Sedative Premedication Research Articles

Combined sedation and topical anesthesia for cataract surgery

PurposeTo determine whether lidocaine jelly is as efficacious as tetracaine drops for obtaining ocular anesthesia and to evaluate sublingual lorazepam as premedication for sedation in cataract surgery. SettingAn ambulatory surgical center dedicated to ophthalmic surgery. MethodsThe study was divided into 2 phases. In the first, 100 patients were divided into 2 groups of 50 each. The first group received tetracaine 0.5% drops for anesthesia. The second group received lidocaine 2% jelly for topical anesthesia. In the second stage, 100 patients were divided into 2 groups of 50 each. The first 50 patients were given 1 mg of sublingual lorazepam before surgery. The second group had cataract surgery without sublingual lorazepam. All patients were operated on by the same surgeon in an ambulatory surgical center. The technique was temporal clear corneal cataract surgery with foldable intraocular lens implantation. Exclusions from the study were the need to convert to peribulbar or retrobulbar anesthesia, intraocular complications, and altered mental status. ResultsIn the first phase of the study, lidocaine 2% jelly was as efficacious as tetracaine 0.5% drops for topical anesthesia in cataract surgery. In the second phase of the study, overall, patients in the lorazepam group had less anxiety, greater amnesia, and lower blood pressure than those not receiving lorazepam as sedation for topical anesthesia. ConclusionsLidocaine 2% jelly combined with sublingual lorazepam provided excellent cost-effective anesthesia and sedation for topical anesthesia in cataract surgery and enhanced patient satisfaction with the procedure.

Postoperative Behavioral Outcomes in Children: Effects of Sedative Premedication

BackgroundAlthough multiple studies document the effect of sedative premedication on preoperative anxiety in children, there is a paucity of data regarding its effect on postoperative behavioral outcomes.MethodsAfter screening for recent stressful life events, children undergoing anesthesia and surg

A randomized double-blind placebo-controlled trial evaluating the cost-effectiveness of droperidol as a sedative premedication for EUS

Background: Droperidol is a neuroleptic agent with anti-emetic properties that produces mild sedation, reduced anxiety, and a state of mental detachment and indifference to one’s surroundings. Routine premedication with droperidol has been shown to improve sedation during esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography. The purpose of this randomized double-blind placebo-controlled study was to determine whether premedication with droperidol improves sedation during routine upper endoscopic ultrasound (EUS) in a cost-effective manner. Methods: One hundred consecutive patients referred for EUS were randomly assigned to receive either 2.5 mg or 5 mg of droperidol or placebo before the procedure. After EUS, the physician, nurse, and recovered patient scored various parameters of procedural sedation. Results: In the group receiving 5 mg of droperidol there was significantly less gagging at intubation, less retching during the procedure, better patient cooperation, less need for physical restraint, and improved nurses’ and physician’s impression of sedation. Significantly less meperidine and less midazolam were required for sedation, making medication costs significantly lower in the group receiving 5 mg droperidol. Conclusions: A 5 mg dose of droperidol given as premedication for routine upper EUS improves sedation during the procedure while significantly decreasing the overall cost of sedation. (Gastrointest Endosc 1999;50:178-82.)

Anesthesia of the sighthound

The sighthounds are an ancient group of dog breeds that have been selectively bred for high-speed pursuit of prey by sight. Probably as a consequence of this selection process, these dogs have a number of idiosyncrasies that can potentially adversely affect their anesthetic management. These include (1) nervous demeanor which can lead to stress-induced clinical complications, such as hyperthermia; (2) lean body conformation with high surface-area-to-volume ratio, which predisposes these dogs to hypothermia during anesthesia; (3) hematological differences such as a higher packed cell volume and lower serum protein compared with other dog breeds which may complicate interpretation of preanesthetic blood work; (4) Impaired biotransformation of drugs by the liver resulting in prolonged recovery from certain intravenous anesthetics, especially thiopental; and increased risks of drug interactions. Safe anesthetic management of sighthounds should include sedative premedication and appropriate use of analgesic drugs to minimize perioperative stress. Thiopental, or any other thiobarbiturate, should not be used in these dogs. Propofol, ketamine/diazepam combination, and methohexital are recommended alternative intravenous anesthetics. Avoid coadministration of agents that inhibit drug biotransformation, such as chloramphenicol. Inhalation anesthesia using isoflurane is the preferred anesthetic maintenance technique. Core body temperature should be monitored closely and techniques to minimize hypothermia should be employed both during anesthesia and into the recovery period.

