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Alizadeh A, Naseri M, Ravanshad Y, Sorouri S, Banihassan M, Azarfar A. Use of sedative drugs at reducing the side effects of voiding cystourethrography in children. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:42. [PMID: 28465701 PMCID: PMC5393102 DOI: 10.4103/1735-1995.202139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/11/2016] [Accepted: 12/02/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Imaging of the kidneys and urinary tract has a significant and critical role for diagnosis of genitourinary system diseases. Although technological progress goes toward less invasive approaches, some of the current methods are still invasive and annoying. Voiding cystourethrography (VCUG) is the best and most accurate method for diagnosis and grading of vesicoureteral reflux. VCUG is a distressful procedure that gives serious anxiety and pain in a large proportion of children and fear for parents; therefore, using effective sedative drugs with the least side effects is necessary and should be considered. MATERIALS AND METHODS In this review article, importance and efficacy of different drugs before catheterization VCUG be compared in the base of literature survey on EMBASE, PubMed, and Cochrane source. RESULTS We found that the treatment should be based on nonpharmacological and pharmacological methods; nonpharmacological treatment includes the psychological preparation before procedures as a safety precaution with little or no risk modality, as well as reassuring support. The presence of parents during painful procedures cannot alleviate children distress. Pharmacological methods include oral midazolam (0.5 mg/kg) and intranasal use (0.2 mg/kg) that had been used 10 min before the procedure can effect on anterograde amnesia and sedation without considerable effect on accuracy and grade of reflux. Nitric oxide has a shorter recovery time versus midazolam but has a potential risk for deep sedation and may interfere with the child's voiding phase. CONCLUSION In summary, oral midazolam of 0.5-0.6 mg/kg or 0.2 mg/kg intranasal is acceptable drug that can be used before VCUG.
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Affiliation(s)
- Anahita Alizadeh
- Department of Clinical Toxicology, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Naseri
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yalda Ravanshad
- Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shahabaddin Sorouri
- Department of Internal Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Malihe Banihassan
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Anoush Azarfar
- Department of Pediatric Nephrology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Paradoxical Reaction to Alprazolam in an Elderly Woman with a History of Anxiety, Mood Disorders, and Hypothyroidism. Case Rep Psychiatry 2016; 2016:6748947. [PMID: 27092285 PMCID: PMC4820591 DOI: 10.1155/2016/6748947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 12/11/2022] Open
Abstract
With less than 1% of patients who use benzodiazepines being affected, paradoxical responses to benzodiazepines are rare. In this case report, we outline the course of an 80-year-old female who developed a paradoxical response to benzodiazepines. Significant medical and psychiatric history includes anxiety, mood disorder, hypothyroidism, bilateral mastectomy, goiter removal, and triple bypass. The patient presented with mental status changes, anxiety, motor restlessness, and paranoia. Over time, a temporal relationship between the severity of the patient's motor agitation and intake of alprazolam was observed. As doses of alprazolam were decreased, her motor agitation became less severe. In addition to motor agitation, the patient also demonstrated increased aggressiveness, a subjective feeling of restlessness, and increased talkativeness. As her dose of alprazolam decreased, many of the patient's symptoms were observed to decrease. This case report also discusses theories regarding the pathophysiology of paradoxical reactions to benzodiazepines, known risk factors, and appropriate treatment.
