What Is Known about Midazolam? A Bibliometric Approach of the Literature

Effect of Co-Administration of Midazolam and Dexmedetomidine on Haemodynamics and Stress Response in Elderly Patients with Non-Small Cell Lung Cancer

OBJECTIVE

This study aimed to evaluate the effect of co-administration of midazolam and dexmedetomidine on hemodynamics and stress response in elderly patients with non-small cell lung cancer (NSCLC).

METHODS

In this prospective, randomized controlled trial, 154 elderly NSCLC patients scheduled for lobectomy in our oncology department from January 2019 to December 2021 were recruited. Patients were randomized 1:1 to receive either dexmedetomidine (control group) or dexmedetomidine plus midazolam (study group) for anesthesia during lobectomy via the random number table method, with 77 patients in each group. Perioperative indicators, hemodynamics, and stress reactions of the patients were recorded and compared between the two groups to investigate the efficacy of the two different anesthetic protocols.

RESULTS

No significant differences were observed between the two groups in terms of operative time, anesthesia time, and intraoperative bleeding volume (p > 0.05). Preoperative pain, pain at anesthesia recovery, and pain levels 7 days postoperatively were also comparable between the two groups. In the study group, the awakening time was 15 ± 2 min significantly shorter compared to the control group (25 ± 3 min). Cooperation within the first hour was significantly faster by 8.5 ± 0.5 min compared to 6.0 ± 1.0 min in the control group (p < 0.05). The cost of materials used was significantly higher in the study group, with an average of 300 ± 25 USD, compared to 200 ± 20 USD in the control group (p < 0.05). Additionally, the two groups showed no significant difference in the need for experience and surveillance (p > 0.05). Significantly lower visual analog scale (VAS) scores were found one day after the surgery in patients given dexmedetomidine plus midazolam than those anesthetized administered with dexmedetomidine only, suggesting an enhanced pain mitigation effect after incorporating midazolam for anesthetic induction. Patients treated with dexmedetomidine plus midazolam presented with a more stable hemodynamic status than those treated with dexmedetomidine only, as evidenced by the significantly lower variability of mean arterial pressure (MAP), oxygen saturation (SpO2), and heart rate (HR). Co-administration of dexmedetomidine plus midazolam for lobectomy anesthesia resulted in significantly lower serum cortisol (Cor) and norepinephrine (NE) concentrations in patients at anesthesia recovery than dexmedetomidine alone. However, this difference was not observed one day postoperatively. There was no statistically significant difference in the incidence of adverse reactions between the two groups.

CONCLUSION

The combination of midazolam with dexmedetomidine anesthesia in lobectomy improves the intraoperative hemodynamic status of elderly patients with NSCLC and mitigates their stress response. However, further research is required to explore the underlying mechanisms.

Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol

BACKGROUND

Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool.

AIM

To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events.

METHODS

We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal.

RESULTS

There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site.

CONCLUSION

Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.

Optimizing Perioperative Experience in Upper Blepharoplasty: The Impact of Premedication on Anxiety, Pain, and Patient Satisfaction

Background The periorbital area undergoes transformative changes with age, influencing both aesthetic appearance and functional aspects of the eyelids. Age-related alterations involve volume loss, shifts in eyelid crease position, drooping eyebrows, reduced skin elasticity, and the presence of dermatochalasis. Dermatochalasis, characterized by redundant upper eyelid skin folds, poses aesthetic and functional challenges, impacting visual acuity and eyelid elevation efficiency. Upper blepharoplasty addresses these age-related changes. Despite the elective nature of upper blepharoplasty, the procedure can evoke preoperative anxiety and discomfort. Various premedication strategies, including benzodiazepines, aim to alleviate anxiety and enhance the overall patient experience. However, ongoing debates persist regarding the optimal strategy for implementation. The study aims to contribute insights into the effectiveness of different premedication approaches in optimizing patient comfort during and after upper blepharoplasty. Methods The research design involves 182 patients divided into three groups: control group (CG) (n = 45) receiving no premedication, Group 1 (n = 98) receiving oral midazolam (a benzodiazepine), and Group 2 (n = 39) receiving a combination of midazolam, eutectic mixture of local anesthetics (EMLA) eyelid ointment, and oral paracetamol with codeine phosphate hemihydrate. The study assesses anxiety levels, pain perception during local anesthetic injection, surgery, and postoperatively, as well as the use of painkillers and adverse effects. Ethical approval was obtained for the study. Results Significant differences were noted among the groups during local anesthetic injection (p < 0.0001), surgery (p < 0.0001), and post surgery (p < 0.0197). CG patients experienced higher pain levels during local anesthetic injection and surgery compared to Groups 1 and 2. Group 1 reported more pain during surgery than Group 2. Substantial differences were observed in preoperative (p < 0.0001), during-surgery (p < 0.0001), and after-surgery (p < 0.0001) anxiety levels. The CG exhibited higher preoperative anxiety compared to Group 1, while Group 1 had lower anxiety during surgery compared to the CG. Group 1 also reported lower anxiety after surgery than both the CG and Group 2. A significant difference was found in post-surgery painkiller usage among the groups (p = 0.0003). Group 2 showed significantly lower usage compared to Group 1 (p = 0.0004) and the CG (p = 0.0006). A significant difference was observed in the duration of painkiller use after surgery (p < 0.0014). The CG had a longer duration than Group 1 (p = 0.0049) and Group 2 (p = 0.0495). Conclusions Midazolam alone as premedication effectively reduced anxiety before, during, and after surgery. EMLA administration for injection pain did not produce superior results, likely due to its delayed onset. Paracetamol with codeine phosphate hemihydrate effectively reduced surgical pain and postoperative pain duration and decreased the need for painkillers.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Neurotoxicology of alcohol: a bibliometric and science mapping analysis

Alcohol consumption is common in many societies and has increased considerably, resulting in many socioeconomic and public health problems. In this sense, studies have been carried out in order to understand the mechanisms involved in alcohol consumption and related harmful effects. This study aimed to identify and map the knowledge and to perform bibliometric analysis of the neurotoxicology of alcohol based on the 100 most cited articles. A search was carried out in the Web of Science Core Collection database and information was extracted regarding the journal, authors, keywords, year of publication, number of citations, country and continent of the corresponding author. For each selected manuscript, the study design, alcohol exposure model, dose, period of exposure, and effect on the central nervous system and research hotspots were mapped. The journal with the highest number of publications was Alcoholism: Clinical and Experimental Research (n = 11 papers), the author who contributed the most was Crews FT (n = 8 papers), the studies had a total of 288 keywords and 75% of the publications were from the United States of America. The experimental studies evaluated the effects of prenatal and postnatal exposure and were conducted in rats and mice using doses ranging from 2.5 to 14 g/kg/day, with administration by subcutaneous, intraperitoneal, intragastric, or inhalation route or with free access through drinking bottles. Among the studies mapped, the oldest one (1989) aimed to understand the systemic damage and mechanisms of action involved, while the most recent focused on understanding the receptors and mechanisms involved in addiction, as well as genetic factors. Our results show the panorama of the most widespread scientific production in the scientific community on the neurotoxicology of ethanol, a high prevalence was observed in studies that addressed fetal alcohol syndrome and/or the effects of ethanol on neurodevelopment.