Premedication and preoperative fasting in pediatric anesthesia. Results of a survey

This study evaluates the current practice of premedication and preoperative fasting in pediatric anaesthesia in Germany. A total of 90 questionnaires were mailed to randomly selected hospitals with departments or sections of anaesthesiology and pediatric surgery. 71 questionnaires were returned and analysed (reply rate 79%). 60% of the responding hospitals start premedication between the ages of 3 and 12 months and 32% between 1 and 2 years of age. Premedication ist most often given orally (64%), followed by rectal (29%) and intranasal (3%) routes. Midazolam is used by 96% of the respondents as the primary sedative premedication. Alternatively, promethazine and chloraldhydrate are most frequently used. Anticholinergic drugs are given routinely by 21% of the respondents. For the apprehensive child intramuscular ketamine is most often used (33%), followed by intranasal midazolam (22%), rectal midazolam (19%) and rectal thiopentone or methohexitone (13%). For children less than 1 year of age 63% of the hospitals restrict clear liquids 2 hours and 34% 3 or 4 hours before anaesthesia. 64% of the respondents require abstinence from milk for 4 hours and 30% for 6 hours prior to surgery. For children older than one year of age fasting period requirements for clear liquids were 2 hours (34%), 3 hours (27%), 4 hours (30%) and 6 hours (9%). For children over 1 year of age the majority allow solid food or milk up to 6 hours prior to anaesthesia (68% and 63%, respectively). The survey shows that premedication is started during the first two years of age by nearly all responding hospitals. Oral or rectal midazolam is the most frequently used premedication regimen. Preoperative fasting guidelines vary.

Parental Presence During Induction of Anesthesia vs. Sedative Premedication

Parental Presence During Induction of Anesthesia vs. Sedative Premedication

11 Pre-operative anxiety, stress and pre-medication

The preoperative period means for the majority of patients a distressing situation, which is characterized by anxiety and fear. This is not only uncomfortable for the patient, but the simultaneously occurring activation of the sympathetic nervous system is potentially dangerous for a predisposed patient. Therefore, the primary goal for the patients preoperatively is to reduce anxiety and to induce sedation. Furthermore, if indicated, premedication should minimize the risk of an aspiration syndrome, prevent postoperative nausea and vomiting (PONV), provide analgesia, reduce secretions and control infections. Besides fear and anxiety, stress may even cause an adaptation syndrome or depression. Physiological reactions of all organ systems to epinephrine and norepinephrine result from the stimulation of the sympathetic nervous system. To quantify these effects physiological and biochemical parameters are used. Fears may be recognized consciously or may be masked; for anxiety there is a differentiation between trait-anxiety and state-anxiety, which are of differing importance. It can be stated that the perioperative anxiety influences the patient's outcome. For the preoperative medication both the individual patient, due to the physical and psychological status and to their history, and the desired goals have to be considered. The most commonly used ways of administration are oral, rectal or intranasal. We can choose our pharmaceutical premedication for anxiolysis and sedation from different substance classes as benzodiazepine, barbiturates, α-2-agonists, being aware of specific effects and side effects and also the possibility of antagonization. On the other hand, the anaesthesiologist has to know the meaning of the psychological premedication too. Other unpleasant experiences for patients postoperatively are nausea and vomiting, which are to be treated prophylactically in patients with a known history of PONV. Anticholinergics are no longer routinely used for premedication, and from a legal point of view this is no longer recommended.

Continuous Spinal Anesthesia for Hip Surgery in a Patient with Shy-Drager Syndrome

Continuous Spinal Anesthesia for Hip Surgery in a Patient with Shy-Drager Syndrome

Premedication in the United States: a status report.

We undertook a mailing survey study to assess the current practice of sedative premedication in anesthesia. A total of 5396 questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Forty-six percent (n = 2421) of those sampled returned the questionnaire after two mailings. The reported rate of sedative premedication in the United States varied widely among age groups and geographical locations. Premedicant sedative drugs were least often used with children younger than age 3 years and most often used with adults less than 65 years of age (25% vs 75%, P = 0.001). Midazolam was the most frequently used premedicant both in adults and children (> 75%). When analyzed based on geographical locations, use of sedative premedicants among adults was least frequent in the Northeast region and most frequent in the Southeast region (50% vs 90%, P = 0.001). When the frequency of premedication was examined against health maintenance organization (HMO) penetration (i.e., HMO enrollment by total population) in the various geographical regions, correlation coefficients (r) ranged from -0.96 to -0.54. Multivariable analysis revealed that HMO penetration is an independent predictor for the use of premedication in adults and children. The marked variation among geographical areas in premedicant usage patterns underscores the lack of consensus among anesthesiologists about the need for premedication. The data suggest that HMO participation may affect delivery of this component of anesthetic care.