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Kim YM, Kang C, Joo YB, Yeon KU, Kang DH, Park IY. Usefulness of Ultrasound-Guided Lower Extremity Nerve Blockade in Surgery for Patellar Fracture. Knee Surg Relat Res 2015; 27:108-16. [PMID: 26060610 PMCID: PMC4458481 DOI: 10.5792/ksrr.2015.27.2.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/28/2015] [Accepted: 03/26/2015] [Indexed: 11/02/2022] Open
Abstract
PURPOSE To evaluate the usefulness of ultrasound-guided nerve blockade in patellar fracture surgery. MATERIALS AND METHODS Twenty-three patients who underwent metal fixation under ultrasound-guided lower extremity blockade after diagnosis of patellar fracture from July 2011 to June 2012 were enrolled in this study. Under ultrasound guidance, femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and sciatic nerve blockades were performed. For evaluation of anesthesia, interference with overall surgery, such as intraoperative knee pain and tourniquet pain, was checked. Individual anesthetic complications, satisfaction with nerve blocks, and choice of future anesthesia method were investigated. RESULTS Nineteen patients underwent surgery without any pain and 4 patients with mild pain. Satisfaction was excellent in 17 patients, good in 5, and unsatisfactory in 1. No complications such as infection or nerve injury occurred. In terms of selection of future anesthesia, 22 patients chose a nerve blockade of the lower extremity under ultrasound guidance, and one chose general anesthesia. CONCLUSIONS Overall, ultrasound-guided nerve block of the lower extremity for patellar fracture surgery showed satisfactory results. Therefore, it could be a useful method to prevent complications associated with general or spinal anesthesia.
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Affiliation(s)
- Young-Mo Kim
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Chan Kang
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Yong-Bum Joo
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Kyu-Ung Yeon
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Dong-Hun Kang
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Il-Young Park
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Daejeon, Korea
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Are Histrionic Personality Traits Associated with Irritability during Conscious Sedation Endoscopy? Gastroenterol Res Pract 2015; 2015:702492. [PMID: 25954307 PMCID: PMC4410519 DOI: 10.1155/2015/702492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 03/30/2015] [Indexed: 12/27/2022] Open
Abstract
Aim. We aimed to evaluate whether histrionic personality traits are associated with irritability during conscious sedation endoscopy (CSE). Materials and Methods. A prospective cross-sectional study was planned. Irritability during CSE was classified into five grades: 0, no response; I, minimal movement; II, moderate movement; III, severe movement; IV, fighting against procedure. Patients in grades III and IV were defined as the irritable group. Participants were required to complete questionnaire sheet assessing the extent of histrionic personality traits, extraversion-introversion, and current psychological status. The present authors also collected basic sociodemographic data including alcohol use history. Results. A total of 32 irritable patients and 32 stable patients were analyzed. The histrionic personality trait score of the irritable group was higher than that of the stable group (9.5 ± 3.1 versus 6.9 ± 2.9; P = 0.001), as was the anxiety score (52.8 ± 8.6 versus 46.1 ± 9.6; P = 0.004). Heavy alcohol use was more frequently observed in the irritable group (65.6% versus 28.1%; P = 0.003). In multivariate analysis, all these three factors were independently correlated with irritability during CSE. Conclusion. This study revealed that histrionic personality traits, anxiety, and heavy alcohol use can affect irritability during CSE.
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Shin YH, Kim MH, Lee JJ, Choi SJ, Gwak MS, Lee AR, Park MN, Joo HS, Choi JH. The effect of midazolam dose and age on the paradoxical midazolam reaction in Korean pediatric patients. Korean J Anesthesiol 2013; 65:9-13. [PMID: 23904933 PMCID: PMC3726857 DOI: 10.4097/kjae.2013.65.1.9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 12/14/2012] [Accepted: 12/17/2012] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although midazolam administration may occasionally induce a paradoxical episode, such as threatened crying and violent behavior in children, systematic studies on the causes of paradoxical reaction are limited. We investigated the effect of children's age and a dose of midazolam on the paradoxical reaction. METHODS A total of one hundred sixty four children of 1-3 years and 3-5 years, were enrolled in this study. Each age group randomly received 0.05 mg/kg or 0.1 mg/kg of intravenous midazolam (41 patients/group). RESULTS The incidence of paradoxical midazolam reaction in the study groups, 1-3 years with 0.1 mg/kg of intravenous midazolam, 1-3 years with 0.05 mg/kg, 3-5 years with 0.1 mg/kg, and 3-5 years with 0.05 mg/kg were as follows: 29.3%, 12.2%, 7.3% and 2.4%, respectively. The incidence among the 4 groups was significantly different (P = 0.002), highest in the 1-3 years receiving 0.1 mg/kg of midazolam (29.3%). Both age (P = 0.004, OR [95%CI] = 5.3 [1.7-16.8]) and dose of midazolam (P = 0.036, OR [95%CI] = 3.0 [1.1-8.4]) were risk factors. Perioperative clinical data including anxiety scales of children were not associated with the paradoxical midazolam reaction. CONCLUSIONS In conclusion, we suggest that children less than 3 years old receiving higher dose of intravenous midazolam are at risk for the paradoxical midazolam reaction.
