this retrospective study, we compared two anesthetic protocols for general anesthesia with isoflurane during emergency laparotomy: sedation with xylazine and the intraoperative infusion of lidocaine (X group) versus medetomidine as a preoperative sedation and intraoperative infusion (M group). (2) The medical records of horses who underwent emergency laparotomies between 2016 and 2023 were reviewed. According to the anesthetic protocol, patients were allocated to the X or M groups. Data about the horse, signalment, history, and anesthetic variables were analyzed. (3) Group X had a significantly higher heart rate (HR), lower respiratory rate (RR) and mean and diastolic arterial pressure (MAP/DAP). A progressive increase in HR and RR was observed in both groups. Group X underwent a decrease in RR and an increase in DAP. In Group M, a decrease in MAP and DAP was observed. Group M exhibited a longer recovery time with similar recovery scores. Both protocols provided safe anesthesia for emergency laparotomy, with minor cardiovascular and respiratory depression. Minor respiratory depression was detected when xylazine was used, while recovery was longer with medetomidine.

Effective dose of intranasal remimazolam for preoperative sedation in preschool children: a dose-finding study using Dixon's up-and-down method.

Most preschool children are distressed during anesthesia induction. While current pharmacological methods are useful, there is a need for further optimization to an "ideal" standard. Remimazolam is an ultra-short-acting benzodiazepine, and intranasal remimazolam for pre-induction sedation may be promising. This study included 32 preschool children who underwent short and minor surgery between October 2022 and January 2023. After pretreatment with lidocaine, remimazolam was administered to both nostrils using a mucosal atomizer device. The University of Michigan Sedation Score (UMSS) was assessed for sedation 6, 9, 12, 15, and 20min after intranasal atomization. We used Dixon's up-and-down method, and probit and isotonic regressions to determine the 50% effective dose (ED50) and 95% effective dose (ED95) of intranasal remimazolam for pre-induction sedation. Results: Twenty-nine pediatric patients were included in the final analysis. The ED50 and ED95 of intranasal remimazolam for successful pre-induction sedation, when processed via probit analysis, were 0.65 (95% confidence interval [CI], 0.59-0.71) and 0.78mg/kg (95% CI, 0.72-1.07), respectively. In contrast, when processed by isotonic regression, they were 0.65 (95% CI: 0.58-0.72mg/kg) and 0.78mg/kg (95% CI: 0.69-1.08mg/kg), respectively. At 6min after intranasal remimazolam treatment, 81.2% (13/16) of "positive" participants were successfully sedated with a UMSS ≧ 1. All the "positive" participants were successfully sedated within 9min. Intranasal remimazolam is feasible for preschool children with a short onset time. For successful pre-induction sedation, the ED50 and ED95 of intranasal remimazolam were 0.65 and 0.78mg/kg, respectively.

Oral Dexmedetomidine Achieves Superior Effects in Mitigating Emergence Agitation and Demonstrates Comparable Sedative Effects to Oral Midazolam for Pediatric Premedication: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although the results of different randomized controlled trials are conflicting. Methods: This study enrolled randomized controlled trials (RCTs) examining premedication with oral dexmedetomidine versus oral midazolam in pediatric patients undergoing general anesthesia. PubMed, the Cochrane Library, Embase, and the Web of Science database were searched from their inception until June 2023. The outcomes were the incidence of satisfactory preoperative sedation, satisfactory sedation during separation from parents, satisfactory sedation during anesthesia induction using an anesthesia mask, and the incidence of emergence agitation. Results: A total of 9 RCTs comprising 885 patients were analyzed. Our data revealed comparable effects of dexmedetomidine and midazolam with respect to satisfactory preoperative sedation and a satisfactory incidence of sedation during parental separation and mask acceptance before anesthesia induction. Notably, our data revealed that the rate of emergence agitation was significantly lower in pediatric patients receiving dexmedetomidine (n = 162) than in those receiving midazolam (n = 159) (odds ratio = 0.16; 95% confidence interval: 0.06 to 0.44; p < 0.001; I2 = 35%). Conclusions: Data from this meta-analysis revealed comparable effects for premedication with oral dexmedetomidine or oral midazolam with respect to satisfactory sedation; furthermore, premedication with oral dexmedetomidine more effectively mitigated emergence agitation in pediatric patients receiving general anesthesia compared with oral midazolam.