Oral midazolam premedication for paediatric day case patients

Forty-nine children having day-stay surgical procedures were randomly assigned to receive oral midazolam 0.75 mg.kg-1 or placebo in a double blind fashion. The child's level of anxiety was assessed before premedication using parental, child and observer scales. The child and observer anxiety scores were repeated in the anaesthetic room. Most children presented for anaesthesia in a calm state, irrespective of whether they had received midazolam. Parents tended to overestimate their child's level of anxiety. Observer anxiety scores reliably predicted behaviour during induction of anaesthesia in the absence of a sedative. Observer scores decreased in the midazolam group (P < 0.02), but not in the placebo group, children below six years having the greatest decrease with midazolam. The median time to discharge from hospital was delayed by 30 min in the midazolam group (P < 0.01). Children do not require routine sedative premedication for day case procedures, but oral midazolam is useful in producing calm behaviour in those children with high observer anxiety scores.

A Randomized, Double-blind, Placebo-controlled Study of Lorazepam as Premedication for Bronchoscopy

To our knowledge, no study has clearly demonstrated the advantage of sedative premedication for bronchoscopy. In a double-blind study, we evaluated the efficacy of oral lorazepam as premedication for bronchoscopy. One hundred patients were randomly assigned to receive placebo (group A) or lorazepam (2 mg) (group B) approximately 1.5 h before bronchoscopy. Immediately after the procedure and the following day, a questionnaire addressing the patient's perception of the procedure was administered. Specifically, subjects were asked to grade the bronchoscopy as very easy, easy, difficult, or very difficult to tolerate and if they would agree to a second bronchoscopy if believed necessary. In addition, their recollection of the procedure was graded as clear, indistinct, or not at all. No difference was found between the two groups for age, duration of the bronchoscopy, and the answers to the questionnaire administered immediately after the procedure. Most patients from both groups found their level of sedation adequate. On the following day, however, group B reported with lower frequency that the technique was difficult or very difficult (38.0% vs 65.3% for group A; p < 0.005) and that they would be less reluctant to a repeated bronchoscopy (30.0% vs 57.1% for group A; p < 0.015). Moreover, their recollection of the procedure was now less precise than for those who had received the placebo (p < 0.005). This suggests that the difference observed between the two groups at 24 h was related to the amnesic effect of lorazepam. We conclude that lorazepam, by improving patient's perception of the bronchoscopy, is a useful premedication and may facilitate patient's investigation when a second bronchoscopy becomes necessary.

Preparing children for the operating room: psychological issues

Children respond psychologically to the prospect of surgery in a variable and age-dependent manner. This review summarizes the psychoanalytic, cognitive, behavioural and family system models of child development. It then reviews studies of hospitalization and anaesthesia in children. These studies suggest that younger children, children previously anaesthetized, and children who experience turbulent anaesthetic inductions are at particular risk for postoperative behavioural disturbances. Strategies of dealing with children and their parents during the perioperative period are discussed. Such strategies include: allowing a parent to be present during induction of anaesthesia, administering sedative premedication, creating a supportive environment, educating children and parents (verbal descriptions, tours, books, videos), and establishing rapport with children and their parents. Age-specific techniques of establishing rapport with children are discussed. If children are less anxious during the perioperative period, not only will they often exhibit less behavioural disturbances postoperatively, but they may face subsequent medical care more easily.

Diagnostico y tratamiento del pólipo juvenil del colon

In a five year period 75 colonoscopies were carried out in 66 children with rectal bleeding. Five patients presented with severe anemia. Their age ranged from 2 to 16 years (mean 6.6). Most of the procedures were performed on an outpatient basis (87%) and under oral sedative premedication (78%). At least the splenic flexure was reached in each case. We found 59 polyps in 47 children (71%). All polyps were snared and removed during the same procedure. There were no serious complications. Colonoscopy is a most usefull diagnostic and therapeutic procedure in children with rectal bleeding, where there is a high probability that a juvenile polyp can be found which can be safely treated during the same session.

Pre‐induction behaviour of children A review of placebo‐controlled trials of sedatives

Placebo-controlled trials of sedative premedication in children are reviewed in an attempt to determine which drugs have been shown to reduce the frequency with which children cry or appear apprehensive. Small samples and inappropriate statistical methods limit the value of many of the studies. Most of the drugs tested will, in sufficient dose, increase the proportion of children who are asleep. Only intramuscular opioid analgesics, either alone or in combination with other drugs, have been shown repeatedly to increase the frequency of calm behaviour in those who are awake. There is some evidence, however, that intramuscular placebo controls have a lower frequency of calm behavior than oral placebo controls.

Physical abuse of a suspected emotionally disturbed child: a report of case

ABSTRACTA 5‐year, 6‐month old black male came to the dental office for routine restorative dentistry. There were no orofacial signs of physical abuse. Because of the patient's previous uncontrollable behavior, a sedative premedication was administered intramuscularly into the left buttock. The injection site revealed several bruises. Further examination of lower back, buttocks, and legs showed a multitude of bruises. Dentists and auxiliary personnel should not limit their examination to the orofacial complex when administering medications to other parts of the body.