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Affiliation(s)
- Young Hee Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Komur M, Arslankoylu AE, Okuyaz C. Midazolam-induced acute dystonia reversed by diazepam. J Anaesthesiol Clin Pharmacol 2012; 28:368-70. [PMID: 22869948 PMCID: PMC3409951 DOI: 10.4103/0970-9185.98346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Midazolam can induce acute dystonia in childhood. We report the development of acute dystonia in a 6-year-old girl after receiving midazolam as a sedative. Dystonic contractions persisted despite flumazenil and biperiden lactate injections and the patient was treated with diazepam. Acute dystonia was rapidly abolished after the administration of diazepam intravenously. Diazepam may be an effective treatment option in patients who are unresponsive to flumazenil.
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Affiliation(s)
- Mustafa Komur
- Department of Pediatric Neurology, Mersin University School of Medicine, Mersin, Turkey
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Cabrera LS, Santana AS, Robaina PE, Palacios MS. Paradoxical reaction to midazolam reversed with flumazenil. J Emerg Trauma Shock 2011; 3:307. [PMID: 20931003 PMCID: PMC2938526 DOI: 10.4103/0974-2700.66551] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Luciano Santana Cabrera
- Intensive Care Unit, Universitary Hospital Insular in Gran Canaria, Las Palmas de Gran Canaria, Spain
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Affiliation(s)
- Marina S George
- Department of Anaesthesia, Great Ormond Street Hospital NHS Trust, Great Ormond Street, London, UK.
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Herd DW. Anxiety in children undergoing VCUG: sedation or no sedation? Adv Urol 2008; 2008:498614. [PMID: 18615194 PMCID: PMC2443423 DOI: 10.1155/2008/498614] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 05/14/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Voiding cystourethrograms are distressing for children and parents. Nonpharmacological methods reduce distress. Pharmacological interventions for VCUG focus on sedation as well as analgesia, anxiolysis, and amnesia. Sedation has cost, time, and safety issues. Which agents and route should we use? Are we sure that sedation does not influence the ability to diagnose vesicoureteric reflux? METHODS Literature search of Medline, EMBASE, and the Cochrane Database. Review of comparative studies found. RESULTS Seven comparative studies including two randomised controlled trials were reviewed. Midazolam given orally (0.5-0.6 mg/kg) or intranasally (0.2 mg/kg) is effective with no apparent effect on voiding dynamics. Insufficient evidence to recommend other sedating agents was found. Deeper sedating agents may interfere with voiding dynamics. CONCLUSION Midazolam reduces the VCUG distress, causes amnesia, and does not appear to interfere with voiding dynamics. Midazolam combined with simple analgesia is an effective method to reduce distress to children undergoing VCUG.
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Affiliation(s)
- David W Herd
- Department of Paediatrics, Starship Children's Hospital, University of Auckland, Private Bag 92024, Auckland, New Zealand.
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Mohri-Ikuzawa Y, Inada H, Takahashi N, Kohase H, Jinno S, Umino M. Delirium during intravenous sedation with midazolam alone and with propofol in dental treatment. Anesth Prog 2006; 53:95-7. [PMID: 17175823 PMCID: PMC1693665 DOI: 10.2344/0003-3006(2006)53[95:ddiswm]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A 62-year-old man visited our clinic for dental implantation under intravenous sedation. He demonstrated increased psychomotor activity and incomprehensible verbal contact during intravenous sedation. Although delirium caused by midazolam or propofol in different patients has been reported, the present case represents a delirium that developed from both drugs in the same patient, possibly because of the patient's smaller tolerance to midazolam and propofol.