Efficacy and Safety of Single-Dose Pregabalin in Preoperative Pediatric Sedation.

This study aimed to investigate the anxiolytic and sedative effects of a single oral dose of 5 mg/kg pregabalin in pediatric patients undergoing elective surgery. It also assessed potential adverse effects and its impact on bispectral index (BIS) responses. This prospective randomized clinical trial enrolled 60 pediatric patients undergoing minor elective surgery. Patients were randomly assigned to receive either oral pregabalin (5 mg/kg) or a placebo one hour before induction of anesthesia. Anxiety levels were assessed using the Visual Analog Scale for Anxiety (VAS-A), and sedation levels were evaluated using the Ramsay Sedation Scale (RSS). Pregabalin premedication significantly reduced preoperative anxiety, as indicated by lower VAS-A scores compared to the control group. Sedation levels, measured using the RSS, were significantly higher in the pregabalin group at various time points post-dose. During intubation, skin incision, and recovery, BIS responses were significantly lower in the pregabalin group. The use of single-dose pregabalin preoperatively in children recorded a significant decrease in anxiety and achieved a state of sedation without an increase in adverse effects.

Intranasal dexmedetomidine vs. oral midazolam for premedication in children: a systematic review and meta-analysis.

To compare the effects of intranasal dexmedetomidine (Dex) and oral midazolam in the preoperative medication of children by using a method of meta-analysis. Cochrane Library, Pubmed, Embase, and Web of Science were searched from inception to July 2023. Randomized controlled trials (RCTs) of intranasal Dex vs. oral midazolam in pediatric premedication were collected. Stata 15.0 statistical software was used to analyze the collected data. Relative risk (RR) and 95% confidence interval (CI) were used as effect sizes. A total of 11 studies with 824 children were included, containing 415 patients in the Dex group and 409 patients in the midazolam group. Compared with the oral midazolam group, the intranasal Dex group had a better preoperative sedation effect at parent-child separation (RR = 1.37, 95% CI: 1.14-1.64) and anesthesia induction (RR = 2.08, 95% CI: 1.03-4.22). In addition, there was no significant difference in the incidence of analgesia remedy (RR = 0.60, 95% CI: 0.36-1.00) the acceptance of anesthesia masks (RR = 0.97, 95% CI: 0.83-1.12), and incidence of adverse events between (RR = 0.25, 95% CI: 0.06-1.13, P = 0.072) between the intranasal Dex and oral midazolam groups. Compared with oral midazolam, intranasal Dex has better sedative effects of parent-child separation and anesthesia induction in pediatric premedication, but there was no difference in the incidence of anesthesia remedy, anesthesia mask acceptance, and incidence of adverse events. Therefore, compared with oral midazolam, intranasal Dex is a better choice for premedication in children.

Comparison of Intranasal Versus Intravenous Dexmedetomidine to Attenuate Haemodynamic Response of Laryngoscopy and Endotracheal Intubation in Elective Lumbar Spine Surgery: A Randomized Controlled Study