Respiratory effects of premedication during enflurane N2O anaesthesia in children.

The influence of premedication on induction characteristics and respiration was studied in 40 children breathing spontaneously during enflurane-nitrous oxide anaesthesia. Two different premedications were used. Twenty children (Group DA) received a rectal solution containing diazepam 0.25 mg kg-1 and atropine 0.015 mg kg-1 and 20 (Group DMS) received a rectal solution of diazepam 0.5 mg kg-1, morphine 0.15 mg kg-1 and scopolamine 0.01 mg kg-1. The children in Group DMS had a significantly higher preoperative sedative score (P less than 0.01), faster induction of anaesthesia (P less than 0.01), lower occurrence of airway problems during induction and a smoother intubation (P less than 0.05) than the children in Group DA. However, the end-tidal carbon dioxide tensions were higher and the occurrence of apnoea was more common in Group DMS than in Group DA. Thus it was concluded that if the more sedative premedication (DMS) is to be used for enflurane anaesthesia in children, controlled ventilation would be preferable.

Çocuk ve Bebeklerin Premedikasyonunda Ketamine Kullanımı

To determine the value of Ketamine as a premedicant agent in children, 121 children under the age of ten were given 3, 4, 5 ve 6 mg/kg Ketamine intramuscularly. Degree of sedation was graded as «unsatisfactory», «fair», «good» and «very good» in all dose groups. Administration of Ketamine in doses of 4-5 mg/kg with appro¬priate dose of Atropine 10-15 minutes prior to induction was found satisfactory in providing a sedative, amnesic, analgesic and vagolytic premedication.

The influence of intramuscularly administered pethidine on the amnesic effects of intravenous diazepam during intravenous regional anaesthesia.

Patients undergoing surgery under regional anaesthesia often receive narcotic analgesics for premedication which may modify the sedative and amnesic effects of intravenously administered diazepam. Sixty-two patients scheduled for upper extremity surgery under intravenous regional anaesthesia received 0.15 mg/kg of diazepam intravenously to supplement the local anaesthesia. Thirty-two of the patients received 0.01 mg/kg of atropine plus 1 mg/kg of pethidine and 30 patients only atropine intramuscularly approximately 1 h before injection of diazepam. Another 30 patients received the same atropine-pethidine premedication and saline intravenously, and served as a reference group. Atropine-pethidine premedication followed by saline did not produce any amnesic effects. Sixty-nine and 38% of patients receiving atropine-pethidine premedication followed by diazepam did not remember a picture shown to them 15 min after diazepam injection or the performance of operation, respectively, the respective figures for patients given atropine premedication followed by diazepam being only 23% and 0% (P less than 0.01 - 0.001 between groups). The anti-recall of painful stimulus (exanguination) was significantly (P less than 0.01) more common when diazepam was given after pethidine premedication (31%) when compared to its injection after atropine alone (7%). The drowsiness produced by the drugs was greatest and the overall patient acceptability of the technique used most satisfactory when pethidine was used for premedication and diazepam for sedation. It is concluded that intramuscularly administered pethidine potentiates the amnesic action of intravenous diazepam for painful stimuli, prolongs the amnesic action of diazepam for visual stimuli and improves the patients' acceptability of intravenous regional anesthesia supplemented by intravenous diazepam.

The effects of vascular catheterizations upon heart rate and blood pressure before aorto-coronary bypass surgery

Ten patients presenting for aorto-coronary bypass surgery were premedicated with their regular dose of propranolol and nitrates and diazepam 0.15 mg x kg-1 by mouth, morphine 0.15 mg x kg-1 and scopolamine 0.4 mg intramuscularly, 60 to 90 minutes before arrival in the operating room. Venous, arterial and pulmonary artery catheterizations were done under local anaesthesia. No significant changes were noted in systolic blood pressure and rate pressure product. Heart rate was decreased after internal jugular puncture and for the remainder of the study. PaCO2 increased and PaO2 decreased from values obtained the day before operation. Cardiovascular stability during vascular catheterization was achieved by emphasizing a detailed preoperative explanation, maintenance of beta-blockade up to the time of operation, substantial sedative premedication, and the liberal use of local anaesthesia.

BEHAVIOUR OF UNSEDATED CHILDREN IN THE ANAESTHETIC ROOM

The behaviour of 344 unsedated children in the anaesthetic room was assessed using a method similar to that described by Doughty (1959). The influence of the experience of the anaesthetist was found to be unimportant. The influence of the child's age was studied; children aged 7 yr and more behaved in a more satisfactory manner. The frequency of satisfactory behaviour compared favourably with that in published trials of sedative premedication which have used this method of assessment. The results support the view that the inclusion of unsedated children in such behavioural studies is essential.