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Affiliation(s)
- Y Mohri-Ikuzawa
- Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
- Address correspondence to Y. Mohri, DDS, PhD, Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan;
| | - H Inada
- Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - N Takahashi
- Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - H Kohase
- Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - S Jinno
- Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - M Umino
- Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Golparvar M, Saghaei M, Sajedi P, Razavi SS. Paradoxical reaction following intravenous midazolam premedication in pediatric patients - a randomized placebo controlled trial of ketamine for rapid tranquilization. Paediatr Anaesth 2004; 14:924-30. [PMID: 15500492 DOI: 10.1111/j.1460-9592.2004.01349.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Paradoxical reactions to benzodiazepines include restlessness, violent behavior, physical assault, act of self-injury and need for restraints. These may occur at variable times after administration. This study was designed to determine the incidence of paradoxical reactions following intravenous midazolam premedication in pediatric patients and to compare the efficacy of extra doses of midazolam with low-dose intravenous ketamine to rapidly tranquillize them. METHODS A total of 706 ASA I, II children scheduled for elective surgery were given intravenous midazolam premedication. Children who developed a paradoxical reaction were randomly divided into three equal groups to receive: (i) extra midazolam, (ii) ketamine, or (iii) placebo as the test drug for treatment of paradoxical reaction. Ease of rapid tranquillization and need for a rescue tranquillizer (i.e. ketamine; irrespective of patient group) were compared among the three groups. RESULTS Twenty-four (3.4%) children developed paradoxical reaction after midazolam premedication. Those who received ketamine as the test drug responded rapidly to ketamine. But the responses of the other two groups to their test drug were poor and the majority of them required ketamine as rescue tranquillizer (six in midazolam, seven in placebo, but no patient in the ketamine group; P < 0.05). CONCLUSIONS The results of this study demonstrate that ketamine is an effective drug for the treatment of paradoxical reaction following intravenous midazolam premedication. The exact mechanisms of these reactions and how it is aborted by ketamine are not clear.
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Affiliation(s)
- Mohammad Golparvar
- Department of Anesthesia, Isfahan University of Medical Sciences, Isfahan, Iran
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Mancuso CE, Tanzi MG, Gabay M. Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options. Pharmacotherapy 2004; 24:1177-85. [PMID: 15460178 DOI: 10.1592/phco.24.13.1177.38089] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Benzodiazepines frequently are administered to patients to induce sedation. Paradoxical reactions to benzodiazepines, characterized by increased talkativeness, emotional release, excitement, and excessive movement, are relatively uncommon and occur in less than 1% of patients. The exact mechanism of paradoxical reactions remains unclear. Most cases are idiosyncratic; however, some evidence suggests that these reactions may occur secondary to a genetic link, history of alcohol abuse, or psychological disturbances. This review evaluates the numerous cases of paradoxical reactions to benzodiazepines in adult and pediatric patients that have been reported in the biomedical literature. It also explores the advantages and disadvantages of the various available treatment options.
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Affiliation(s)
- Carissa E Mancuso
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago, Illinois 60612-7230, USA
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Fulton SA, Mullen KD. Completion of upper endoscopic procedures despite paradoxical reaction to midazolam: a role for flumazenil? Am J Gastroenterol 2000; 95:809-11. [PMID: 10710082 DOI: 10.1111/j.1572-0241.2000.01866.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Paradoxical excitation after benzodiazepine administration is well described. Although it is relatively uncommon, its occurrence can severely impede or even prevent the performance of upper endoscopy. We describe three cases in which paradoxical reactions to midazolam responded so well to flumazenil administration that the procedure was successfully completed in each instance. We review the limited literature on this topic and suggest that flumazenil may have greater utility in the management of this particular problem than is considered at present.
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Affiliation(s)
- S A Fulton
- Department of Internal Medicine, Case Western Reserve University at Metrohealth Medical Center, Cleveland, Ohio 44109-1998, USA
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Khan LC, Lustik SJ. Treatment of a Paradoxical Reaction to Midazolam with Haloperidol. Anesth Analg 1997. [DOI: 10.1213/00000539-199707000-00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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