Background: In general anaesthesia, hemodynamic alterations during endotracheal intubation are vital concerns. The efficacy of intranasal and intravenous Dexmedetomidine (DEX) in decreasing the stress response generated by laryngoscopy and endotracheal intubation was investigated in this study. Methods: Seventy adults were randomised into two groups in this prospective, randomised, double-blind study: Group DIV (n=35) and Group DIN (n=35). Dexmedetomidine (DEX) infusion (0.5 μg /kg) was administered intravenously over 40 minutes to the DIV group and intranasally (1 μg /kg) to the DIN group 40 minutes before induction. The primary outcome was to compare the mean arterial pressure (MAP) between the two groups starting 40 minutes before induction and continuing every 10 minutes until induction of anaesthesia, at the time of intubation, and then every minute afterwards until 5 minutes, 7 minutes, and 10 minutes following intubation. Comparisons of heart rate (HR), systolic (SBP) and diastolic blood pressure (DBP), sedation and any adverse effects were the secondary outcomes. Results: The two groups had no statistically significant difference in MAP, HR, SBP and DBP. The DIV group's preoperative sedation score before induction was significantly higher than the DIN group's (P = 0.014). Conclusion: This study demonstrates that dexmedetomidine administered intravenously is equally efficient as intranasal dexmedetomidine in attenuating hemodynamic response during laryngoscopy and intubation.

Radiologically inserted gastrostomy tube in neurological disease: A retrospective study

Objectives: This study aimed to compare the safety and efficacy of balloon and non-balloon (or dilator) gastrostomy devices in radiologically inserted gastrostomy (RIG) for patients with neurological disease. Material and Methods: A retrospective analysis of 152 patients was conducted at a tertiary care hospital from July 2017 to September 2020. 104 and 48 patients were included in the balloon and non-balloon groups, respectively. The frequency of complications per specific neurological indication as well as the breakdown of the different complications pertaining to each indication was recorded for analysis. The recovery time, fluoroscopy time, contrast volume, peak radiation, and pain management dosages for each procedure were all reviewed to evaluate for statistical differences between the balloon and non-balloon groups. An adjusted model odds ratio (OR) was conducted to evaluate how each of the variables (type of gastrostomy tube, body mass index [BMI], age, and gender) affected the frequency of complications within our cohort. Results: This study included 152 patients, with an average age of 65.17 years (interquartile range [IQR] = 12.66) and an average BMI of 26.97 (IQR = 7.19). The majority of patients were male (71.1%). The most common indication for the procedure was stroke (24.3%), followed by post-intubation dysphagia (16.4%) and intracranial hemorrhage (11.8%). Amyotrophic lateral sclerosis (ALS) and altered mental status had a similar prevalence at 9.9%. The overall complication rate was 33.8%, overall mortality rate 3.3%, 30-day mortality rate of 2.6%, and no other major complications according to CIRSE criteria. Notably, patients with neurodegenerative disorders exhibited comparable rates of minor complications: 33.3% in ALS (5/15 patients), 50% in myasthenia gravis (1/2 patients), and 100% in muscular dystrophy (1/1 patient). The study compared two groups: the balloon group (104 patients) and the dilator group (48 patients). The balloon group received significantly lower preoperative sedation in the form of fentanyl (Avg = 4.46 min vs. 6.54 min, P = 0.287). The balloon group had shorter fluoroscopy time, lower radiation exposure dose, and shorter operating time compared to the dilator group, though not statistically significant. In the logistic regression model, there was no statistical difference in complication rates between the dilator and balloon groups. BMI, age, and gender did not significantly affect minor complication rates. Conclusion: RIG tube insertions may serve as a valuable, alternative approach in providing enteral support in patients with neurological disease.

A review of frequently used Kampo prescriptions. Part 3. Yokukansan

AbstractBackgroundThe source of yokukansan (YKS) is thought to be Baoying‐Jinjiang (Hoeikinkyōroku in Japanese) by Xue Ji. YKS was originally designed for children and indicated for spasms, clenching of teeth, digestive dysfunction due to mental instability, and insomnia.Key FindingsYKS formula consists of seven types of crude drugs. Clinical studies have revealed that YKS exerts physiological effects including the treatment of behavioral and psychiatric symptoms of dementia (BPSD), preoperative sedation and anxiety, and postoperative delirium. A meta‐analysis showed that YKS could improve BPSD and daily living activities; however, no improvement in cognitive function was observed. Preclinical studies have also reported that YKS modulates neuronal pathways in the central nervous system, including the serotonergic, glutamatergic, GABAergic, and other neurotransmitter pathways. The incidence of adverse events associated with YKS was 5.17%, with the major adverse effect being pseudoaldosteronism. Routine blood sampling is considered for hypokalemia prevention.ConclusionYKS is useful for BPSD and perioperative mental instability. The modulation of the serotonergic and glutamatergic neural pathways is one of mechanisms. Pseudoaldosteronism is one of the side effects.

A Comparative Study of Intramuscular Ketamine and a Combination of Intramuscular Dexmedetomidine and Ketamine as Premedication in Paediatric Anesthesia

Introduction: Preoperative anxiety is an issue of concern in paediatric anaesthesia practice. Forceful transfer of children into the operating room can cause long-term psychological trauma. This clinical study compares intramuscular ketamine and a combination of intramuscular dexmedetomidine and ketamine as anaesthetic premedicants in terms of +anxiolysis, sedation and ease of IV cannulation.&#x0D; Objectives: To compare the level of preoperative anxiety, sedation and ease of cannulation following premedication between intramuscular ketamine and a combination of intramuscular dexmedetomidine and ketamine.&#x0D; Methods: Total of 60 patients belonging to American Society of Anaesthesiologists physical status I-II, in the age group of two to ten years, scheduled for elective surgery under general anaesthesia were included in the study; Group A patients received ketamine 3mg/kg body weight while Group B patients received ketamine 2mg/kg body weight and dexmedetomidine 1mcg/kg body weight intramuscular. The outcome variables were sedation score (Richmond Agitation Sedation Scale), IV cannula acceptance (IV cannula Acceptance Score), and parental separation (Separation Score).&#x0D; Results: The groups were comparable in patient characteristics and hemodynamic parameters between the groups. Median (IQR) sedation score at 10 min were -1 (-2—0) and 0(-1—1) (p&lt; 0.001); mean parental separation scores were 3.76± 0.43 and 3.36±0.55 (p&lt; 0.001); IV cannula acceptance score were 3.73±0.44 and 4.53±7.27 (p= 0.001) in Group A and Group B respectively.&#x0D; Conclusion: Combination of dexmedetomidine and ketamine is superior to ketamine alone in terms of sedation at 15 min and ease of IV cannulation but comparable in terms of anxiolysis.

Effect of oral pregabalin on post operative analgesia in patients undergoing lumbar spine fusion surgeries under general anesthesia

Pregabalin has been used successfully as a component of multimodal analgesia regimen in a variety of surgical procedures. However, side effects such as dizziness and somnolence have been reported especially with doses ≥300mg. We hypothesized that using a lower cumulative dose of oral pregabalin in a divided dosing regimen would lower the incidence of side effects while providing adequate postoperative analgesia in patients undergoing lumbar spine fusion surgery. Seventy adult patients of either sex of ASA 1-3, undergoing lumbar spine fusion surgery under general anesthesia were randomly divided into two equal groups. Group B received oral pregabalin 150mg one hour before induction and 75mg 2 hours after surgery. Group A received oral placebo at the corresponding time points. Pain was assessed using Visual Analogue Score (VAS) at extubation, 2, 4, 6, 12, 18 and 24 hours after surgery. In the first 24 hours after surgery, the mean VAS scores were significantly lower in Group B (P0.001) at all time points while tramadol consumption for rescue analgesia (P0.001) and postoperative nausea (P0.013) and vomiting (P0.011) were significantly higher in Group A. Preoperative anxiety and sedation scores and postoperative incidence of dizziness and somnolence were comparable between the two groups. Low dose oral pregabalin preoperatively and postoperatively using a divided dose regimen can be safely used to provide adequate postoperative analgesia with low incidence of side effects after lumbar spine fusion surgeries.